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Planning, Implementing,
and Evaluating Health
Promotion Programs
A Primer
SeVenth edition
James F. McKenzie, Ph.d., M.P.h., M.C.h.e.S.
Ball State University
Brad L. neiger, Ph.d., M.C.h.e.S.
Brigham Young University
Rosemary thackeray, Ph.d., M.P.h.
Brigham Young University

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Library of Congress Cataloging-in-Publication Data
McKenzie, James F.
Planning, implementing, and evaluating health promotion programs: a primer/
James F. McKenzie, Brad L. Neiger, Rosemary Thackeray.—7th ed.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-13-421992-9—ISBN 0-13-421992-9
I. Neiger, Brad L. II. Thackeray, Rosemary. III. Title.
[DNLM: 1. Health Promotion—United States. 2. Health Education—United States.
3. Health Planning—United States. 4. Program Evaluation—United States. WA 590]
613.0973—dc23
2015044450
ISBN-10: 0-13-421992-9
ISBN-13: 978-0-13-421992-9
1 2 3 4 5 6 7 8 9 10—V355—20 19 18 17 16
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Acknowledgments of third party content appear on pages 477–478, which constitutes an extension of this
copyright page.

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This book is dedicated to seven special people—
Bonnie, Anne, Greg, Mitchell, Julia, Sherry,
and Callie Rose
and to our teachers and mentors—
Marshall H. Becker (deceased), Mary K. Beyer, Noreen Clark (deceased),
Enrico A. Leopardi, Brad L. Neiger, Lynne Nilson, Terry W. Parsons,
Glenn E. Richardson, Irwin M. Rosenstock (deceased),
Yuzuru Takeshita, and Doug Vilnius

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Preface xiii
Acknowledgments xvii
Chapter 1 health education, health Promotion, health education
Specialists, and Program Planning 1
Health Education and Health Promotion 4
Health Education Specialists 4
Assumptions of Health Promotion 9
Program Planning 10
Summary 13
Review Questions 13
Activities 13
Weblinks 14
PART I Planning a HealtH Promotion Program 15
Chapter 2 Starting the Planning Process 17
The Need for Creating a Rationale to Gain the Support
of Decision Makers 18
Steps in Creating a Program Rationale 20
Step 1: identify Appropriate Background information 20
Step 2: title the Rationale 26
Step 3: Writing the Content of the Rationale 26
Step 4: Listing the References Used to Create the Rationale 30
Planning Committee 33
Parameters for Planning 36
Summary 37
Review Questions 37
Activities 37
Weblinks 38
Chapter 3 Program Planning Models in health Promotion 41
Evidence-Based Planning Framework for Public Health 43
Mobilizing for Action Through Planning and Partnerships (MAPP) 45
Contents
v

vi Contents
MAP-IT 46
PRECEDE-PROCEED 48
the eight Phases of PReCede-PRoCeed 48
Intervention Mapping 50
Healthy Communities 51
SMART 53
the Phases of SMARt 55
Other Planning Models 57
An Application of the Generalized Model 58
Final Thoughts on Choosing a Planning Model 62
Summary 63
Review Questions 63
Activities 64
Weblinks 64
Chapter 4 Assessing needs 67
What to Expect from a Needs Assessment 70
Acquiring Needs Assessment Data 71
Sources of Primary data 71
Sources of Secondary data 82
Steps for Conducting a Literature Search 87
Using technology to Map needs Assessment data 88
Conducting a Needs Assessment 90
Step 1: determining the Purpose and Scope of the needs
Assessment 91
Step 2: Gathering data 91
Step 3: Analyzing the data 93
Step 4: identifying the Risk Factors Linked to the health Problem 96
Step 5: identifying the Program Focus 97
Step 6: Validating the Prioritized needs 98
Application of the Six-Step needs Assessment Process 98
Special Types of Health Assessments 100
health impact Assessment 100
organizational health Assessment 101
Summary 102
Review Questions 102
Activities 103
Weblinks 103
Chapter 5 Measurement, Measures, Measurement instruments,
and Sampling 105
Measurement 106
the importance of Measurement in Program Planning and evaluation 107
Levels of Measurement 108
types of Measures 111

Contents vii
Desirable Characteristics of Data 111
Reliability 112
Validity 114
Bias Free 117
Measurement Instruments 117
Using an existing Measurement instrument 117
Creating a Measurement instrument 118
Sampling 121
Probability Sample 123
nonprobability Sample 126
Sample Size 127
Pilot Testing 127
Ethical Issues Associated with Measurement 129
Summary 130
Review Questions 130
Activities 131
Weblinks 131
Chapter 6 Mission Statement, Goals, and objectives 133
Mission Statement 134
Program Goals 135
Objectives 136
different Levels of objectives 136
Consideration of the time needed to Reach the outcome
of an objective 138
developing objectives 139
Questions to be Answered When developing objectives 139
elements of an objective 139
Goals and Objectives for the Nation 142
Summary 148
Review Questions 149
Activities 149
Weblinks 150
Chapter 7 theories and Models Commonly Used for health
Promotion interventions 151
Types of Theories and Models 154
Behavior Change Theories 154
intrapersonal Level theories 157
interpersonal Level theories 176
Community Level theories 182
Cognitive-Behavioral Model of the Relapse Process 186
Limitations of Theory 187
Summary 188

viii Contents
Review Questions 188
Activities 189
Weblinks 190
Chapter 8 interventions 191
Types of Intervention Strategies 193
health Communication Strategies 194
health education Strategies 203
health Policy/enforcement Strategies 206
environmental Change Strategies 210
health-Related Community Service Strategies 211
Community Mobilization Strategies 212
other Strategies 215
Creating Health Promotion Interventions 225
intervention Planning 225
Adopting a health Promotion intervention 226
Adapting a health Promotion intervention 226
designing a new health Promotion intervention 228
Limtations of Interventions 233
Summary 234
Review Questions 234
Activities 235
Weblinks 236
Chapter 9 Community organizing and Community Building 237
Community Organizing Background and Assumptions 238
The Processes of Community Organizing and Community Building 241
Recognizing the issue 244
Gaining entry into the Community 244
organizing the People 245
Assessing the Community 248
determining Priorities and Setting Goals 252
Arriving at a Solution and Selecting intervention Strategies 254
Final Steps in the Community organizing and Building Processes 254
Summary 255
Review Questions 255
Activities 255
Weblinks 256
PART II imPlementing a HealtH Promotion Program 259
Chapter 10 identification and Allocation of Resources 261
Personnel 264
internal Personnel 264

Contents ix
external Personnel 265
Combination of internal and external Personnel 266
items Related to Personnel 267
Curricula and Other Instructional Resources 272
Space 275
Equipment and Supplies 276
Financial Resources 276
Participant Fee 277
third-Party Support 277
Cost Sharing 278
Cooperative Agreements 278
organization/Agency Sponsorship 278
Grants and Gifts 279
Combining Sources 282
Preparing and Monitoring a Budget 282
Summary 287
Review Questions 287
Activities 287
Weblinks 288
Chapter 11 Marketing: developing Programs that Respond
to the Wants and needs of the Priority Population 291
Marketing and Social Marketing 291
The Marketing Process and Health Promotion Programs 293
exchange 293
Consumer orientation 294
Segmentation 296
Marketing Mix 301
Pretesting 310
Continuous Monitoring 312
Summary 314
Review Questions 314
Activities 315
Weblinks 316
Chapter 12 implementation: Strategies and Associated Concerns 319
Logic Models 321
Defining Implementation 322
Phases of Program Implementation 322
Phase 1: Adoption of the Program 323
Phase 2: identifying and Prioritizing the tasks to Be Completed 323
Phase 3: establishing a System of Management 326
Phase 4: Putting the Plans into Action 331
Phase 5: ending or Sustaining a Program 335
Implementation of Evidence-Based Interventions 335

x Contents
Concerns Associated with Implementation 336
Safety and Medical Concerns 336
ethical issues 338
Legal Concerns 340
Program Registration and Fee Collection 341
Procedures for Record Keeping 341
Procedural Manual and/or Participants’ Manual 341
Program Participants with disabilities 342
training for Facilitators 342
dealing with Problems 345
documenting and Reporting 345
Summary 346
Review Questions 346
Activities 347
Weblinks 348
PART III evaluating a HealtH Promotion Program 349
Chapter 13 evaluation: An overview 351
Basic Terminology 352
Purpose of Evaluation 354
Framework for Program Evaluation 356
Practical Problems or Barriers in Conducting an Evaluation 358
Evaluation in the Program Planning Stages 360
Ethical Considerations 360
Who Will Conduct the Evaluation? 361
Evaluation Results 362
Summary 362
Review Questions 363
Activities 363
Weblinks 363
Chapter 14 evaluation Approaches and designs 365
Formative Evaluation 366
Pretesting 373
Pilot testing 373
Summative Evaluation 374
Selecting an Evaluation Design 375
Experimental, Control, and Comparison Groups 376
Evaluation Designs 378
Internal Validity 381
External Validity 382

Contents xi
Summary 383
Review Questions 383
Activities 384
Weblinks 384
Chapter 15 data Analysis and Reporting 387
Data Management 388
Data Analysis 389
Univariate data Analyses 390
Bivariate data Analyses 391
Multivariate data Analyses 392
Applications of data Analyses 393
Interpreting the Data 394
Evaluation Reporting 396
designing the Written Report 397
Presenting data 397
how and When to Present the Report 398
Increasing Utilization of the Results 399
Summary 400
Review Questions 400
Activities 400
Weblinks 401
Appendix A Code of ethics for the health education Profession 403
Appendix B health education Specialist Practice Analysis (heSPA 2015)–
Responsibilities, Competencies and Sub-competencies 409
Glossary 419
References 433
Name Index 459
Subject Index 465
Text Credits 477

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this book is written for students who are enrolled in a professional course in health
promotion program planning. It is designed to help them understand and develop the skills
necessary to carry out program planning regardless of the setting. The book is unique among
the health promotion planning textbooks on the market in that it provides readers with both
theoretical and practical information. A straightforward, step-by-step format is used to make
concepts clear and the full process of health promotion planning understandable. This book
provides, under a single cover, material on all three areas of program development: planning,
implementing, and evaluating.
Learning Aids
Each chapter includes chapter objectives, a list of key terms, presentation of content,
chapter summary, review questions, activities, and Weblinks. In addition, many of the
key concepts are further explained with information presented in boxes, figures, and
tables. There are also two appendixes: Code of Ethics for the Health Education Profession
and Health Education Specialist Practice Analysis 2015—Responsibilities, Competencies, and
Sub-competencies; an extensive list of references; and a Glossary.
Chapter Objectives
The chapter objectives identify the content and skills that should be mastered after read-
ing the chapter, answering the review questions, completing the activities, and using
the Weblinks. Most of the objectives are written using the cognitive and psychomotor
(behavior) educational domains. For most effective use of the objectives, we suggest that
they be reviewed before reading the chapter. This will help readers focus on the major
points in each chapter and facilitate answering the questions and completing the activi-
ties at the end.
Key Terms
Key terms are introduced in each chapter and are important to the understanding of the
content. The terms are presented in a list at the beginning of each chapter and are printed
in boldface at the appropriate points within the chapter. In addition, all the key terms are
presented in the Glossary. Again, as with the chapter objectives, we suggest that readers skim
PrefaCe
xiii

xiv Preface
the key terms list before reading the chapter. Then, as the chapter is read, particular attention
should be paid to the definition of each term.
Presentation of Content
Although each chapter could be expanded—in some cases, entire books have been written
on topics we have covered in a chapter or less—we believe that each chapter contains the
necessary information to help students understand and develop many of the skills required
to be successful health promotion planners, implementers, and evaluators.
Responsibilities and Competencies Boxes
Within the first few pages of all except the first chapter, readers will find a box that contains
the responsibilities and competencies for health education specialists that are applicable to
the content of the chapter. The responsibilities and competencies presented in each chapter
are the result of the most recent practice analysis—the Health Education Specialist Practice
Analysis 2015 (HESPA 2015), which is published in A Competency-Based Framework for Health
Education Specialists—2015 (NCHEC & SOPHE, 2015). These boxes will help readers under-
stand how the chapter content applies to the responsibilities and competencies required of
health education specialists. In addition, these boxes should help guide candidates as they
prepare to take either the Certified Health Education Specialist (CHES) or Master Certified
Health Education Specialist (MCHES) exam. A complete listing of the Responsibilities,
Competencies, and Sub-competencies are presented in Appendix B.
Chapter Summary
At the end of each chapter, readers will find a one- or two-paragraph review of the major con-
cepts covered in the chapter.
Review Questions
The questions at the end of each chapter provide readers with some feedback regarding their
mastery of the content. These questions also reinforce the objectives and key terms presented
in each chapter.
Activities
Each chapter includes several activities that allow students to use their new knowledge and
skills. The activities are presented in several different formats for the sake of variety and to ap-
peal to the different learning styles of students. It should be noted that, depending on the ones
selected for completion, the activities in one chapter can build on those in a previous chapter
and lead to the final product of a completely developed health promotion program plan.
Weblinks
The final portion of each chapter consists of a list of updated links on the World Wide Web.
These links encourage students to explore a number of different Websites that are available
to support planning, implementing, and evaluating programs.

Preface xv
new to this edition
In revising this textbook, we incorporated as many suggestions from reviewers, colleagues, and
former students as possible. In addition to updating material throughout the text, the follow-
ing points reflect the major changes in this new edition:
⦁ Chapter 1 has been updated to include information about the revised areas of
responsibility, competencies, and subcompetencies based on the Health Education
Specialist Practice Analysis (HESPA 2015) (NCHEC & SOPHE, 2015), and the implications
of HESPA 2015 for the Health Education Profession.
⦁ Chapter 2 has been expanded to include additional information on sources of evidence
to support a program rationale, additional information on determining the financial
burden of ill health, a new example of a written program rationale, and information on
the importance of partnering with others when creating a program.
⦁ Chapter 3 has been restructured to place more emphasis on the prominent planning
models used in health promotion. The chapter also now includes the Evidence-
Based Planning Framework in Public Health, the CHANGE tool used to plan healthy
community initiatives, and more evidence-based examples of how planning models are
used in practice.
⦁ Chapter 4 has new information on the importance of needs assessment in the accredita-
tion of health departments and the IRS requirement for not-for-profit hospitals, new
information on using technology while conducting a needs assessment, and a new
section on organizational health assessments.
⦁ Chapter 5 includes new information on wording questions for different levels of
measurement, how to present data in charts and graphs, how to write questions and
response items for data collection instruments, and guidelines for the layout and visual
presentation of data collection instruments.
⦁ Chapter 6 now includes a new section on short-term, intermediate, and long-term
objectives, and a new SMART objective checklist.
⦁ Chapter 7 includes additional information on the expansion of the socio-ecological
approach, additional information on the constructs of the social cognitive theory,
the inclusion of the diffusion of innovations theory which was previously found in
Chapter 11, and a new section on the limitations of theory.
⦁ Chapter 8 features new information on motivational interviewing, new content on
the built environment, new content on behavioral economics, information on the
Affordable Care Act and its impact on incentives, and new content on the limitations
of interventions.
⦁ Chapter 9 includes new information on the renaming of community organizing
strategies and updated figures on community organizing and community building
typology and on mapping community capacity.
⦁ Chapter 10 now includes expanded information on using volunteers as a program
resource, and program funding by governmental agencies.
⦁ Chapter 11 has been reworked and now has several new boxes and tables that include a
social marketing planning sheet, factors to consider when selecting pre-testing methods,
a 4Ps marketing mix example, types of questions to ask for formative research, and
examples of segmentation.

xvi Preface
⦁ Chapter 12 content includes expanded information on logic models, new content on
professional development including a template for a professional development plan, new
content on monitoring implementation, and new content on the implementation of an
evidence-based intervention.
⦁ Chapter 13 now includes updated information on CDC’s Framework for Program
Evaluation and new information on CDC’s characteristics of a good evaluator. In
addition, new information has been added to support the importance of evaluation and
the use of evaluation standards.
⦁ Chapter 14 includes updated terminology and context for internal and external validity,
and updated context for experimental, quasi-experimental, and non-experimental
evaluation designs.
⦁ Chapter 15 includes updated information for data management, data cleaning, and
the transition to data analysis. In addition, new information is presented to show
the relationship between levels of measurement and the selection of statistical tests
including parametric and non-parametric tests.
⦁ All chapters include more practical planning examples and, where appropriate, new
application boxes have been added to chapters.
⦁ A new appendix has been added that contains all of the Responsibilities, Competencies,
and Sub-competencies that resulted from the Health Education Specialist Practice
Analysis 2015.
⦁ To assist students, the Companion Website (https://media.pearsoncmg.com/bc/bc_
mckenzie_health_7) has been updated and includes chapter objectives, practice quizzes,
Responsibilities and Competencies boxes, Weblinks, a new example program plan, the
Glossary, and flashcards.
⦁ To assist instructors, all of the teaching resources have been updated by Michelle LaClair,
Pennsylvania State College of Medicine. These resources are available for download on
the Pearson Instructor Resource Center. Go to http://www.pearsonhighered.com and
search for the title to access and download the PowerPoint® presentations, electronic
Instructor Manual and Test Bank, and TestGen Computerized Test Bank.
Students will find this book easy to understand and use. We are confident that if the
chapters are carefully read and an honest effort is put into completing the activities and
visiting the Weblinks, students will gain the essential knowledge and skills for program
planning, implementation, and evaluation.

https://media.pearsoncmg.com/bc/bc_mckenzie_health_7

https://media.pearsoncmg.com/bc/bc_mckenzie_health_7

http://www.pearsonhighered.com

A project of this nature could not have been completed without the assistance and
understanding of many individuals. First, we thank all our past and present students, who
have had to put up with our working drafts of the manuscript.
Second, we are grateful to those professionals who took the time and effort to review
and comment on various editions of this book. For the first edition, they included Vicki
Keanz, Eastern Kentucky University; Susan Cross Lipnickey, Miami University; Fred Pearson,
Ricks College; Kerry Redican, Virginia Tech; John Sciacca, Northern Arizona University;
and William K. Spath, Montana Tech. For the second edition, reviewers included Gordon
James, Weber State; John Sciacca, Northern Arizona University; and Mark Wilson, University
of Georgia. For the third edition, reviewers included Joanna Hayden, William Paterson
University; Raffy Luquis, Southern Connecticut State University; Teresa Shattuck, University
of Maryland; Thomas Syre, James Madison University; and Esther Weekes, Texas Women’s
University. For the fourth edition, reviewers included Robert G. LaChausse, California
State University, San Bernardino; Julie Shepard, Director of Health Promotion, Adams
County Health Department; Sherm Sowby, California State University, Fresno; and William
Kane, University of New Mexico. For the fifth edition, the reviewers included Sally Black,
St. Joseph’s University; Denise Colaianni, Western Connecticut State University; Sue Forster-
Cox, New Mexico State University; Julie Gast, Utah State University; Ray Manes, York
College CUNY; and Lois Ritter, California State University East Bay. For the sixth edi-
tion, reviewers included Jacquie Rainey, University of Central Arkansas; Bridget Melton,
Georgia Southern University; Marylen Rimando, University of Iowa; Beth Orsega-Smith,
University of Delaware; Aimee Richardson, American University; Heather Diaz, California
State University, Sacramento; Steve McKenzie, Purdue University; Aly Williams, Indiana
Wesleyan University; Jennifer Banas, Northeastern Illinois University; and Heidi Fowler,
Georgia College and State University. For this edition, reviewers included Kimberly A. Parker,
Texas Woman’s University; Steven A. Branstetter, Pennsylvania State University; Jennifer
Marshall, University of South Florida; Jordana Harshman, George Mason University; Tara
Tietjen-Smith, Texas A & M University, Commerce; Amy L. Versnik Nowak, University of
Minnesota, Duluth; Amanda Tanner, University of North Carolina, Greensboro; Deric R.
Kenne, Kent State University; and Deborah J. Gibson, University of Tennessee, Martin.
Third, we thank our friends for providing valuable feedback on various editions of
this book: Robert J. Yonker, Ph.D., Professor Emeritus in the Department of Educational
Foundations and Inquiry, Bowling Green State University; Lawrence W. Green, Dr. P. H.,
Professor, Department of Epidemiology and Biostatistics, School of Medicine, University
aCknowledgments
xvii

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

1
1
Chapter Health Education, Health Promotion,
Health Education Specialists, and
Program Planning
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁⦁ Explain the relationship among good health
behavior, health education, and health promotion.
⦁⦁ Explain the difference between health education
and health promotion.
⦁⦁ Write your own definition of health education.
⦁⦁ Explain the role of the health educator as
defined by the Role Delineation Project.
⦁⦁ Explain how a person becomes a Certified
Health Education Specialist or a Master
Certified Health Education Specialist.
⦁⦁ Explain what the Competencies Update
Project (CUP), Health Educators Job Analysis
(HEJA-2010), and Health Education Specialists
Practice Analysis (HESPA-2015) have in common.
⦁⦁ Explain how the Competency-Based Framework
for Health Education Specialist is used by colleges
and universities, the National Commission for
Health Education Credentialing, Inc. (NCHEC),
Council for the Accreditation of Educator
Preparation (CAEP), and the Council on
Education for Public Health (CEPH)
⦁⦁ Identify the assumptions upon which health
education is based.
⦁⦁ Define the term pre-planning.
Key Terms
Advanced level
1-health education
specialist
Advanced level-2
health education
specialist
community
decision makers
entry-level health
education
specialist
Framework
health behavior
health education
health education
specialist
health promotion
Healthy People
pre-planning
primary prevention
priority population
Role Delineation
Project
secondary
prevention
stakeholders
tertiary prevention

2 Chapter 1
History has shown that much progress was made in the health and life expectancy
of Americans since 1900. During these 116+ years, we have seen a sharp drop in infant
mortality (NCHS, 2015); the eradication of smallpox; the elimination of poliomyelitis in
the Americas; the control of measles, rubella, tetanus, diphtheria, Haemophilus influenzae
type  b, and other infectious diseases; better family planning (CDC, 2001); and an increase
of 31.5 years in the average life span of a person in the United States (CDC, 2015e). Over
this same time, we have witnessed disease prevention change “from focusing on reducing
environmental exposures over which the individual had little control, such as providing
potable water, to emphasizing behaviors such as avoiding use of tobacco, fatty foods, and
a sedentary lifestyle” (Breslow, 1999, p. 1030). Yet, even with this change in focus we, as a
society, have  done little to encourage health community design, and as individuals, most
Americans have not changed their lifestyle enough to reduce their risk of illness, disability,
and premature death. As a result, unhealthy lifestyle characteristics have lead to the United
States ranking 94th (out of 225 countries) in crude death rate; 42nd (out of 224 countries) in
life expectancy at birth; and 1st in health care spending (CIA, 2015).
Today in the United States, much of the death and disability of Americans is associated with
chronic diseases. Seven out of every 10 deaths among Americans each year are from chronic
diseases, while heart disease, cancer, and stroke account for approximately 50% of deaths
each year (CDC, 2015b). In addition, more than 86% of all health care spending in the United
States is on people with chronic conditions (CDC, 2015b). Chronic diseases are not only the
most common, deadly, and costly, they are also the most preventable of all health problems
in the United States (CDC, 2105b). They are the most preventable because four modifiable
risk behaviors—lack of exercise or physical activity, poor nutrition, tobacco use, and exces-
sive alcohol use—are responsible for much of the illness, suffering, and early death related to
chronic diseases (CDC, 2015b) (see Table 1.1). In fact, one study estimates that all causes of
mortality could be cut by 55% by never smoking, engaging in regular physical activity, eating
a healthy diet, and avoiding being overweight (van Dam, Li, Spiegelman, Franco, & Hu, 2008).
TablE 1.1 Comparison of Most Common Causes of Death and Actual Causes of Death
Most Common Causes of Death, United States, 2013* Actual Causes of Death, United States, 2000**
1. Heart disease 1. Tobacco
2. Cancer 2. Poor diet and physical inactivity
3. Chronic lower respiratory diseases 3. Alcohol consumption
4. Unintentional injuries 4. Microbial agents
5. Stroke 5. Toxic agents
6. Alzheimer’s disease 6. Motor vehicles
7. Diabetes 7. Firearms
8. Influenza and pneumonia 8. Sexual behavior
9. Kidney disease 9. Illicit drug use
10. Suicide
*Kochanek, Murphy, Xu, & Arias (2014).
**Mokdad, Marks, Stroup, & Greberding (2004, 2005).

Health Education, Health Promotion, Health Education Specialists, and Program Planning 3
But modifying risk behaviors does not come easy to Americans. One study (Reeves  &
Rafferty, 2005) has shown that only 3% of U.S. adults adhere to four healthy lifestyle
characteristics (not smoking, engaging in regular physical activity, maintaining a healthy
weight, and eating five fruits and vegetables a day). If moderate alcohol use were included
in the healthy lifestyle characteristics the percentage would be even lower (King, Mainous,
Carnemolla, & Everett, 2009). Now in the second decade of the twenty-first century, behav-
ior patterns continue to “represent the single most prominent domain of influence over
health prospects in the United States” (McGinnis, Williams-Russo, & Knickman, 2002, p. 82).
Though the focus on good health, wellness, and health behavior (those behaviors that
impact a person’s health) seem commonplace in our lives today, it was not until the last
fourth of the twentieth century that health promotion was recognized for its potential to
help control injury and disease and to promote health.
Most scholars, policymakers, and practitioners in health promotion would pick 1974 as the
turning point that marks the beginning of health promotion as a significant component of
national health policy in the twentieth century. That year Canada published its landmark
policy statement, A New Perspective on the Health of Canadians (Lalonde, 1974). In the United
States, Congress passed PL 94-317, the Health Information and Health Promotion Act, which
created the Office of Health Information and Health Promotion, later renamed the Office of
Disease Prevention and Health Promotion (Green 1999, p. 69).
This paved the way for the U.S. government’s Healthy People: The Surgeon General’s Report
on Health Promotion and Disease Prevention (USDHEW, 1979), which brought together much
of what was known about the relationship of personal behavior and health status. The docu-
ment also presented a “personal responsibility” model that provided Americans with a pre-
scription for reducing their health risks and increasing their chances for good health.
It may not have been the content of Healthy People that made the publication so sig-
nificant, because several publications written before it provided a similar message. Rather,
Healthy People was important because it summarized the research available up to that
point, presented it in a very readable format, and made the information available to the
general public. Healthy People was followed by the release of the first set of health goals and
objectives for the nation, titled Promoting Health/Preventing Disease: Objectives for the Nation
(USDHHS, 1980).
These goals and objectives, now in their fourth generation (USDHHS, 2015c), have de-
fined the nation’s health agenda and guided its health policy since their inception. And, in
part, they have kept the importance of good health visible to all Americans.
This focus on good health has given many people in the United States a desire to do some-
thing about their health. This desire, in turn, has increased the need for good health informa-
tion that can be easily understood by the average person. One need only look at the Internet,
current best-seller list, read the daily newspaper, observe the health advertisements delivered
via electronic mass media, or consider the increase in the number of health-promoting facilities
(not illness or sickness facilities) to verify the interest that American consumers have in health.
Because of the increased interest in health and changing health behavior, health professionals
are now faced with providing the public with information. However, obtaining good informa-
tion does not mean that those who receive it will make healthy decisions and then act on those
decisions. Good health education and health promotion programs are needed to assist people
in reducing their health risks in order to obtain and maintain good health.

4 Chapter 1
⦁ Health Education and Health Promotion
There is more to health education than simply disseminating health information (Auld et al.,
2011). Health education is a much more involved process. Two formal definitions of health
education have been frequently cited in the literature. The first comes from the Report of the
2011 Joint Committee on Health Education and Promotion Terminology (Joint Committee on
Health Education and Promotion Terminology [known hereafter as the Joint Committee
on Terminology], 2012). The committee defined health education as “[a]ny combination
of planned learning experiences using evidence-based practices and/or sound theories that
provide the opportunity to acquire knowledge, attitudes, and skills needed to adopt and
maintain healthy behaviors” (Joint Committee on Terminology, 2012, p. S17). The second
definition was presented by Green and Kreuter (2005), who defined health education as “any
planned combination of learning experiences designed to predispose, enable, and reinforce
voluntary behavior conducive to health in individuals, groups, or communities” (p. G-4).
Another term that is closely related to health education, and sometimes incorrectly used
in its place, is health promotion. Health promotion is a broader term than health education. In
the Report of the 2011 Joint Committee on Health Education and Promotion Terminology (Joint
Committee on Terminology, 2012, p. S19) health promotion is defined as “[a]ny planned
combination of educational, political, environmental, regulatory, or organizational mecha-
nisms that support actions and conditions of living conducive to the health of individuals,
groups, and communities.” Green and Kreuter (2005) offered a slightly different definition
of health promotion, calling it “any planned combination of educational, political, regulatory
and organizational supports for actions and conditions of living conducive to the health of
individuals, groups, and communities” (p. G-4).
To help us further understand and operationalize the term health promotion, Breslow (1999)
has stated, “Each person has a certain degree of health that may be expressed as a place in a spec-
trum. From that perspective, promoting health must focus on enhancing people’s capacities
for living. That means moving them toward the health end of the spectrum, just as prevention
is aimed at avoiding disease that can move people toward the opposite end of the spectrum”
(p. 1031). According to these definitions of health promotion, health education is an important
component of health promotion and firmly implanted in it (see Figure 1.1). “Health promotion
takes into account that human behavior is not only governed by personal factors (e.g., knowl-
edge, expectancies, competencies, and well-being), but also by structural aspects of the environ-
ment” (Vogele, 2005, p. 272). However, “without health education, health promotion would be
a manipulative social engineering enterprise” (Green & Kreuter, 1999, p. 19).
The effectiveness of health promotion programs can vary greatly. However, the success
of a program can usually be linked to the planning that takes place before implementation
of the program. Programs that have undergone a thorough planning process are usually the
most successful. As the old saying goes, “If you fail to plan, your plan will fail.”
⦁ Health Education Specialists
The individuals best qualified to plan health promotion programs are health education special-
ists. A health education specialist has been defined as “[a]n individual who has met, at a
minimum, baccalaureate-level required health education academic preparation qualifications,

Health Education, Health Promotion, Health Education Specialists, and Program Planning 5
who serves in a variety of settings, and is able to use appropriate educational strategies and
methods to facilitate the development of policies, procedures, interventions, and systems
conducive to the health of individuals, groups, and communities” (Joint Committee on
Terminology, 2012, p. S18). Today, health education specialists can be found working in a vari-
ety of settings, including schools (K–12, colleges, and universities), community health agencies
(governmental and nongovernmental), worksites (business, industry, and other work set-
tings), and health care settings (e.g., clinics, hospitals, and managed care organizations). (Note:
Prior to the term health education specialists being used by the health education profession,
health education specialists were referred to as health educators. Throughout the remainder of
this book the term health education specialist will be used except when the term health educator is
part of a title or when the term carries historical relevance.)
The role of the health education specialist in the United States as we know it today
is one that has evolved over time based on the need to provide people with educational
interventions to enhance their health. The earliest signs of the role of the health educa-
tion specialist appeared in the mid-1800s with school hygiene education, which was
closely associated with physical activity. By the early 1900s, the need for health educa-
tion spread to the public health arena, but it was the writers, journalists, social workers,
and visiting nurses who were doing the educating—not health education specialists as
we know them today (Deeds, 1992). As we gained more knowledge about the relationship
between health, disease, and health behavior, it was obvious that the writers, journal-
ists, social workers, visiting nurses, and primary caregivers—mainly physicians, dentists,
other independent practitioners, and nurses—were unable to provide the needed health
Environ-
mental
Environ-
mental
E
nv
iro
n-
m
en
ta
l
E
nviron-
m
entalE
nv
iro
n-
m
en
ta
l
E
nviron-
m
ental
Policy Social
Regulatory Organi-
zational
Political Economic
HEA
LTH PROMOTION
HEALTH PROMOTIO
N
Health
Education
⦁▲ Figure 1.1 Relationship of Health Education and Health Promotion

6 Chapter 1
education. The combination of the heavy workload of the primary caregivers, the lack of
formal training in the process of educating others, and the need for education at all levels
of prevention—primary, secondary, and tertiary—(see Table 1.2) created a need for
health education specialists.
As the role of the health educator grew over the years, there was a movement by those
in the discipline to clearly define their role so that people inside and outside the profession
would have a better understanding of what the health education specialist did. In January
1979, the Role Delineation Project began (National Task Force on the Preparation and
Practice of Health Educators, 1985). Through a comprehensive process, this project yielded
a generic role for the entry-level health educator—that is, responsibilities for health
education specialists taking their first job regardless of their work setting. Once the role of
the entry-level health educator was delineated, the task became to translate the role into a
structure that professional preparation programs in health education could use to design
competency-based curricula. The resulting document, A Framework for the Development of
Competency-Based Curricula for Entry Level Health Educators (NCHEC, 1985), and its revised
version, A Competency-Based Framework for the Professional Development of Certified Health
Education Specialists (NCHEC, 1996), provided such a structure. These documents, simply
referred to as the Framework were comprised of the seven major areas of responsibility,
TablE 1.2 Levels of Prevention
Level of Prevention Health Status Example Interventions
Primary prevention –
measures that forestall the
onset of a disease, illness,
or injury
Healthy, without signs and
symptoms of disease, illness
or injury
Activities directed at
improving well-being
while preventing
specific health problems,
e.g., legislation to
mandate safe practices,
exercise programs,
immunizations, fluoride
treatments
Secondary prevention –
measures that lead to early
diagnosis and prompt
treatment of a disease,
illness, or injury to minimize
progression of health
problem
Presence of disease, illness,
or injury
Activities directed at
early diagnosis, referral,
and prompt treatment,
e.g., mammograms,
self-testicular exam,
laboratory tests to
diagnosis diabetes,
hypercholesterolemia,
hypothyroidism,
programs to prevent
reinjury
Tertiary prevention –
measures aimed at
rehabilitation following
significant disease, illness,
or injury
Disability, impairment, or
dependency
Activities directed at
rehabilitation to return
a person to maximum
usefulness, e.g., disease
management programs,
support groups, cardiac
rehabilitation programs

Health Education, Health Promotion, Health Education Specialists, and Program Planning 7
which defined the scope of practice, and several different competencies and subcompeten-
cies, which further delineated the responsibilities.
Even though the seven areas of responsibility defined the role of the entry-level health
educator, they did not fully express the work of the health education specialist with an
advanced degree. Thus, over a four-year period beginning in 1992, the profession worked
to define the role of an advanced-level practitioner. By July 1997, the governing boards of
the National Commission for Health Education Credentialing, Inc. (NCHEC), the American
Association of Health Education (AAHE), and the Society for Public Health Education
(SOPHE) had endorsed three additional responsibilities for the advanced-level health educa-
tor. Those responsibilities revolved around research, administration, and the advancement
of the profession (AAHE, NCHEC, & SOPHE, 1999).
The seven entry-level and three additional advanced-level responsibilities served the
profession well, but during the mid- to late-1990s it became obvious that there was a need
to revisit the responsibilities and competencies and to make sure that they still defined
the role of the health educator. Thus in 1998, the profession launched a six-year multi-
phase research study known as the National Health Educator Competencies Update Project
(CUP) to reverify the entry-level health educator responsibilities, competencies, and
subcompetencies and to verify the advanced-level competencies and subcompetencies
(Airhihenbuwa et al., 2005).
What became obvious from the analysis of the CUP data was that the seven respon-
sibilities and many of the competencies and subcompetencies identified in the earlier
Role Delineation Project were still valid. However, the wording of the responsibilities was
changed slightly, some competencies and subcompetencies were dropped, and a few new
ones were added. Also, certain subcompetencies were reported as more important and per-
formed more regularly by health education specialists who had both more work experience
and academic degrees beyond the baccalaureate level. Thus, the CUP model that emerged
included responsibilities, competencies, and subcompetencies and the development of a
three-tiered (i.e., Entry, Advanced Level-1, and Advanced Level-2) hierarchical model
reflecting the role of the health educator. The results of the CUP, which were published
approximately 20 years after the initial role delineation project, lead to the creation of
a revised framework titled A Competency-Based Framework for Health Educators (NCHEC,
SOPHE, & AAHE, 2006).
To keep the role of the health education specialist contemporary and to meet best practice
guidelines of the National Commission for Certifying Agencies (NCCA), a third national
research study known as the Health Educator Job Analysis (HEJA-2010) was conducted. The
results of this study generated a new Framework titled A Competency-Based Framework for
Health Education Specialist–2010 (NCHEC, SOPHE, AAHE, 2010). The NCCA, the agency that
accredits the Certified Health Education Specialist (CHES) and the Master Certified Health
Education Specialist (MCHES) exam programs, has a standard that requires periodic updates
of a job/practice analysis to keep the practice of the profession contemporary.
The most recent edition of the Framework titled A Competency-Based Framework for Health
Education Specialist–2015 (NCHEC & SOPHE, 2015) is the result of the Health Education
Specialist Practice Analysis (HESPA-2015). Over the years, the number of Areas of Responsibility
outlined in the Framework have remained fairly consistent (see Box 1.1). What has changed
over the years is the wording of the Areas of Responsibilities and the number and wording

8 Chapter 1
of the competencies and subcompetencies found under the Areas of Responsibility. In the
2015 Framework, there are 36 competencies and 258 subcompetencies (141 Entry-level, 76
Advanced 1-level, and 41 Advanced 2-level ) (NCHEC & SOPHE, 2015).
In reviewing the current seven areas of responsibility, it is obvious that four of the seven
are directly related to program planning, implementation, and evaluation and that the other
three could be associated with these processes, depending on the type of program being
planned. In effect, these responsibilities distinguish health education specialists from other
professionals who try to provide health education experiences.
The importance of the defined role of the health education specialist is becoming greater
as the profession of health promotion continues to mature. This is exhibited by its use in
several major professional activities. First, the Framework has provided a guide for all colleges
and universities to use when designing and revising their curricula in health education to
prepare future health education specialists. Second, the Framework was used by the National
Commission for Health Education Credentialing, Inc. (NCHEC) to develop the core criteria for
certifying individuals as health education specialists (Certified Health Education Specialists,
or CHES). The first group of individuals (N=1,558) to receive the CHES credential did so be-
tween October 1988 and December 1989, during the charter certification period. “Charter
certification allows qualified individuals to be certified based on their academic training, work
experience, and references without taking the exam” (Cottrell, Girvan, McKenzie & Seabert,
2015, p. 171). In 1990, using a criterion-referenced examination based on the Framework, the
nationwide testing program to certify health education specialists was begun by NCHEC, Inc.
In 2011, again using a criterion-referenced examination based on the Framework,
NCHEC began offering an examination to certify advanced-level health education spe-
cialists. Those who passed the examination were awarded the Master Certified Health
Education Specialist (MCHES) credential. Prior to the first MCHES examination, this new
certification was made available to those who had held active CHES status since 2005 and
who could demonstrate that they were practicing health education at an advanced-level.
This process was known as the Experience Documentation Opportunity (EDO). All those
1.1
Box Areas of Responsibility for Health Education Specialists
AREA oF RESponSiBiliTy i: Assess Needs, Resources, and Capacity for Health Education/
Promotion
AREA oF RESponSiBiliTy ii: Plan Health Education/Promotion
AREA oF RESponSiBiliTy iii: Implement Health Education/Promotion
AREA oF RESponSiBiliTy iV: Conduct Evaluation and Research Related to Health
Education/Promotion
AREA oF RESponSiBiliTy V: Administer and Manage Health Education/Promotion
AREA oF RESponSiBiliTy Vi: Serve as a Health Education/Promotion Resource Person
AREA oF RESponSiBiliTy Vii: Communicate, Promote, and Advocate for Health, Health
Education/Promotion, and the Profession
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc.
(NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc.
(NCHEC) and the Society for Public Health Education (SOPHE).

Health Education, Health Promotion, Health Education Specialists, and Program Planning 9
who successfully completed the EDO were granted the MCHES credential in April 2011.
Currently, both the CHES and MCHES examinations are given twice a year—once in April
and once in October—at approximately 130 college-campus locations around the United
States. Both examinations are composed of 165 questions (150 are scored and 15 are pi-
lot questions) and are offered in a paper-and-pencil format (NCHEC, 2015). Information
about eligibility for the examinations and the percentage of questions from each Area of
Responsibility are available on the NCHEC Website (see the link for the Website in the
Weblinks section at the end of the chapter).
Third, the Framework is used by program accrediting bodies to review college and uni-
versity academic programs in health education. Both the Council for the Accreditation
of Educator Preparation (CAEP), which accredits teacher education programs, and the
Council on Education for Public Health (CEPH), which accredits public health programs,
use components of the Framework when accrediting programs that have a focus on health
education. The accrediting processes used by both CAEP and CEPH are based on programs
conducting a self-study by comparing components of their program to accrediting body
criteria or standards. After the self-study is completed, peer external reviewers visit the cam-
pus of the college or university seeking accreditation to verify the contents of the self-study.
The governing boards of CAEP and CEPH review the findings of the self-study and external
reviewers report and vote on awarding accreditation.
The use of the Framework by the profession to guide academic curricula, provide the
core criteria for the health education specialist examinations, and form the basis of pro-
gram accreditation processes has done much to advance the health education profession.
“In 1998 the U.S. Department of Commerce and Labor formally acknowledged ‘health
educator’ as a distinct occupation. Such recognition was justified, based to a large extent,
on the ability of the profession to specify its unique skills” (AAHE, NCHEC, & SOPHE,
1999, p. 9). In 2010, in its most recent update, the U.S. Department of Labor Bureau
of Labor Statistics (BLS) described the work of health educators (Standard Occupation
Classification [SOC] 21-1091) using the following language:
Provide and manage health education programs that help individuals, families, and their
communities maximize and maintain healthy lifestyles. Collect and analyze data to identify
community needs prior to planning, implementing, monitoring, and evaluating programs
designed to encourage healthy lifestyles, policies, and environments. May serve as resource
to assist individuals, other health professionals, or the community, and may administer fiscal
resources for health education programs (USDOL, BLS, 2015, para. 1).
⦁ Assumptions of Health Promotion
So far, we have discussed the need for health, what health education and health promotion
are, and the role health education specialists play in delivering successful health promotion
programs. We have not yet discussed the assumptions that underlie health promotion—all
the things that must be in place before the whole process of health promotion begins. In the
mid-1980s, Bates and Winder (1984) outlined what they saw as four critical assumptions of
health education. Their list has been modified by adding several items, rewording others,
and referring to them as “assumptions of health promotion.” This expanded list of assump-
tions is critical to understanding what we can expect from health promotion programs.

10 Chapter 1
Health promotion is by no means the sole answer to the nation’s health problems or, for
that matter, the sole means of getting a smoker to stop smoking or a nonexerciser to exercise.
Health promotion is an important part of the health system, but it does have limitations.
Here are the assumptions:
1. Health status can be changed.
2. “Health and disease are determined by dynamic interactions among biological,
psychological, behavioral, and social factors” (Pellmar, Brandt, & Baird, 2002, p. 217).
3. “Behavior can be changed and those changes can influence health” (IOM, 2001, p. 333).
4. “Individual behavior, family interactions, community and workplace relationships and
resources, and public policy all contribute to health and influence behavior change”
(Pellmar et al., 2002, p. 217).
5. “Interventions can successfully teach health-promoting behaviors or attenuate risky
behaviors” (IOM, 2001, p. 333).
6. Before health behavior is changed, the determinants of behavior, the nature of the
behavior, and the motivation for the behavior must be understood (DiClemente,
Salazar, & Crosby, 2013).
7. “Initiating and maintaining a behavior change is difficult” (Pellmar et al., 2002, p. 217).
8. Individual responsibility should not be viewed as victim blaming, yet the importance of
health behavior to health status must be understood.
9. For health behavior change to be permanent, an individual must be motivated and
ready to change.
The importance of these assumptions is made clearer if we refer to the definitions of
health education and health promotion presented earlier in the chapter. Implicit in those
definitions is the goal of having program participants voluntarily adopt actions conducive
to health. To achieve such a goal, the assumptions must indeed be in place. We cannot ex-
pect people to adopt lifelong health-enhancing behavior if we force them into such change.
Nor can we expect people to change their behavior just because they have been exposed to
a health promotion program. Health behavior change is very complex, and health educa-
tion specialists should not expect to change every person with whom they come in contact.
However, the greatest chance for success will come to those who have the knowledge and
skills to plan, implement, and evaluate appropriate programs.
⦁ Program Planning
Because many of health education specialists’ responsibilities are involved in some way with
program planning, implementation, and evaluation, health education specialists need to
become well versed in these processes. “Planning an effective program is more difficult than
implementing it. Planning, implementing, and evaluating programs are all interrelated, but
good planning skills are prerequisite to programs worthy of evaluation” (Minelli & Breckon,
2009, p. 137). All three processes are very involved, and much time, effort, practice, and on-
the-job training are required to do them well. Even the most experienced health education
specialists find program planning challenging because of the constant changes in settings,
resources, and priority populations.

Health Education, Health Promotion, Health Education Specialists, and Program Planning 11
Hunnicutt (2007) offered four reasons why systematic planning is important. The first is
that planning forces planners to think through details in advance. Detailed plans can help
to avoid future problems. Second, planning helps to make a program transparent. Good
planning keeps the program stakeholders (any person, community, or organization with
a vested interest in a program; e.g., decision makers, partners, clients) informed. The plan-
ning process should not be mysterious or secretive. Third, planning is empowering. Once
decision makers (those who have the authority to approve a plan; e.g., administrator of
an organization, governing board, chief executive officer) give approval to the resulting
comprehensive program plan, planners and facilitators are empowered to implement the
program. Without an approved plan, planners will spend a great deal of time waiting for
the “next step” to be approved and risk losing program momentum. And fourth, planning
creates alignment. Once the decision makers have approved the program, all organization
members have a better understanding of where it “fits” in the organization and the impor-
tance that the plan carries.
A general understanding of all that is involved in creating a health promotion program
can be obtained by reviewing the Generalized Model (see Figure 1.2). (A more in-depth
explanation of this model can be found in Chapter 3.) This model includes the five major
steps involved in planning a program. However, prior to undertaking the first step in the
Generalized Model, it is important to do some pre-planning. Pre-planning allows a core
group of people (or steering committee) to gather answers to key questions (see Box 1.2)
that are critical to the planning process before the actual planning process begins. It also
helps to clarify and give direction to planning, and helps stakeholders avoid confusion as
the planning progresses.
Also prior to starting the actual planning process, planners need to have a very good
understanding of the “community” where the program will be implemented. When we
say community, do not think of just a geographic area with specific boundaries like a
neighborhood, city, county, or state. Community should be defined as “a collective body
of individuals identified by common characteristics such as geography, interests, experi-
ences, concerns, or values” (Joint Committee on Terminology, 2012, p. S15). For example,
a community could be a religious community, a cancer-survivor community, a workplace
community, or even a cyber community. Understanding the community means finding
out as much as possible about the priority population (those for whom the program
is intended to serve) and the environment in which it exists. Each setting and group is
unique with its own nuances, resources, and culture. These are important to know at the
beginning of the process. Planners should never assume they “know” a community. The
more background information that planners secure, the better the resulting program can
be. However, it is not enough to understand the community, planners also need to engage
members of the priority population. Engaging the priority population means involving
Assessing
needs
Setting
goals and
objectives
Developing
an
intervention
Implementing
the
intervention
Evaluating
the
results
⦁▲ Figure 1.2 Generalized Model

12 Chapter 1
those in the priority population or a representative group from the priority population in
the planning process.
Finally, before the actual planning begins thought must be given to “when the best time
is to plan such a program, what data are needed, where the planning should occur, what
resistance can be expected, and generally, what will enhance the success of the project”
(Minelli & Breckon, 2009, p. 138).
The remaining chapters of this book present a process that health education specialists
can use to plan, implement, and evaluate successful health promotion programs and will
introduce you to the necessary knowledge and skills to carry out these tasks.
1.2
Box Example Key Questions to Be Answered in the pre-planning process
purpose of program
⦁⦁ How is the community defined?
⦁⦁ What are the desired health outcomes?
⦁⦁ Does the community have the capacity and infrastructure to address the problem?
⦁⦁ Is a policy change needed?
Scope of the planning process
⦁⦁ Is it intra- or inter-organizational?
⦁⦁ What is the time frame for completing the project?
planning process outcomes (deliverables)
⦁⦁ Written plan?
⦁⦁ Program proposal?
⦁⦁ Program documentation or justification?
leadership and structure
⦁⦁ What authority, if any, will the planners have?
⦁⦁ How will the planners be organized?
⦁⦁ What is expected of those who participate in the planning process?
identifying and engaging partners
⦁⦁ How will the partners be selected?
⦁⦁ Will the planning process use a top-down or bottom-up approach?
identifying and securing resources
⦁⦁ How will the budget be determined?
⦁⦁ Will a written agreement (i.e., MOA—memorandum of agreement) outlining
responsibilities be needed?
⦁⦁ If MOA is needed, what will it include?
⦁⦁ Will external funding (i.e., grants or contracts) be needed?
⦁⦁ Are there community resources (e.g., volunteers, space, donations) to support the
planned program?
⦁⦁ How will the resources be obtained?
Fo
cu
s
O
n

Health Education, Health Promotion, Health Education Specialists, and Program Planning 13
Summary
The increased interest in personal health and behavior change, and the flood of new health
information have expanded the need for quality health promotion programs. Individuals are
seeking guidance to enable them to make sound decisions about behavior that is conducive
to their health. Those best prepared to help these people are health education specialists
who complete a curriculum based upon the role defined by the profession. Properly trained
health education specialists are aware of the limitations of the discipline and understand the
assumptions on which health promotion is based. They also know that good planning does
not happen by accident. Much time, effort, practice, and on-the-job training are needed to
plan an effective program. The planning process begins with pre-planning.
Review Questions
1. Explain the role Healthy People played in the relationship between the American people
and health.
2. How is health education defined by the Joint Committee on Terminology (2012)?
3. What are the key phrases in the definition of health education presented by Green and
Kreuter (2005)?
4. What is the relationship between health education and health promotion?
5. Why is there a need for health education specialists?
6. What is the Role Delineation Project?
7. How is the Competency-Based Framework for Health Education Specialists used by colleges
and universities? By NCHEC? By CAEP? By CEPH?
8. How does one become a Certified Health Education Specialist (CHES)?
9. How does one become a Master Certified Health Specialist (MCHES)?
10. What are the seven Areas of Responsibilities of health education specialists?
11. What is the National Health Educator Competencies Update Project (CUP)?
12. What is the Health Educator Job Analysis – 2010 (HEJA-2010)?
13. What is the Health Education Specialist Practice Analysis – 2015 (HESPA-2015)?
14. What assumptions are critical to health promotion?
15. What are the steps in the Generalized Model?
16. What is meant by the term pre-planning? Why is it important? What are some questions
that should be answered during the pre-planning process?
17. How have stakeholders, decision makers, and community been defined in this chapter?
Activities
1. Based on what you have read in this chapter and your knowledge of the profession of
health education, write your own definitions for health, health education, health promotion,
and health promotion program.

14 Chapter 1
2. Write a response indicating what you see as the importance of each of the nine
assumptions presented in the chapter. Write no more than one paragraph per
assumption.
3. With your knowledge of health promotion, what other assumptions would you add to
the list presented in this chapter? Provide a one-paragraph rationale for each.
4. If you have not already done so, go online (http://profiles.nlm.nih.gov/ps/access
/NNBBGK ) or to the government documents section of the library on your campus
and read Healthy People: The Surgeon General’s Report on Health Promotion and Disease
Prevention (USDHEW, 1979).
5. Say you are in your senior year and will graduate next May with a bachelor’s degree
in health education. What steps would you have to take in order to be able to take the
CHES exam in April prior to your graduation? (Hint: Check the Website of the National
Commission for Health Education Credentialing, Inc.)
6. In a one-page paper describe the differences and similarities in the two credentials—
CHES and MCHES—available to health education specialists. (Hint: Check the Website of
the National Commission for Health Education Credentialing, Inc.)
7. In a one-page paper describe what the job outlook is projected to be for health education
specialists for the next ten years. (Hint: Check the Website of the Bureau of Labor
Statistics Occupational Outlook Handbook.)
Weblinks
1. http://www.healthypeople.gov
Healthy People
This is the Webpage for the U.S. government’s Healthy People initiative including
a complete presentation of Healthy People 2020.
2. http://www.nchec.org/
National Commission for Health Education Credentialing, Inc. (NCHEC)
The NCHEC, Inc. Website provides the most current information about the CHES
and MCHES credentials.
3. http://www.bls.gov/ooh/community-and-social-service/health-educators.htm
Occupational Outlook Handbook
This is a Webpage provided by the Bureau of Labor Statistics that describes the
occupation outlook for health educators and community health workers.

http://profiles.nlm.nih.gov/ps/access/NNBBGK

http://profiles.nlm.nih.gov/ps/access/NNBBGK

http://www.healthypeople.gov

http://www.nchec.org/

http://www.bls.gov/ooh/community-and-social-service/health-educators.htm

The chapters in this section of the book provide the basic
information needed to plan a health promotion program.
Each chapter presents readers with the information they
will need to build the knowledge to develop the skills to
create a successful program in a variety of settings.
Part I Planning a HealtH
Promotion Program
Chapter 2 17
Starting the Planning Process
Chapter 3 41
Program Planning Models
in Health Promotion
Chapter 4 67
assessing Needs
Chapter 5 105
Measurement, Measures,
Measurement Instruments,
and Sampling
Chapter 6 133
Mission Statement, Goals,
and Objectives
Chapter 7 151
theories and Models
Commonly Used for Health
Promotion Interventions
Chapter 8 191
Interventions
Chapter 9 237
Community Organizing
and Community Building

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17
As noted earlier (Chapter 1), planning a health promotion program is a multistep
process that begins after doing pre-planning. “To plan is to engage in a process or a proce-
dure to develop a method of achieving an end” (Minelli & Breckon, 2009, p. 137). However,
because of the many different variables and circumstances of any one setting, the multistep
process of planning does not always begin the same way. There are times when the need for
a program is obvious and there is recognition that a new program should be put in place. For
example, if a community’s immunization rate for its children is less than half the national
average, a program should be created. There are other times when a program has been suc-
cessful in the past but needs to be changed or reworked slightly before being implemented
again. And, there are situations where planners have been given the independence and
authority to create the programs that are needed in a community in order to improve the
health and quality of life. However, when the need is not so obvious, or when there has
not been successful health promotion programming in the past or decision makers want
“proof” (i.e., evidence) that a program is needed and will be successful, the planning process
often begins with the planners creating a rationale to gain the support of key people in or-
der to obtain the necessary resources to ensure that the planning process and the eventual
implementation proceed as smoothly as possible.
literature
organizational
culture
planning committee
planning parameters
planning team
program ownership
return on investment
(ROI)
social math
steering committee
Key Terms
advisory board
cost-benefit analysis
(CBA)
doers
epidemiology
evidence
evidence-based
practice
Guide to Community
Preventive Services
influencers
institutionalized
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁⦁ Develop a rationale for planning and
implementing a health promotion program.
⦁⦁ Explain the importance of gaining the support
of decision makers.
⦁⦁ Identify the individuals who could make up a
planning committee.
⦁⦁ Explain what planning parameters are and the
impact they have on program planning.
Starting the Planning Process
2
Chapter

18 Part 1 Planning a Health Promotion Program
This chapter presents the steps of creating a program rationale to obtain the support of
decision makers, identifying those who may be interested in helping to plan the program,
and establishing the parameters in which the planners must work. Box 2.1 identifies the
responsibilities and competencies for health education specialists that pertain to the mate-
rial presented in this chapter.
The Need for Creating a Rationale to Gain the Support
of Decision Makers
No matter what the setting of a health promotion program—whether a business, an in-
dustry, the community, a clinic, a hospital, or a school—it is most important that the
program have support from the highest level (e.g., the administration, chief executive
2.1
Box Responsibilities and Competencies for Health Education Specialists
The content of this chapter includes information on several tasks that occur early in
the program planning process. These tasks are not associated with a single area of
responsibility, but rather five areas of responsibility of the health education specialist:
RESponSiBility i: Assess Needs, Resources, and Capacity for Health Education/
Promotion
Competency 1.2: Access existing information and data related
to health
Competency 1.6: Examine factors that enhance or impede the
process of health education/promotion
RESponSiBility ii: Plan Health Education/Promotion
Competency 2.1: Involve priority populations, partners, and other
stakeholders in the planning process
RESponSiBility V: Administer and Manage Health Education/Promotion
Competency 5.3: Manage relationships with partners and other
stakeholders
Competency 5.4: Gain acceptance and support for health education/
promotion
Competency 5.5: Demonstrate leadership
RESponSiBility Vi: Serve as a Health Education/Promotion Resource Person
Competency 6.1: Obtain and disseminate health-related information
Competency 6.3: Provide advice and consultation on health
education/ promotion issues
RESponSiBility Vii: Communicate, Promote, and Advocate for Health and Health
Education/ Promotion, and the Profession
Competency 7.2: Engage in advocacy for health education/promotion
Competency 7.3: Influence policy and/or systems change to promote
health and health education/promotion
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc.
(NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc.
(NCHEC) and the Society for Public Health Education (SOPHE).

Chapter 2 Starting the Planning Process 19
officer, church elders, board of health, or board of directors) of the “community” for
which the  program is being planned (Allen & Hunnicutt, 2007; Chapman, 1997, 2006;
Hunnicutt & Leffelman, 2006; Ryan, Chapman, & Rink, 2008). It is the individuals in
these top-level decision-making positions who are able to provide the necessary resource
support for the program.
“Resources” usually means money, which can be turned into staff, facilities, materials, supplies,
utilities, and all the myriad number of things that enable organized activity to take place over
time. “Support” usually means a range of things: congruent organizational policies, program
and concept visibility, expressions of priority value, personal involvement of key managers, a
place at the table of organizational power, organizational credibility, and a role in integrated
functioning (Chapman, 1997, p. 1).
There will be times when the idea for, or the motivating force behind, a program comes
from the top-level people. When this happens, it is a real boon for the program planners
because they do not have to sell the idea to these people to gain their support. However,
this scenario does not occur frequently.
Often, the idea or the big push for a health promotion program comes from someone
other than one who is part of the top-level of the “community.” The idea could start with
an employee, an interested parent, a health education specialist within the organization, a
member of the parish or congregation, or a concerned individual or group from within the
community. The idea might even be generated by an individual outside the “community,”
such as one who may have administrative or oversight responsibilities for activities in a
community. An example of this arrangement is the employee of a state health department
who provides consultative services to a local health department. Or it may be an individual
from a regional agency who is partnering with a group within the community to carry out a
collaborative project. When the scenario begins at a level below the decision makers, those
who want to create a program must “sell” it to the decision makers. In other words, in order
for resources and support to flow into health promotion programming, decision makers
need to clearly perceive a set of values or benefits associated with the proposed program
(Chapman, 2006). Without the support of decision makers, it becomes more difficult, if
not impossible, to plan and implement a program. A number of years ago, Behrens (1983)
stated that health promotion programs in business and industry have a greater chance for
success if all levels of management, including the top, are committed and supportive. This
is still true today of health promotion programs in all settings, not just programs in busi-
ness and industry (see Box 2.2).
If they need to gain the support of decision makers, program planners should de-
velop a rationale for the program’s existence. Why is it necessary to sell something that
everyone knows is worthwhile? After all, does anyone doubt the value of trying to help
people gain and maintain good health? The answer to these and similar questions is that
few people are motivated by health concerns alone. Decisions by top-level management
to develop new programs are based on a variety of factors, including finances, policies,
public image, and politics, to name a few. Thus to sell the program to those at the top,
planners need to develop a rationale that shows how the new program will help decision
makers to meet the organization’s goals and, in turn, to carry out its mission. In other
words, planners need to position their program rationale politically, in line with the
organization.

20 Part 1 Planning a Health Promotion Program
Steps in Creating a Program Rationale
Planners must understand that gaining the support of decision makers is one of the most
important steps in the planning process and it should not be taken lightly. Many program
ideas have died at this stage because the planners were not well prepared to sell the program
to decision makers. Thus, before making an appeal to decision makers, planners need to have
a sound rationale for creating a program that is supported by evidence that the proposed pro-
gram will benefit those for whom it is planned.
There is no formula or recipe for writing a rationale, but through experience, the authors have
found a logical format for putting ideas together to help guide planners (see Figure  2.1). Note
that Figure 2.1 is presented as an inverted triangle. This inverted triangle is symbolic in design to
reflect the flow of a program rationale beginning at the top by identifying a health problem in
global terms and moving toward a more focused solution at the bottom of the triangle.
Step 1: identify Appropriate Background information
Before planners begin to write a program rationale, they need to identify appropriate sources
of information and data that can be used to sell program development. The place to begin
the process of identifying appropriate sources of information and data to support the devel-
opment of a program rationale is to conduct a search of the existing literature. Literature
includes the articles, books, government publications, and other documents that explain
the past and current knowledge about a particular topic. By conducting a search, planners
gain a better understanding of the health problem(s) of concern, approaches to reducing or
eliminating the health problem, and an understanding of the people for whom the program
is intended (remember these individuals are referred to as the priority population). There are a
number of different ways that planners can carry out a review of the literature (see Chapter 4
for an explanation of the literature search process).
2.2
Box
Though the importance of decision
makers’ support to the success of
health promotion programs has been
known for a number of years, it is only
recently that efforts have been put forth
to actually measure decision makers’
support for health promotion programs.
Della, DeJoy, Goetzel, Ozminkowski, and
Wilson (2008) created a valid instrument
to assess leadership support for health
promotion programs in work settings.
The measurement tool, referred to as the
Leading by Example (LBE) Instrument,
is a four-factor scale. The four factors
are (1) business assignment with health
Measuring Decision Makers’ Support for Health promotion
promotion objectives, (2) awareness
of the economics of health and worker
productivity, (3) worksite support for
health promotion, and (4) leadership
support for health promotion (Della et al.,
2010). Della and colleagues feel that the
LBE could be used in two ways. The first
would be through a single administration
“to assess specific areas in which the
health promotion climate might support/
hinder programmatic efforts” (p. 139).
The second would be to administer
the LBE two different times to monitor
change in support for health promotion
programs over time.
Fo
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Chapter 2 Starting the Planning Process 21
In general, the types of information and data that are useful in writing a rationale in-
clude those that (1) express the needs and wants of the priority population, (2) describe
the status of the health problem(s) within a given population, (3) show how the potential
outcomes of the proposed program align with what the decision makers feel is important,
(4) show compatibility with the health plan of a state or the nation, (5) provide evidence
that the proposed program will make a difference, and (6) show how the proposed program
will protect and preserve the single biggest asset of most organizations and communities—
the people. Though many of these types of information and data are generated through
a review of the literature, the first one discussed below—needs and wants of the priority
population—is not.
Information and data that express the needs and wants of the priority population can be gen-
erated through a needs assessment. A needs assessment is the process of identifying, analyzing,
and prioritizing the needs of a priority population. Needs assessments are carried out through
a multiple-step process in which data are collected and analyzed. The analysis generates a
Title the work “A rationale for the development of . . .” and indicate who is submitting
the work.
Identify the health problem in global terms, backing it up with appropriate
(international, national, or state) data. If possible, also include
the economic costs of the problem.
Narrow the health problem by showing its relationship to the
proposed priority population. Create a problem statement.
State why it is a problem and why it should be dealt with.
Again, back up the statement with appropriate data.
State a proposed solution to the problem (name
and purpose of the proposed health promotion
program). Provide a general overview of
the program.
State what can be gained from such a
program in terms of the values and
benefits to the decision makers.
State why the program will
be successful.
Provide the
references
used in
preparing
the
rationale.
⦁▲ Figure 2.1 Creating a rationale

22 Part 1 Planning a Health Promotion Program
prioritized list of needs of the priority population (see Chapter 4 for a detailed explanation of the
needs assessment process). Even though information and data that express the needs and wants
of the priority population can be very useful in generating a rationale for a proposed program,
more than likely at this point in the planning process, a formal needs assessment will not have
been completed. Often, a complete needs assessment does not take place until decision mak-
ers give permission for the planning to begin. However, the review of literature may generate
information about a needs assessment of another related or similar program. If so, it can provide
valuable information and data that can help to develop the rationale.
Information and data that describe the status of a health problem within a population can
be obtained by analyzing epidemiological data. Epidemiologic data are those that result from
the process of epidemiology, which has been defined as “[t]he study of the occurrence and
distribution of health-related events, states and processes in specific populations, including
the study of determinants influencing such processes, and the application of this knowledge
to control relevant health problems” (Porta, 2014, p. 95). Epidemiological data are available
from a number of different sources including governmental agencies, governmental health
agencies, non-governmental health agencies, and health care systems. table 2.1 provides
some examples of useful sources of epidemiological data.
taBle 2.1 example Sources of epidemiological Data
Source example Data
International
World Health organization World Health Statistics Report
(http://www.who.int/gho/publications/
world_health_statistics/en/)
Country Statistics
(http://www.who.int/gho/countries/en/)
National
Centers for Disease Control
and Prevention
National Center for Health
Statistics
National Health and Nutrition Examination Survey (NHANES)
(http://www.cdc.gov/nchs/nhanes.htm)
National Health Interview Survey (NHIS)
(http://www.cdc.gov/nchs/nhis.htm)
State
Centers for Disease Control
and Prevention
Behavioral Risk Factor Surveillance System (BRFSS)
(http://www.cdc.gov/brfss/about/index.htm)
Youth Risk Behavior Surveillance System (YRBSS)
http://www.cdc.gov/healthyyouth/data/yrbs/index.htm
Pennsylvania Department
of Health
Health Statistics
(http://www.portal.state.pa.us/portal/server.pt/community/
health_statistics/14136)
Local
Robert Wood Johnson
Foundation & University of
Wisconsin Population Health
Institute
County Health Rankings & Roadmaps
(http://www.countyhealthrankings.org/)

http://www.who.int/gho/publications/world_health_statistics/en/

http://www.who.int/gho/publications/world_health_statistics/en/

http://www.who.int/gho/countries/en/

http://www.cdc.gov/nchs/nhanes.htm

http://www.cdc.gov/nchs/nhis.htm

http://www.cdc.gov/brfss/about/index.htm

http://www.cdc.gov/healthyyouth/data/yrbs/index.htm

http://www.portal.state.pa.us/portal/server.pt/community/health_statistics/14136

http://www.portal.state.pa.us/portal/server.pt/community/health_statistics/14136

http://www.countyhealthrankings.org/

Chapter 2 Starting the Planning Process 23
Epidemiologic data gain additional significance when it can be shown that the described
health problem(s) is(are) the result of modifiable health behaviors and that spending money
to promote healthy lifestyles and prevent health problems makes good economic sense. Here
are a couple examples where modifiable health behaviors and health-related costs have been
connected. The first deals with smoking. Approximately 17.8% of U.S. adults 18 years of age
and older are cigarette smokers (CDC, 2015g). It has been estimated that the cost of ill effects
from smoking in the United States totals approximately $300 billion per year. Almost equal
amounts are spent on direct medical care ($170 billion) and productivity losses due to pre-
mature death and exposure to secondhand smoke ($156 billion) (CDC, 2015g). The second
example deals with diabetes. It has been estimated that annual costs associated with diabetes
are approximately $245 billion; $176 billion from direct medical costs and $69 billion indirect
costs related to disability, work loss, and premature death (CDC, 2014a). We know that not all
cases of diabetes are related to health behavior, but it is known for people with prediabetes,
lifestyle changes, including a 5%–7% weight loss and at least 150 minutes of physical activity
per week, can reduce the rate of onset of type 2 diabetes by 58% (CDC, 2012b). In addition,
we know people with diagnosed diabetes have medical expenditures that are about 2.3 times
higher than medical expenditures for people without diabetes (CDC, 2012b). When a ratio-
nale includes an economic component it is often reported based on a cost-benefit analysis
(CBA). A CBA of a health promotion program will yield the dollar benefit received from the
dollars invested in the program. A common way of reporting a CBA is through a metric called
return on investment (ROI). ROI “measures the costs of a program (i.e., the investment)
versus the financial return realized by that program” (Cavallo, 2006, p. 1) (see Box 2.3 for
formulas to calculate ROI). An example of ROI is a study that examined the economic impact
of an investment of $10 per person per year in a proven community-based program to in-
crease physical activity, improve nutrition, and prevent smoking and other tobacco use. The
results of the study showed that the nation could save billions of dollars annually and have an
ROI in one year of 0.96 to 1, 5.6 to 1 in 5 years, and 6.2 to 1 in 10–20 years (TFAH, 2009).
However, it should be noted that “proving” the economic impact of many health pro-
motion programs is not easy. There are a number of reasons for this including the multiple
2.3
Box Return on investment
In general, ROI compares the dollars invested in something to the benefits produced by
that investment:
ROI =
(benefits of investment – amount invested)
amount invested
In the case of an investment in a prevention program, ROI compares the savings
produced by the intervention, net cost of the program, to how much the program cost:
ROI =
net savings
cost of intervention
When ROI equals 0, the program pays for itself. When ROI is greater than 0, then the
program is producing savings that exceed the cost of the program.
Source: Copyright © 2009 by Trust for America’s Health. Reprinted with permission.
Fo
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24 Part 1 Planning a Health Promotion Program
causes of many health problems, the complex interventions needed to deal with them, and
the difficulty of carrying out rigorous research studies. Additionally, McGinnis and col-
leagues (2002) feel that part of the problem is that health promotion programs are held
to a different standard than medical treatment programs when cost-effectiveness is being
considered.
In a vexing example of double standards, public investments in health promotion seem to
require evidence that future savings in health and other social costs will offset the investments
in prevention. Medical treatments do not need to measure up to the standard; all that is
required here is evidence of safety and effectiveness. The cost-effectiveness challenge often is
made tougher by a sense that the benefits need to accrue directly and in short term to the payer
making investments. Neither of these two conditions applies in many interventions in health
promotion (p. 84).
A helpful tool for calculating the financial burden of chronic diseases has been the
Chronic Disease Cost Calculator Version 2 created by the Centers for Disease Control and
Prevention and RTI International (see the link for the Website in the Weblinks section
at the end of the chapter). For those planners interested in using economic impact and
cost-effectiveness of health promotion programs as part of a program rationale, we recom-
mend that the work of the following authors be reviewed: Centers for Disease Control and
Prevention (CDC, 2015f), Chapman (2012), Cohen, Neumann, and Milton (2008), Goetzel
and Ozminkowski (2008), Laine et al. (2014), McKenzie (1986), O’Donnell (2014), and
Miller & Hendrie (2008).
Other information and data that are useful in creating a rationale are those that show
how the potential outcomes of the proposed program align with what decision makers feel is
important. Planners can often get a hint of what decision makers value by reviewing the orga-
nization’s mission statement, annual report, and/or budget for health-related items. Planners
could also survey decision makers to determine what is important to them (Chapman, 1997).
table 2.2 provides a list of values or benefits that can be derived from health promotion pro-
grams, while table 2.3 provides a list of sources where information about values or benefits
could be found.
taBle 2.2 Values or Benefits from Health Promotion Programs
Value or Benefit for: types of Values or Benefits
Community Establishing good health as norm; improved quality of life; improve
the economic well-being of the community; provide model for
other communities
Employee/Individual Improved health status; reduction in health risks; improved health
behavior; improved job satisfaction; lower out-of-pocket costs for
health care; increased well-being, self-image, and self-esteem
Employer Increased worker morale; enhanced worker performance/
productivity; recruitment and retention tool; reduced absenteeism
and presenteeism; reduced disability days/claims, reduced health
care costs; enhanced corporate image
Sources: Adapted from ACS (2009); CDC (2014c); and Chapman (1997).

Chapter 2 Starting the Planning Process 25
A fourth source of information for a rationale is a comparison between the proposed
program and the health plan for the nation or a state. Comparing the health needs of the
priority population with those of other citizens of the state or of all Americans, as outlined in
the goals and objectives of the nation (USDHHS, 2015c), should enable planners to show the
compatibility between the goals of the proposed program and those of the nation’s health
plan (see Chapter 6 for a discussion of the Healthy People 2020 goals and objectives).
A fifth source of information and data is evidence that the proposed program will be ef-
fective and make a difference if implemented. By evidence we mean the body of data that
can be used to make decisions when planning a program. Such data can come from needs
assessments, knowledge about the causes of a health problem, research that has tested the
effectiveness of an intervention, and evaluations conducted on other health promotion
programs. When program planners systematically find, appraise, and use evidence as the
basis for decision making when planning a health promotion program, it is referred to as
evidence-based practice (Cottrell & McKenzie, 2011).
Various forms of evidence can be placed on a continuum anchored at one end by objec-
tive evidence (or science-based evidence) and subjective evidence at the other of the contin-
uum (Chambers & Kerner, 2007). Others (Howlett, Rogo, & Shelton, 2014) have organized
the various forms of evidence as a hierarchy within an evidence pyramid with the objective
evidence at the top of the pyramid and the more subjective evidence at the base of the
pyramid. Irrespective of format for aligning and presenting the various forms of evidence,
“[m]ore objective types of evidence include systematic reviews, whereas more subjective
data involve personal experience and observations as well as anecdotes” (Brownson, Diez
taBle 2.3 Selected Sources of information about Values or Benefits of Health
Promotion Programs
Source location of information
American Heart Association http://www.heart.org/HEARTORG/GettingHealthy
/WorkplaceWellness/Workplace-Wellness_UCM_460416
_SubHomePage.jsp
Centers for Disease Control and Prevention
National Center for Health Statistics http://www.cdc.gov/nchs/
Worklife http://www.cdc.gov/niosh/twh/default.html
Workplace Health Promotion http://www.cdc.gov/workplacehealthpromotion/
The Community Tool Box http://ctb.ku.edu/en
National Committee for Quality Assurance http://www.ncqa.org
National Business Group on Health https://www.businessgrouphealth.org/preventive
/businesscase/index.cfm
Prevention Institute http://www.preventioninstitute.org/
Robert Wood Johnson Foundation http://www.rwjf.org/en.html
Trust for America’s Health (TFAH) http://healthyamericans.org/reports/
U.S. Department of Health & Human Services
Office of Assistant Secretary for Planning &
Evaluation
http://aspe.hhs.gov
Wellness Council of America (WELCOA) http://www.welcoa.org/resources/

http://www.heart.org/HEARTORG/GettingHealthy/WorkplaceWellness/Workplace-Wellness_UCM_460416_SubHomePage.jsp

http://www.cdc.gov/nchs/

http://www.cdc.gov/niosh/twh/default.html

http://www.cdc.gov/workplacehealthpromotion/

http://ctb.ku.edu/en

Health Care Accreditation, Health Plan Accreditation Organization – NCQA

https://www.businessgrouphealth.org/preventive/businesscase/index.cfm

http://www.preventioninstitute.org/

http://www.rwjf.org/en.html

http://healthyamericans.org/reports/

http://aspe.hhs.gov

http://www.welcoa.org/resources/

26 Part 1 Planning a Health Promotion Program
Roux, & Swartz, 2014, p. 1). Because it is derived from a scientific process, objective evi-
dence is seen as a higher quality of evidence. Planners should strive to use the best evidence
possible but also understand that “evidence is usually imperfect” (Brownson, Baker, Leet,
Gillespie, & True, 2011, p. 6) and, as planners, they will often be faced with having to use
the best evidence available (Muir Gray, 1997). Over the years, the number of organizations/
agencies that have worked to identify evidence of various types of health-related programs
(i.e., health care, disease prevention, health promotion) has increased (see Box 2.4 for ex-
amples). A most useful source for those planning health promotion programs is the Guide
to Community Preventive Services, referred to simply as The Community Guide (CDC,
2015c). The Community Guide summarizes the findings from systematic reviews of public
health interventions covering a variety of topics. The systematic reviews are used to answer
several questions (CDC, 2015c, para. 1):
⦁⦁ “Which program and policy interventions have been proven effective?
⦁⦁ Are there effective interventions that are right for my community?
⦁⦁ What might effective interventions cost; what is the likely return on investment?”
The Community Guide was developed and is continually updated by the nonfederal Task
Force on Community Preventive Services. The Task Force, which is comprised of public
health experts who are appointed by the director of the CDC, is charged with reviewing and
assessing the quality of available evidence and developing appropriate recommendations.
Finally, when preparing a rationale to gain the support of decision makers, planners
should not overlook the most important resource of any community—the people who make
up the community. Promoting, maintaining, and in some cases restoring human health
should be at the core of any health promotion program. Whatever the setting, better health
of those in the priority population provides for a better quality of life. For those planners
who end up practicing in a worksite setting, the importance of protecting the health of em-
ployees (i.e., protecting human resources) should be noted in developing a rationale. “Labor
costs typically represent 60% to 70% of total annual operating costs for most organizations”
(Chapman, 2006, p. 10); thus people are a company’s single biggest asset. “Fit and healthy
people are more productive, are better able to meet extra ordinary demands and deal with
stress, are absent less, reflect better on the company or community as exemplars, and so
forth” (Chapman, 2006, p. 29).
Step 2: title the Rationale
Once planners have identified and are familiar with the sources of information and data that
can be used to sell program development, they are ready to begin the process of putting a ra-
tionale together. Thus, the next step is giving a title to the rationale. This can be quite simple
in nature, such as “A Rationale for (Title of Program): A Program to Enhance the Health of
(Name of Priority Population).” Immediately following the title should be a listing of who
contributed to the authorship of the rationale.
Step 3: Writing the Content of the Rationale
The first paragraph or two of the rationale should identify the health problem from a
“global perspective.” By global perspective we mean presenting the problem using informa-
tion and data at the most macro level (whether it be international, national, regional, state,

Chapter 2 Starting the Planning Process 27
2.4
Box
the Campbell Collaboration
Type of evidence: Produces systematic
reviews on the effects of social
interventions in crime and justice,
education, international development,
and social welfare.
Website: http://www
.campbellcollaboration.org/
Centre for Reviews and Dissemination;
the University of york
Type of evidence: Synthesized research
evidence on various topics including
health technology assessment, public
health, and child health.
Website: http://www.york.ac.uk/crd/
Cochrane
Type of evidence: Synthesized research
evidence on health and health care. Can
be searched using various terms including
health education and health promotion.
Website: http://www.cochrane.org/
Canadian task Force on preventive
Health Care
Type of evidence: Practice guidelines
that support primary care providers in
delivering preventive health care. Also,
has information for general public.
Website: http://www.canadiantaskforce.ca
Health Evidence, McMaster University,
Canada
Type of evidence: Effectiveness of public
health interventions in Canada.
Website: http://healthevidence.org
national Cancer institute
Document: Research-tested Intervention
Programs
Type of evidence: A searchable database
of cancer control interventions and
program materials that are designed to
provide program planners and public
Examples of Sources of Evidence
health practitioners easy and immediate
access to research-tested materials.
Website: http://rtips.cancer.gov/rtips
/index.do
Substance Abuse and Mental Health
Services
Document: National Registry of Evidence-
based Programs and Practices
Type of Evidence: Searchable online
registry of substance abuse and mental
health interventions.
Website: http://nrepp.samhsa.gov
task Force on Community preventive
Services
Document: Guide to Community
Preventive Services
Type of evidence: Programs and policies
to improve health and prevent disease in
communities.
Website: http://www.thecommunityguide
.org
U.S. preventive Services task Force
Document: The Guide to Clinical
Preventive Services
Type of evidence: Recommendations on
the use of screening, counseling, and
other preventive services that are typically
delivered in primary care settings.
Website: http://www.ahrq.gov
/professionals/clinicians-providers
/guidelines-recommendations/uspstf
/index.html
World Health organization
Document: Health Evidence Network (HEN)
Type of evidence: Summarized evidence
for public health, health care, and health
systems policymakers.
Website: http://www.euro
.who.int/en/data-and-evidence
/evidence-informed-policy-making
/health-evidence-network-hen
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http://www.campbellcollaboration.org/

http://www.york.ac.uk/crd/

http://www.cochrane.org/

Home

http://healthevidence.org

http://rtips.cancer.gov/rtips/index.do

http://nrepp.samhsa.gov

http://www.thecommunityguide.org

http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/uspstf/index.html

http://www.euro.who.int/en/data-and-evidence/evidence-informed-policy-making/health-evidence-network-hen

http://www.campbellcollaboration.org/

http://rtips.cancer.gov/rtips/index.do

http://www.thecommunityguide.org

http://www.euro.who.int/en/data-and-evidence/evidence-informed-policy-making/health-evidence-network-hen

http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/uspstf/index.html

28 Part 1 Planning a Health Promotion Program
or local) possible. In other words, begin the rationale by presenting the problem at the most
macro level for which supporting data are available. So, if there is international informa-
tion and data on the problem, say for example HIV/AIDS, begin describing the problem at
that level. If data are not available to present the problem at the international level, say for
example people without health insurance, move down to next level where the presentation
can be supported with data. If available, also include the economic costs of such a problem;
it will strengthen the rationale. “Much of the decision-making that occurs, for change to
take place in an organization is based on financial considerations, and any change within
an organization typically must be supported by a positive return on investment. Lacking
sound financial support or a firm understanding of the financial implications, a good idea
may not be realized in practice” (Gambatese, 2008, p. 153). Most health problems are also
present at other levels. Presenting the problem at these higher levels shows decision makers
that dealing with the health problem is consistent with the concerns of others.
Showing the relationship of the health problem to the “bigger problem” at the interna-
tional, national, and/or state levels is the next logical step in presenting the rationale. Thus,
the next portion of the rationale is to identify the health problem that is the focus of the
rationale. This declaration of the health problem is referred to as the problem statement or
statement of the problem. The problem statement should begin with a concise explanation of
the issue that needs to be addressed (WKKF, 2004). The statement should also include why it
is a problem and why it should be dealt with (see Box 2.5). If available, the statement should
also include supporting data for the problem. Such data may come from a needs assessment
if it has already been completed or from related literature.
2.5
Box Examples of problem Statements
For a local-level program
The number of children entering kindergarten who have not received two doses of the
measles-mumps-rubella (MMR) vaccine in Mitchell County continues to increase. In
the 2011–12 school year, 95% of the children who entered kindergarten had received
two doses, while only 91% were immunized properly in 2015–16. Because the number
of cases of MMR does not seem too high to parents/guardians, many do not feel it is
necessary to subject their children to immunizations. Infectious diseases remain a major
cause of illness, disability, and mortality. “Vaccines are among the most cost-effective
clinical preventive services and are a core component of any preventive services package.
Childhood immunization programs provide a very high return on investment” (USDHHS,
2015c, para. 6).
For a state-level program
Overweight and obesity are critical health threats facing the state of ABC. Between 2012
and 2015, the percentage of overweight adults in ABC increased from 34% to 35%, while
the percentage of obese adults increased from 30% to 32%. Overweight and obesity
are caused by an imbalance in the calories consumed vs. calories burned ratio. Both
overweight and obesity increase the risks for heart disease, stroke, diabetes, and cancer.
The annual costs (direct and indirect) of these diseases to the state have been estimated
at $25 billion. There is good evidence that shows both the physical and financial costs of
overweight and obesity are preventable.
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Chapter 2 Starting the Planning Process 29
In presenting the problem statement you may find it useful to use the technique of
social math. Social math has been defined as “the practice of translating statistics and
other data so they become interesting to the journalist, and meaningful to the audience”
(Dorfman, Woodruff, Herbert, & Ervice, 2004, p. 112). In other words, data, especially large
numbers, are presented in such a way that makes them easier to grasp by putting them in
a context that gives instant meaning. “It is critical to select a social math fact that is 100
percent accurate, visual if possible, dramatic, and appropriate for the target audience”
(NCIPC, 2008, 17). For example, $2.9 trillion was spent on health in 2013 in the United
States (CMS, 2015b); 2.9 trillion is a large number and hard “to put our heads around.”
But equating that number with spending $9,255 for every person in the United States
(CMS, 2015b) that year makes the number more comprehensible. Or, we could present the
$2.9 trillion in social math terms by saying if every dollar equaled one second, then $2.9
trillion would equal 92,211 years! (See Box 2.6 for other examples.)
2.6
Box Examples of Social Math
⦁⦁ Break the numbers down by time.
If you know the amount over a year, what does that look like per hour? Per minute?
For example, the average annual salary of a childcare worker nationally is $15,430,
roughly $7.42 per hour. While many people understand that an annual salary of
$15,430 is low, breaking the figure down by the hour reinforces that point—and
makes the need for some kind of intervention even more clear.
⦁⦁ Break down the numbers by place.
Comparing a statistic with a well-known place can give people a sense of the statistic’s
magnitude. For instance, approximately 250,000 children are on waiting lists for
childcare subsidies in California. That’s enough children to fill almost every seat in
every Major League ballpark in California. Such a comparison helps us visualize the
scope of the problem and makes a solution all the more imperative.
⦁⦁ Provide comparisons with familiar things.
Providing a comparison to something that is familiar can have great impact. For
example, “While Head Start is a successful, celebrated educational program, it is so
underfunded that it serves only about three-fifths of eligible children. Applying that
proportion to social security would mean that almost a million currently eligible seniors
wouldn’t receive benefits.”
⦁⦁ Provide ironic comparisons.
For example, the average annual cost of full-time, licensed, center-based care for
a child under age 2 in California is twice the tuition at the University of California
at Berkeley. What’s ironic here is how out of balance our public conversation is.
Parents and the public focus so much on the cost of college when earlier education is
dramatically more expensive.
⦁⦁ Localize the numbers.
Make comparisons that will resonate with community members. For example, saying,
“Center-based childcare for an infant costs $11,450 per year in Seattle, Washington,”
is one thing. Saying, “In Seattle, Washington, a father making minimum wage would
have to spend 79 percent of his income per year to place his baby in a licensed care
center,” is much more powerful because it illustrates why it is nearly impossible.
Source: National Center for Injury Prevention and Control (2008; revised 2010). Adding Power to Our Voices: A Framing Guide for Communicating About
Injury. Atlanta, GA: Author. Retrieved May 14, 2015, from http://www.cdc.gov/injury/pdfs/cdcframingguide-a
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30 Part 1 Planning a Health Promotion Program
At this point in the rationale, propose a solution to the problem. The solution should
include the name and purpose of the proposed health promotion program, and a general
overview of what the program may include. Since the writing of a program rationale often
precedes much of the formal planning process, the general overview of the program is often
based upon the “best guess” of those creating the rationale. For example, if the purpose of a
program is to improve the immunization rate of children in the community, a “best guess”
of the eventual program might include interventions to increase awareness and knowledge
about immunizations, and the reduction of the barriers that limit access to receiving immu-
nizations. Following such an overview, include statements indicating what can be gained
from the program. Do your best to align the potential values and benefits of the program
with what is important to the decision makers.
Next, state why this program will be successful. This is the place to use the results of
evidence-based practice to support the rationale. It can also be helpful to point out the similarity
of the priority population to others with which similar programs have been successful. And
finally, using the argument that the “timing is right” for the program can also be useful. By
this we mean that there is no better time than now to work to solve the problem facing the
priority population.
Step 4: listing the References Used to Create the Rationale
The final step in creating a rationale is to include a list of the references used in preparing
the rationale. Having a reference list shows decision makers that you studied the available
information before presenting your idea. (See Box 2.7 for an example of a program rationale.)
2.7
Box Example program Rationale
A Rationale for a Comprehensive tobacco Control program in philadelphia
County, pennsylvania
The World Health Organization (WHO) has noted that tobacco “is one of the biggest
public health threats the world has ever faced, killing nearly six million people a year.
More than five million of those deaths are the result of direct tobacco use while more
than 600,000 are the result of non-smokers being exposed to second-hand smoke.
Approximately one person dies every six seconds due to tobacco, accounting for one in
10 adult deaths” (WHO, 2014, para. 4). In addition, it has been estimated that up to 50%
of current users will die of a tobacco-related disease (WHO, 2014). To further quantify
the burden of tobacco on the people of the world is to note that six million deaths is the
equivalent of losing the entire population of the state of Maryland each year.
The impact of tobacco use and secondhand smoke exposure has also been a problem
in the United States. In 2013, the percentage of adult (> 18 years of age) smokers in
United States was 17.8%, which is the lowest it has ever been, but it still totals 42.1
million people. Tobacco is the single most preventable cause of disease, disability,
and death in the United States (CDC, 2014), and accounts for approximately 480,000
deaths per year. It has been estimated that 41,000 of those deaths are of non-smokers
exposed to secondhand smoke (CDC, 2015b). In total, tobacco use and secondhand
smoke exposure are responsible for 20% of all deaths in the United States each year. In
addition, more than 16 million Americans are living with a disease caused by smoking
(CDC, 2015b). That means for every person who dies because of smoking, at least
A
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Chapter 2 Starting the Planning Process 31
2.7
Box
continued
30 people live with a serious smoking-related illness. Smoking causes cancer, heart
disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease
(COPD), which includes emphysema and chronic bronchitis, and it also increases risk
for tuberculosis, certain eye diseases, and problems of the immune system, including
rheumatoid arthritis (CDC, 2015d).
In addition to the costly physical burden of tobacco use and secondhand smoke
exposure in the United States, there is also a significant economic cost. The total
financial burden of tobacco to the United States is more than $300 billion per year.
This includes $170 billion in direct medical costs and more than $156 billion in lost
productivity due to premature death and exposure to secondhand smoke (CDC, 2015c).
Tobacco use and secondhand smoke exposure are also concerns for the residents
of Pennsylvania. While the current national percentage of adult cigarette smokers is
17.8%, the current percentage of smokers in Pennsylvania is 21.0% (CI 19.9-22.0%)
(CDC, 2015a). In addition, just over 4% of those residing in Pennsylvania use chewing
tobacco, snuff, or snus (CDC, 2015a). Locally, the burden of tobacco use is even greater.
Philadelphia County Pennsylvania, which is conterminous with the City of Philadelphia,
is home to more than 1.5 million people. The current percentage of adult smokers in
Philadelphia County is 23% (CI 22-25%) (University of Wisconsin [UW], 2015), which
is clearly above both the state and national averages. In fact, Philadelphia has the
highest rate of adult smoking among the 10 largest U.S. cities (CDC, 2013). Further,
Philadelphia County is ranked last out of the 67 counties in Pennsylvania in both
health outcomes and health factors (UW, 2015). The three leading causes of death in
Philadelphia County are heart diseases, cancer, and stroke. All three of these causes
have a common risk factor—smoking. Philadelphia County has implemented several
interventions to reduce smoking including a public education program to encourage
adults to quit, a clean indoor air ordinance, an ordinance to eliminate smoking at the
city-owned outdoor recreational facilities, and compliance checks to ensure retailers
are properly checking for identification before selling tobacco products (CDC, 2013).
Although each of these efforts can contribute to the reduction in smoking, more needs
to be done.
To reduce the prevalence of smoking in a community the CDC has recommended a
comprehensive approach, which it has outlined in a document titled Best Practices for
Comprehensive Tobacco Control Programs–2014 (CDC, 2014). The program includes five
components: 1) state and community interventions, 2) mass-reach health communication
interventions, 3) cessation interventions, 4) surveillance and evaluation, and 5)
infrastructure administration and management.
The goals of such a program are to:
⦁⦁ “Prevent initiation among youth and young adults.
⦁⦁ Promote quitting among adults and youth.
⦁⦁ Eliminate exposure to secondhand smoke.
⦁⦁ Identify and eliminate tobacco-related disparities among population groups”
(CDC, 2014, p. 9).
This approach is not without its merits, it is recommended based on solid evidence.
“The Community Preventive Services Task Force recommends comprehensive tobacco
control programs based on strong evidence of effectiveness in reducing tobacco use
and secondhand smoke exposure. Evidence indicates these programs reduce the
prevalence of tobacco use among adults and young people, reduce tobacco product
consumption, increase quitting, and contribute to reductions in tobacco-related diseases

32 Part 1 Planning a Health Promotion Program
2.7
Box
and deaths. Economic evidence indicates that comprehensive tobacco control programs
are cost-effective, and savings from averted healthcare costs exceed intervention costs”
(CPSTF, 2014, para. 1).
After reviewing the data, it is clear that there is a significant smoking problem
in Philadelphia County Pennsylvania. In order to deal with this problem, it is
recommended that the Coalition for a Smokefree Philadelphia County build a
comprehensive tobacco control program based on Best Practices for Comprehensive
Tobacco Control Programs– 2014 but adapt it to fit the population of Philadelphia
County. The National Association of County and City Health Officials has created the
“Guidelines for Comprehensive Local Tobacco Control Programs” (CDC, 2014) to show
how the best practice guidelines can be adapted to a local level. It is also recommended
that the Coalition begin its work by reviewing the existing tobacco prevention programs
in the county. Those current activities that are in line with best practices should be
keep, and those that are not should either be modified to be in line with the best
practices or be dropped.
A comprehensive tobacco program has great potential for success in Philadelphia
County for several reasons. First, it would be an evidence-based program with solid
science to back it up. Second, similar programs in other large cities in the United States
have been successful (CDC, 2014). And third, the program will be well planned and
tailored to the residents of Philadelphia County. There is no better time than now to
invest in the health of the people of Philadelphia County Pennsylvania!
References
Centers for Disease Control and Prevention. (2015a). Behavioral risk factor surveillance system:
Prevalence and trends data, Pennsylvania – 2013. Retrieved May 16, 2015 from http://apps.nccd
.cdc.gov/brfss/page.asp?cat=TU&yr=2013&state=PA#TU
Centers for Disease Control and Prevention. (2014). Best practices for comprehensive tobacco control
programs–2014. Atlanta, GA: U.S. Department of Health, CDC, National Center for Chronic Disease
Prevention and Health Promotion, Office of Smoking and Health. Retrieved May 16, 2015 from
http://www.cdc.gov/tobacco/stateandcommunity/best_practices/pdfs/2014/comprehensive
Centers for Disease Control and Prevention. (2013). Community profile: Philadelphia,
Penn-sylvania. Retrieved May 16, 2015 from http://www.cdc.gov/nccdphp/dch/programs
/CommunitiesPuttingPreventiontoWork/communities/profiles/both-pa_philadelphia.htm
Centers for Disease Control and Prevention. (2015b). Current cigarette smoking among adults in
the United States. Retrieved May 16, 2015 from http://www.cdc.gov/tobacco/data_statistics
/fact_sheets/adult_data/cig_smoking/
Centers for Disease Control and Prevention. (2015c). Economic facts about U.S. tobacco production
and use. tobacco use: Retrieved May 16, 2015 from http://www.cdc.gov/tobacco/data_statistics
/fact_sheets/economics/econ_facts/index.htm#costs
Centers for Disease Control and Prevention. (2015d). Smoking and tobacco use: Fast facts. Retrieved
May 16, 2015 from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm
Community Preventive Services Task Force (CPSTF). (2014). Reducing tobacco use and secondhand
smoke exposure: Comprehensive tobacco control programs. Retrieved May 16, 2015 from http:
//www.thecommunityguide.org/tobacco/comprehensive.html
University of Wisconsin Population Health Institute (2015). County health rankings & roadmaps.
Retrieved May 16, 2015 from http://www.countyhealthrankings.org/
World Health Organization. (2014). Tobacco. Retrieved May 16, 2015 from http://www.who.int
/mediacentre/factsheets/fs339/en/
World Health Organization. (2015). WHO global report on trends in prevalence of tobacco smoking 2015.
Retrieved May 16, 2015 from http://apps.who.int/iris/bitstream/10665/156262/1/9789241564922
_eng ?ua=1
continued

http://apps.nccd

http://www.cdc.gov/tobacco/stateandcommunity/best_practices/pdfs/2014/comprehensive

http://www.cdc.gov/nccdphp/dch/programs/CommunitiesPuttingPreventiontoWork/communities/profiles/both-pa_philadelphia.htm

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm#costs

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm

http://www.thecommunityguide.org/tobacco/comprehensive.html

http://www.countyhealthrankings.org/

http://www.who.int/mediacentre/factsheets/fs339/en/

http://apps.who.int/iris/bitstream/10665/156262/1/9789241564922_eng ?ua=1

http://www.cdc.gov/nccdphp/dch/programs/CommunitiesPuttingPreventiontoWork/communities/profiles/both-pa_philadelphia.htm

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm#costs

http://www.who.int/mediacentre/factsheets/fs339/en/

http://apps.who.int/iris/bitstream/10665/156262/1/9789241564922_eng ?ua=1

Chapter 2 Starting the Planning Process 33
Planning Committee
The number of people involved in the planning process is determined by the resources and
circumstances of a particular situation. “One very helpful method to develop a clearer and
more comprehensive planning approach is to establish a committee” (Gilmore, 2012, p. 35).
Identifying individuals who would be willing to serve as members of the planning com-
mittee (sometimes referred to as a steering committee or advisory board or planning
team) becomes one of the planner’s first tasks. Because an effective planning committee is
usually composed of interested and well-respected individuals, it is important to establish it
carefully (Chapman, 2009).
When composing a planning committee it is also a good time to consider the concept of
partnering to meet the eventual goals of the program that will be planned. Partnering can
be defined as the association of two more entities (i.e., individuals, groups, agencies, organi-
zations) working together on a project of common interest. Such associations usually means
sharing of resources and tasks to be completed. There are a number of reasons to partner and
include things such as: 1) meeting the needs of a priority population which could not be
met by the capacities of an individual partner, 2) sharing of financial and other resources, 3)
solving a problem or achieving a goal that is a priority to several partners, 4) bringing more
stakeholders to the “table,” 5) bringing more credibility to the program, 6) working with oth-
ers that have the same values (Picarella, 2015), 7) seeing and solving a problem from multiple
perspectives and thus creating different effects (Schiavo 2014), and 8) creating a greater re-
sponse to a need because there is strength in numbers.
In looking for partners (sometimes referred to as collaborators) planners should consider
these questions: 1) Who is also interested in meeting the needs of the priority population?
2) Who also sees the unmet need of a priority population as a problem? 3) Who has unused
resources that could help solve a problem? and 4) Who would benefit from being your part-
ner? The Prevention Institute has created an interactive framework and tool for analyzing
collaborative efforts. The framework/tool, called the Collaborator Multiplier, is “based on
the understanding that sectors often have different understandings of issues and divergent
reasons for engaging in the same effort” (Prevention Institute, 2011, para. 2) (see the link for
the Website in the Weblinks section at the end of the chapter). Here are some examples of
groups who could become partners: two non-governmental health agencies who are both
interested in seeing the reduction in smoking rates, a local service organization (i.e., Lions
Club, Kiwanis) and a school-based clinic to improve student health, an employer and a
health insurance carrier to improve the quality of life for employees, and a local health de-
partment and pro-environmental group working to improve the air quality in a community.
After consideration is given to forming partnerships, thought needs to be given to the
size of the planning committee. The number of individuals on a planning committee can
differ depending on the setting for the program and the size of the priority population. For
example, the size of a planning committee for an obesity program in a community of 50,000
people would probably be larger than that of a committee planning a similar program for a
business with 50 employees. There is no ideal size for a planning committee, but the follow-
ing 10 guidelines, which have been presented earlier (McKenzie, 1988) and are given here in
a modified form with updates, should be helpful in setting up a committee.

34 Part 1 Planning a Health Promotion Program
1. The committee should be composed of individuals who represent a variety of
subgroups within the priority population. To the extent possible, the committee
should have representation from all segments of the priority population (e.g.,
administrators/students/teachers, age groups, health behavior participants/
nonparticipants, labor/management, race/ethnic groups, different genders,
socioeconomic groups, union/nonunion members). The greater the number of
individuals who are represented by committee members, the greater the chance of
the priority population developing a feeling of program ownership. With program
ownership there will be better planned programs, greater support for the programs,
and people who will be willing to help sell the program to others because they feel it
is theirs (Strycker et al., 1997).
2. If the program that is being planned deals with a specific health risk or problem, then it
would be important that someone with that health risk (e.g., smoker) or problem (e.g.,
diabetes) be included on the planning committee (Bartholomew, Parcel, Kok, Gottlieb &
Fernández, 2011).
3. The committee should include willing individuals who are interested in seeing the
program succeed. Select a combination of doers and influencers. Doers are people
who will be willing to “roll up their sleeves” and do the physical work needed to see
that the program is planned and implemented properly. Influencers are those who
with a single phone call, email, or signature on a form will enlist other people to
participate or will help provide the resources to facilitate the program. Both doers
and influencers are important to the planning process.
4. The committee should include an individual who has a key role within the organization
sponsoring the program—someone whose support would be most important to ensure
a successful program and institutionalization.
5. The committee should include representatives of other stakeholders (any person
or organization with a vested interest in a program) not represented in the priority
population. For example, if health care providers are needed to implement a health
promotion program they need to be represented on the planning committee.
6. The committee membership should be reevaluated regularly to ensure that the
composition lends itself to fulfilling program goals and objectives.
7. If the planning committee will be in place for a long period of time, new individuals
should be added periodically to generate new ideas and enthusiasm. It may be helpful
to set a term limits for committee members. If terms of office are used, it is advisable
to stagger the length of terms so that there is always a combination of new and
experienced members on the committee.
8. Be aware of the “politics” that are always present in an organization or priority
population. There are always some people who bring their own agendas to
committee work.
9. Make sure the committee is large enough to accomplish the work, but small enough
to be able to make decisions and reach consensus. If necessary, subcommittees can be
formed to handle specific tasks.
10. In some situations there might be a need for multiple layers of planning committees.
If the priority population is highly dispersed geographically and/or broken into
decentralized subgroups (e.g., various offices of the same corporation, or several

Chapter 2 Starting the Planning Process 35
different local groups within the same state, or different buildings within a school
corporation), these various subgroups may need their own local planning committee
that operates with some latitude but maintains and complements the core planning
committee as the base of the program (Chapman, 2009).
The actual means by which the committee members are chosen varies according to the
setting. Five commonly used techniques are:
1. Asking for volunteers by word of mouth, a newsletter, a needs assessment, or some
other widely distributed publication
2. Holding an election, either throughout the community or by subdivisions of the
community
3. Inviting/recruiting people to serve
4. Having members formally appointed by a governing group or individual
5. Having an application process then selecting those with the most desirable characteristics
Once the planning committee has been formed, someone must be designated to lead it.
This is an important step (Strycker et al., 1997). The leader (chairperson) should be interested
and knowledgeable about health promotion programs, and be organized, enthusiastic, and
creative (McKenzie, 1988). One might think that most planners, especially health education
specialists, would be perfect for the committee chairperson’s job. However, sometimes it is
preferable to have someone other than the program planners serve in the leadership capacity.
For one thing, it helps to spread out the workload of the committee. Planners who are not good
at delegating responsibility may end up with a lot of extra work when they serve as the lead-
ers. Second, having someone else serve as the leader allows the planners to remain objective
about the program. And third, the planning committee can serve in an advisory capacity to
the planners, if this is considered desirable. Figure 2.2 illustrates the composition of a balanced
planning committee.
Once the planning committee has been organized and a leader is selected, the com-
mittee needs to be well organized and well run to be effective. The committee should
meet regularly, have a formal agenda for each meeting, and keep minutes of the meet-
ings (Hunnicutt, 2007). Further, the committee meetings should be efficient, not long
and boring (Johnson & Breckon, 2007). In other words, meetings should be productive
and represent a good use of the committee members’ time. In addition, it is important for
the committee to communicate frequently both with the decision makers and those in
the priority population so that all can be kept informed. By communicating regularly, the
committee has the unique opportunity to educate and inform others about health and the
specific priorities of the program (Hunnicutt, 2007).
Representatives
of all segments of
priority population
Representative
of sponsoring
agency
Good
leadership
Doers Influencers+ + + +
Other
stakeholders
+
Solid
committee
=
⦁▲ Figure 2.2 Makeup of a Solid Planning/Steering Committee

36 Part 1 Planning a Health Promotion Program
Parameters for Planning
Once the support of the decision makers has been gained and a planning committee formed,
the committee members must identify the planning parameters within which they will
work. There are several questions to which committee members should have answers before
they become too deeply involved in the planning process. In an earlier work (McKenzie,
1988), several such questions were presented, using the example of school-site health pro-
motion programs. The questions are modified for presentation here. It should be noted,
however, that not all of the questions would be appropriate for every program because of the
different circumstances of each setting and the answers to some of the questions may have
already been obtained during pre-planning.
1. What is the decision makers’ philosophical perspective on health promotion
programs? What are the values and benefits of the programs to the decision
makers (Chapman, 1997)? Do they see the programs as something important or
as “extras”?
2. What type of commitment are decision makers willing to make to the program?
Are they interested in the program becoming institutionalized? That is, are
they interested in seeing that the “program becomes imbedded within the host
organization, so that the program becomes sustained and durable” (Goodman et al.,
1993, p. 163)? Or are they more interested in providing a one-time or pilot program?
(Note: Goodman and colleagues [1993] have developed a scale for measuring
institutionalization.)
3. What type of financial support are decision makers willing to provide? Does it include
personnel for leadership and clerical duties? Released/assigned time for managing the
program and participation? Space? Equipment? Materials?
4. Are decision makers willing to consider changing the organizational culture so
that there is a culture of health (Terry, 2012)? That is, are decision makers interested
in establishing a health supporting culture (Golaszewski, Allen, & Edington,
2008) that is based on health-related values, beliefs, and practices? Among other
things, such a culture might include health-supporting policies, services, and
facilities. For example, are they interested in “well” days instead of sick days?
Are they as interested in presenteeism—that is, showing up for work even if one
is too ill, stressed, or distracted to be productive—as much as they are interested
in absenteeism? Would they like to create employee nonsmoking and safety belt
policies? Change vending machine selections to more nutritious foods? Set aside
an employee room for meditation? Develop a health promotion page on the
organization’s Website?
5. Will all individuals in the priority population have an opportunity to take advantage
of the program, or will it be available to only certain subgroups?
6. What type of committee will the planning committee be? Will it be a permanent or a
temporary (ad hoc) committee (Hitt, Black, & Porter, 2012)? A permanent committee
would indicate that decision makers want the planning committee to be a part of the
ongoing structure of the organization.
7. What is the authority of the planning committee? Will it be an advisory group or
a programmatic decision-making group? What will the chain of command be for
program approval?

Chapter 2 Starting the Planning Process 37
After the planning parameters have been defined, the planning committee should under-
stand how the decision makers view the program, and should know what type and number
of resources and amount of support to expect. Identifying the parameters early will save the
planning committee a great deal of effort and energy throughout the planning process.
Summary
Creating a program rationale to gain the support of decision makers is an important initial
step in program planning. Planners should take great care in developing a rationale for
“selling” the program idea to these important people. The rationale should show how the
benefits of the program align with the values of the decision makers, address the potential
return on investment, and be backed by the best evidence available. A program rationale can
be written using the following four steps: (1) Identify appropriate background information,
(2) title the rationale, (3) write the content of the rationale, and (4) list the references used to
create the rationale. A planning committee can be most useful in helping with some of the
planning activities and in helping to sell the program to the priority population. When the
planning committee is being formed consider potential collaborating partners. Planning
committee members should include program stakeholders including interested individuals,
doers and influencers, and others who are representative of the priority population. If the
planning committee is to be effective, it will need to work efficiently and to know the plan-
ning parameters set for the program by the decision makers.
Review Questions
1. What is the reason for creating a program rationale?
2. Why is the support of decision makers important in planning a program?
3. What kinds of reasons should be included in a rationale for planning and
implementing a health promotion program?
4. How important is selling the idea of a program to decision makers?
5. What items should be addressed when creating a program rationale?
6. What is a problem statement? What does it include?
7. What is social math? Give an example of how it could be used in a program rationale.
8. Who would make good planning partners?
9. Who should be selected as the members of a planning committee?
10. What are planning parameters? Give a few examples.
11. Why is it important to know the planning parameters at the beginning of the
planning process?
Activities
1. Write a two-page rationale that sells a program you are planning to decision makers,
using the guidelines presented in this chapter.

38 Part 1 Planning a Health Promotion Program
2. Write a two-page rationale for beginning an exercise program for a company with 200
employees. A needs assessment of this priority population indicates that the number
one cause of lost work time in this cohort is back problems and the number one cause of
premature death is heart disease.
3. Select a disease (e.g., diabetes, cancer, heart disease) or a health behavior (e.g., physical
inactivity, smoking) and write a paragraph describing the health problem using social math.
4. Visit the Websites of the Community Preventive Services Task Force (CPSTF) and U.S.
Preventive Services Task Force (USPSTF)—see Box 2.4 for URLs of the Websites. At the
two sites, find out what the recommendations are for clinical skin cancer screenings and
educational programs for skin cancer. Summarize your findings in one to two paragraphs.
Based on the recommendations, write another one to two paragraphs describing what
advice you would give with regard to future health promotion programming to a
community coalition that is trying to reduce the number of cases of skin cancer in its
community.
5. For a program you are planning, write a two-page description of the individuals (by
position/job title, not name) who will be asked to serve on the planning committee, and
provide a rationale for asking each to serve. Also, list any other agencies/organization
who you believe would make good partners.
6. Provide a list (by position/job title, not name) and a rationale for each of the 10
individuals you would ask to serve on a community-wide safety belt program. Use the
town or city in which your college/university is located as the community.
7. Read the example rationale presented in Box 2.7 and then critique it using the guidelines
presented in this chapter. Critique by describing the following: (a) the strengths of the
rationale, (b) the weaknesses, and (c) how you would change the rationale to make it
stronger. Be critical! Closely examine the content, reasoning, and references.
Weblinks
1. http://www.thecommunityguide.org
Guide to Community Preventative Services
This Webpage includes evidence-based recommendations for programs and policies to
promote population-based health from the Community Preventive Services Task Force
(CPSTF).
2. https://new.wellsteps.com/
WellSteps
This is the home page for WellSteps, a company that helps other companies create
worksite wellness programs. At the site you will find a number of different resources and
tools that can assist you as you begin the planning process. One tool found at this site is
the return on investment (ROI) calculator for health care costs [https://www.wellsteps
.com/roi/resources_tools_roi_cal_health.php] that can help you determine if a health
promotion for a company would make good economic sense.
3. http://www.countyhealthrankings.org
County Health Rankings
At this Website you will find a set of reports that rank the overall health of every county
in the United States. If you are planning county-wide programs you will find this to be a

http://www.thecommunityguide.org

https://new.wellsteps.com/

https://www.wellsteps.com/roi/resources_tools_roi_cal_health.php

https://www.wellsteps.com/roi/resources_tools_roi_cal_health.php

http://www.countyhealthrankings.org

Chapter 2 Starting the Planning Process 39
valuable resource when creating rationales. The County Health Rankings are a part of the
a collaboration between the Robert Wood Johnson Foundation and the University of
Wisconsin Population Health Institute.
4. http://www.astho.org
Association of State and Territorial Health Officials (ASTHO)
ASTHO is the national nonprofit organization representing the state and territorial public
health agencies of the United States, the U.S. Territories, and the District of Columbia.
This Website has links to all the state and territorial health departments. If you are
planning a program for the community setting, this site contains a lot of information
that could help you develop a rationale for your program.
5. http://www.preventioninstitute.org/index.php
Prevention Institute
This Website is the home page of the Prevention Institute, a California-based
organization that works from the approach of what can be done before people become
ill or injured.
6. http://www.cdc.gov/chronicdisease/calculator/index.html
Chronic Disease Cost Calculator, Version 2
This Webpage presents background information and download links to the user guide
and Chronic Disease Cost Calculator, Version 2.

http://www.astho.org

http://www.preventioninstitute.org/index.php

http://www.cdc.gov/chronicdisease/calculator/index.html

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41
A key role, if not the central role, of the health education specialist is planning,
implementing, and evaluating programs. Box 3.1 identifies the responsibilities and com-
petencies for health education specialists that pertain to the material presented in this
chapter. Good health promotion programs are not created by chance; they are the product
of coordinated effort and are usually based on a systematic planning model or approach.
Planning models, which are visual representations and descriptions of steps or phases in the
planning process are the means by which structure and organization are given to the suc-
cessful development and delivery of health promotion programs. Models provide planners
with direction and a framework from which to build interventions that can improve the
health of individuals and communities.
Through the years, various planning models have been developed and presented for
health promotion with varying degrees of acceptance and use. Although these models
share common elements, they often label and describe these elements differently, giving
the impression that something unique and meaningful has been offered. However, when
new models emerge and appear novel, they are usually quite similar to the existing models.
For this reason, we use what we call the Generalized Model to teach basic principles of plan-
ning and evaluation emphasized in most planning models. With this as a backdrop, it is
3
Chapter Program Planning Models
in Health Promotion
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁⦁ Explain the value of using a model in planning
a program.
⦁⦁ Explain the value of the Generalized Model in
particular.
⦁⦁ Identify key models in planning health
promotion programs and briefly describe each.
⦁⦁ Identify the basic components of the planning
models presented and how they relate to the
Generalized Model.
⦁⦁ Apply a model to a program you are planning.
Key Terms
CHANGE tool
community context
ecological framework
enabling factors
evidence-based
planning
framework for
public health
formative research
Generalized Model
Healthy Communities
Model
Intervention Mapping
Model
MAP-IT Model
MAPP Model
population-based
approach
PRECEDE-PROCEED
Model
predisposing factors
reinforcing factors
SMART Model
three Fs of program
planning

42 Part 1 Planning a Health Promotion Program
important to note that the Generalized Model is not a new or unique model either but rather
a simple composite of what is represented in most, if not all other models. It is presented here
as both a teaching model and framework for professional practice.
As illustrated in Figure 3.1, the Generalized Model consists of five basic phases or steps:
(1) assessing needs; (2) setting goals and objectives; (3) developing interventions; (4) imple-
menting interventions; and (5) evaluating results. In addition, pre-planning is a quasi-phase
in the model but is not included formally since it involves actions that occur before plan-
ning technically begins. The first phase in the Generalized Model, assessing needs, is the
process of collecting and analyzing data to determine the health needs of a population and
usually includes priority setting and the identification of a priority population. Setting goals
and objectives identifies what will be accomplished while interventions or programs are the
means by which the goals and objectives will be achieved (i.e., the how). Implementation is
the process of putting interventions into action and evaluation focuses on both improving
P
r
e
–
p
l
a
n
n
i
n
g
Assessing
needs
Setting goals
and objectives
Developing
interventions
Implementing
interventions
Evaluating
results
Collecting and analyzing data to determine
the health needs of a population; setting
priorities; and selecting a priority population
Improving quality and
determining effectiveness
Putting interventions into action
How goals and objectives
will be achieved
What will be accomplished
⦁▲ Figure 3.1 The Generalized Model
3.1
Box Responsibilities and Competencies for Health Education Specialists
This chapter covers planning models as well as other considerations and criteria
necessary to develop a planning sequence from start to finish. Responsibilities and
competencies related to the credentialing of health education specialists in this chapter
include the following:
Area II: Plan Health Education/Promotion
Competency 2.1: Involve priority populations, partners, and other stakeholders in
the planning process
Competency 2.4: Develop a plan for the delivery of health education/promotion
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc.
(NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc.
(NCHEC) and the Society for Public Health Education (SOPHE).

Chapter 3 Program Planning Models in Health Promotion 43
the quality of interventions (formative evaluation) as well as determining their effective-
ness (summative evaluation). Collectively, these phases define planning and evaluation at
its core. To illustrate how planning models in general are aligned with the phases outlined
in the Generalized Model, we briefly describe seven prominent models used in health pro-
motion settings. As you read the following descriptions, also note the many similarities
these models have in common.
Evidence-Based Planning Framework for Public Health
The ultimate goal of any planning effort is to improve health outcomes. To help ensure
that health outcomes are improved, it is important to use evidence-based (i.e. effective or
proven) approaches in all phases of planning. Ross Brownson, one of the premier authori-
ties in evidence-based public health, and by association, health promotion, has written
extensively on evidence-based outcomes (Brownson, Baker, Leet, Gillespie, & True, 2011;
Brownson, Fielding, & Maylahn, 2009). Brownson and associates at the Prevention Research
Center (PRC) at Washington University in St. Louis have developed a set of seven skills
that collectively serve as an evidence-based planning framework for public health
(Washington University Prevention Research Center, 2015). This framework, while not devel-
oped as a planning model per se, is in fact, very similar to most planning models, including
the Generalized Model. Box  3.2 displays the seven skills or phases of this framework.
Phases 1–2, community assessment and quantifying the issue, essentially represent a needs
assessment common to most planning models. In this framework, community assessment
requires planners to understand the community context, or the characteristics and cir-
cumstances that define the community, and also understand the health concerns of com-
munity members and how to implement programs most effectively to them. Most often, this
requires collecting new data, including a process defined in the framework as community
audits (i.e. documenting observations about the community). The community assessment
also involves organizing and examining existing data (e.g. mortality, morbidity, risk factor
data, etc.). Quantifying the issue (Phase 2), closely related to Phase 1, is the process of using
descriptive epidemiology (i.e., occurrence and distribution of disease by person, place, and
time) derived from surveillance systems and other secondary data sets (i.e., existing data) to
3.2
Box Evidence-Based Planning Framework for Public Health
PHaSE 1 Community Assessment
PHaSE 2 Quantifying the Issue
PHaSE 3 Developing a Concise Statement of the Issue
PHaSE 4 Determining What is Known using Scientific Literature
PHaSE 5 Developing and Prioritizing Program and Policy Options
PHaSE 6 Developing an Action Plan and Implementing Interventions
PHaSE 7 Evaluating the Program or Policy
Source: Washington University Prevention Research Center (2015). Evidence based public healthcourse. Retrieved from http://prcstl.wustl.edu/training
/Pages/EBPH-Course-Information.aspx
H
ig
hl
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ht
s

Training

44 Part 1 Planning a Health Promotion Program
analyze and display disease frequencies. In this step, data are also presented in tables and fig-
ures as prevalence or incidence rates, or as percentages, to help stakeholders make decisions
about health concerns in the community. Combined with data from community members,
the most significant health problems in the community begin to emerge (Washington
University Prevention Research Center, 2015).
Phase 3, developing a concise statement of the issue, summarizes an analysis of root causes
of the most significant health problems in the community. For example, root causes may
include lack of interventions that address primary risk factors related to a health problem
or inadequate policies to protect the community from a known threat. Root causes may
also take the form of social determinants (i.e. inadequate education, low employment,
high crime, etc., related to health disparities). This analysis leads to a concise written
statement of root causes, or statement of the issue (Washington University Prevention
Research Center, 2015).
Phase 4, determining what is known using scientific literature, directs planners to identify
evidence-based solutions related to the root causes and related problems identified in the
statement of the issue (Phase 3). Planners search resources such as the Guide to Community
Preventive Services (CDC, 2015), or scientific journals, books, government reports, etc.,
and categorize potential solutions as recommended with strong evidence, recommended
with sufficient evidence, insufficient evidence, and not recommended (no evidence).
This process leads planners to various interventions that may effectively address the root
causes of the health problems identified (Washington University Prevention Research
Center, 2015).
Once potential interventions are examined, Phase 5, developing and prioritizing program
and policy options, directs planners to prioritize specific interventions or actions steps using
methods such as the Delphi technique, Nominal Group technique, Basic Priority Rating
model, multi-level voting, or any other process that is systematic, objective, and allows for
standardized comparisons (see Chapter 4 for descriptions of these methods). Planners are
encouraged to identify priorities related to actions that lead to improved health outcomes
(Washington University Prevention Center, 2015).
Phase 6, developing an action plan and implementing interventions, is what most plan-
ners would call implementation. In this step, goals and objectives are developed and action
strategies (i.e. interventions) are planned. Logic models are developed to visually display
the relationship between inputs (resources) and outputs (what will be accomplished).
Management of action strategies, personnel, and communication with partners and
community members are also addressed in this step (Washington University Prevention
Center, 2015).
Finally, in Phase 7, evaluating the program or policy, planners take measures to improve the
existing program or policy (i.e. formative evaluation) as well as measure effectiveness (i.e.
summative, or impact and outcome evaluation). Basic decisions are made such as whether
to conduct quantitative or qualitative evaluation and whether to use descriptive or infer-
ential statistics (see Chapter 15 for descriptions). Planners decide on appropriate outcomes
to measure, then decide how to collect, record, analyze and disseminate data (Washington
University Prevention Center, 2015). A close examination of the planning approach used by
Brownson and associates, who are clearly well respected in the field of evidence-based strate-
gies, not only validates steps used in the Generalized Model, but also supports the argument
that most planning models are composed of the same basic elements.

Chapter 3 Program Planning Models in Health Promotion 45
Mobilizing for Action Through Planning
and Partnerships (MAPP)
In 1997, the CDC and the National Association of County and City Health Officials (NACCHO)
collaborated on the development of a new model and released the MAPP model—Mobilizing
for Action through Planning and Partnerships in 2000 (NACCHO, 2001). While the MAPP
model was presented as a foundational approach to planning and evaluation in public health
settings, particularly among local (i.e. city or county) health departments, it has broad relevance
to all health promotion settings. In fact, the MAPP model is considered a very robust model in
practice today. Hershey (2011) provides an in-depth case study of how MAPP can be used suc-
cessfully at the local level.
Use of the MAPP model is intended to improve health and quality of life through mobi-
lized partnerships and taking strategic action (NACCHO, 2001). Figure 3.2 displays the six
phases of MAPP as well as the four MAPP assessments.
In the first phase of MAPP, organizing for success and partnership development, planners
assess whether the MAPP process is timely, appropriate, or even possible. This involves as-
sessing resources (including budgets), the expertise of available personnel, support of key
decision makers and other stakeholders, and the general interest of community members.
If resources are not available, the process is not undertaken. If the decision is made to pro-
ceed with a MAPP process, the following work groups are created: (1) a core support team,
which prepares most, if not all of the material needed for the planning process; (2) the
MAPP committee, composed of key sponsors (usually influential people or organizations
Organize
for success
Partnership
development
Visioning
Four MAPP assessments
Identify strategic issues
Formulate goals and strategies
Evaluate Plan
Implement
Action
C
om
munity themes and

str
eng
ths assessment
Local p
u
b
lic h
e
a
lth
system
a
sse
ssm
e
nt
status assessmen
t
Community health
F
o
rc
e
s
o
f
ch
a
n
g
e
a
ss
e
ss
m
e
n
t
⦁▲ Figure 3.2 Display of the Six Phases of MAPP and the Four MAPP
Assessments
Source: Achieving Healthier Communities through MAPP: A User’s Handbook. Copyright © 2009
by the National Association of County and City Health Officials. Reprinted with permission.

46 Part 1 Planning a Health Promotion Program
from the private sector who lend support and other resources) and stakeholders who guide
and oversee the process; and (3) the community itself, which provides input, representa-
tion, and decision making. This phase answers basic questions about the general feasibil-
ity, resources, and appropriateness of the MAPP process (NACCHO, 2001).
Phase 2 of the MAPP process, visioning, guides the community through a process that re-
sults in a shared vision (what the ideal future looks like) and common values (principles and
beliefs that will guide the remainder of the planning process) (NACCHO, 2001). Generally,
a facilitator conducts the visioning process and involves anywhere from 50 to 100 partici-
pants including the advisory committee, the MAPP committee, and key community leaders
(NACCHO, 2001). This process is typical of what should occur in pre-planning (see the
Generalized Model).
Phase 3, the four MAPP assessments, represents the defining characteristic of the
MAPP model. The four assessments include (1) the community themes and strengths
assessment (community or consumer opinion), (2) the local public health assessment
(general capacity of the local health department and the local health system), (3) the
community health status assessment (measurement of the health of the community by
use of mortality, morbidity, risk factor and other related data, etc.), and (4) the forces of
change assessment (forces such as legislation, technology, and other environmental or
social phenomena that do or will impact the community). Collectively, the MAPP assess-
ments provide insight on the gaps that exist between current status in the community
and what was learned in the visioning phase as well as strategic direction for goals and
strategies (NACCHO, 2001). The MAPP assessments provide an excellent framework for
the types of data collection that should be part of any comprehensive needs assessment
(see Chapter 4).
In Phase 4 of MAPP, identify strategic issues, planners develop a prioritized list of the
most important issues facing the health of the community. Only issues that jeopardize
the vision and values of the community are considered. Important tasks in this phase
include consideration of what would happen if certain issues were not addressed, un-
derstanding why an issue is strategic, consolidating overlapping issues, and identifying
a prioritized list. In Phase 5, formulate goals and strategies, planners create goals related
to the vision and prioritize strategic issues then select strategies to accomplish the goals.
Finally, Phase  6, the action cycle, is similar to implementation and evaluation phases in
other planning models. In this phase, implementation details are considered, evaluation
plans (i.e. gathering credible evidence) are developed, and plans for disseminating results
are made (NACCHO, 2001).
MAP-IT
More recently, in December 2010, Healthy People 2020, a national planning framework, was
released to help guide public health and health promotion planning efforts for the next
decade (USDHHS, 2015c). MAP-IT (Mobilize, Assess, Plan, Implement and Track) was intro-
duced as a planning model to assist communities in implementing their own adaptations of
Healthy People 2020. A few case studies have demonstrated how this can transpire (Offiong,
Oji, Bunyan, Lewis, Moore, Olusanya, 2011; Devito-Staub, 2014). The phases in MAP-IT are
displayed in Box 3.3.

Chapter 3 Program Planning Models in Health Promotion 47
MAP-IT starts by mobilizing key individuals and organizations into a coalition that can
work together to improve the health of the community (USDHHS, 2011c). Once partners
are identified and the coalition is organized, roles are established for each partner and re-
sponsibilities are assigned. These responsibilities may include facilitating community input
through meetings and other events, developing and presenting educational and/or training
programs, leading fundraising or policy initiatives, and providing technical assistance in
planning or evaluation (USDHHS, 2011c). In essence, the mobilize phase of MAP-IT is the
same thing as pre-planning in the Generalized Model.
The second phase of MAP-IT, assess, is the equivalent of a needs assessment. This
phase directs planners to ask and answer questions such as: (1) Who is affected by key
health problems in our community? (2) What resources do we have to address the prob-
lems that we identify? And (3) What resources are required to have a meaningful impact?
This phase of the model examines both the problems as well as the assets within a com-
munity to help planners focus on what the community can do versus what it would like
to do (USDHHS, 2011c).
In the assess phase, both state and local data are collected and analyzed to help coalition
members set priorities. In addition, the MAP-IT model directs planners to examine the social
determinants, or root causes of the problems associated with the data collected. This might
include an investigation of how the physical or social environments affect the health of the
community, how a lack of access to health services contributes to death and illness, and how
individual behavior as well as biology and genetics affect the health issues identified as pri-
orities (USDHHS, 2011c).
The third phase of MAP-IT, plan, involves developing goals and objectives, measures,
baselines, and targets. This means that as part of the objectives that are developed, planners
determine what will be measured (e.g., a decrease in smoking among adults), the baseline
(e.g., percent of adults in the community who smoke), and the targeted decrease (e.g., a
decrease of three percent in five years). In this phase, planners also identify the specific inter-
ventions that will be used to accomplish the identified goals and objectives. This means ad-
dressing the following questions: (1) What do we need to do to reach our goals? And (2) How
will we know when we have reached our goals? This phase is the equivalent of developing
goals and objectives as well as interventions.
The fourth phase in MAP-IT, implement, involves organizing the coalition so it can put
the plan into action. Here, a detailed work plan, including all of the information devel-
oped in Phase 3, is assembled to identify clear action steps, describe who is responsible for
3.3
Box Phases of MaP-IT
PHaSE 1 Mobilize
PHaSE 2 Assess
PHaSE 3 Plan
PHaSE 4 Implement
PHaSE 5 Track
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48 Part 1 Planning a Health Promotion Program
completing the action steps, and display a timeline with related deadlines. A communication
plan is also produced in this phase to outline how program partners will reach and recruit
participants and communicate the benefits of engaging in the program.
The final phase of MAP-IT, track, is the equivalent of evaluation. Here, coalition partners
ask and answer specific questions such as: (1) Are we evaluating our work appropriately
(i.e., formative evaluation)? (2) Did we follow the plan (i.e., process evaluation)? (3) What
did we change (i.e., impact evaluation)? And, (4) Did we reach our goal (i.e., outcome eval-
uation) (USDHHS, 2011c)? MAP-IT encourages regular evaluations to measure and track
progress over time and draws special attention to the quality of data being collected, the
limitations of self-reported data, and the validity and reliability of data collected (USDHHS,
2011c). Progress on the impact of related interventions is shared often with stakeholders
(USDHHS, 2011c).
PRECEDE-PROCEED
“PRECEDE is an acronym for predisposing, reinforcing, and enabling constructs in
educational/ecological diagnosis and evaluation” (Green & Kreuter, 2005, p. 9). “PROCEED
stands for policy, regulatory, and organizational constructs in educational and environmen-
tal development” (Green & Kreuter, 2005, p. 9). The model is very robust with hundreds of
published papers citing evidence of its usefulness in improving health outcomes. It is per-
haps one of the oldest and most enduring planning models used in health promotion. In
the last few years it has been cited as integral in better understanding women’s decisions to
seek clinical breast exams (Hayes-Constant, Winkler, Bishop, & Taboada-Palomino, 2014),
designing an oral health strategy (Binkley & Johnson, 2013), developing an intuitive eating
approach to weight management (Cole & Horacek, 2009) and improving the quality of life in
elders (Mazloomymahmoodabad, Masoudy, Fallahzadeh, & Jalili, 2014).
The first half of the model, PRECEDE, “consists of a series of planned assessments that
generate information that will be used to guide subsequent decisions” (Green & Kreuter,
2005, p. 8). The second half of the model, PROCEED, “is marked by the strategic implemen-
tation of multiple actions based on what was learned from the assessments in the initial
phase” (Green & Kreuter, 2005, p. 9).
The Eight Phases of PRECEDE-PROCEED
As displayed in Figure 3.3, PRECEDE-PROCEED is composed of eight phases. The underly-
ing approach of this model is to begin by identifying the desired outcome, to determine what
causes it, and finally to design an intervention aimed at reaching the desired outcome. In
other words, PRECEDE-PROCEED begins with the final consequences and works backward to
the causes. Once the causes are known, an intervention can be designed.
Phase 1 in the model is called social assessment and situational analysis and seeks to
subjectively define the quality of life (problems and priorities) of those in the priority
population while involving individuals in the priority population in an assessment of their
own needs and aspirations. Social indicators of quality of life include achievement, alien-
ation, comfort, crime, discrimination, happiness, self-esteem, unemployment, and welfare
(Green & Kreuter, 2005).

Chapter 3 Program Planning Models in Health Promotion 49
In Phase 2, epidemiological assessment, planners use data to identify and rank the
health goals or problems that may contribute to or interact with problems identified in
Phase 1. These data include traditional indicators analyzed in needs assessments (e.g.,
mortality, morbidity, and disability data) as well as genetic, behavioral, and environ-
mental factors (Green & Kreuter, 2005). It is important to note that ranking the health
problems in this phase is critical, because there are rarely, if ever, enough resources to
deal with all or even multiple problems. Also, this phase of the model is used to plan
health programs. Note that in Figure 3.3, arrows work backward to connect the genetics,
behavior, and environment boxes of Phase 2 with the health box and with the quality of
life box of Phase 1.
Once identified, the risk factors or conditions related to broader health problems need to be
prioritized. This can be accomplished by first ranking these factors by importance and change-
ability and then using a 2 × 2 matrix with “more important” and “less important” on the
horizontal axis and “more changeable” and “less changeable” along the vertical axis (Green
& Kreuter, 2005). The risk factors that fall into the “more important” and “more changeable”
quadrant in the matrix will be the highest priorities.
Phase 3, educational and ecological assessment, identifies and classifies the various factors
that have the potential to influence a given behavior into three categories: predisposing,
reinforcing, and enabling. Predisposing factors include knowledge and many affective
traits such as a person’s attitude, values, beliefs, and perceptions. These factors can facilitate
or hinder a person’s motivation to change and can be altered through direct communica-
tion. Barriers or facilitators created mainly by societal forces or systems make up enabling
factors, which include access to health care facilities or other health-related services, avail-
ability of resources, referrals to appropriate providers, transportation, negotiation and prob-
lem-solving skills, among others. Reinforcing factors involve the different types of feed-
back and rewards that those in the priority population receive after behavior change, which
may either encourage or discourage the continuation of the behavior. Reinforcing behaviors
Phase 1 –
Social
Assessment
Phase 2 –
Epidemiologi-
cal
Assessment
Phase 3 –
Educational &
Ecological
Assessment
Phase 4 –
Administrative
& Policy
Assessment
and
Intervention
Alignment
Phase 5 –
Implementa-
tion
Phase 6 –
Process
Evaluation
Phase 7 –
Impact
Evaluation
Phase 8 –
Outcome
Evaluation
⦁▲ Figure 3.3 PRECEDE-PROCEED Model for Health Promotion Planning and Evaluation

50 Part 1 Planning a Health Promotion Program
can be delivered by, but not limited to, family, friends, peers, teachers, self, and others who
control rewards (Green & Kreuter, 2005).
Phase 4 is composed of two parts: (1) intervention alignment; and (2) administrative and
policy assessment. The intent of intervention alignment is to match appropriate strategies
and interventions with projected changes and outcomes identified in earlier phases (Green
& Kreuter, 2005). In administration and policy assessment, planners determine if the capa-
bilities and resources of existing personnel and participating organizations are available to
develop and implement the program. It is between Phases 4 and 5 that PRECEDE (the assess-
ment portion of the model) ends and PROCEED (implementation and evaluation) begins.
However, there is no distinct break between the two phases; they actually run together, and
planners can move back and forth between phases.
The four final phases of the model—Phases 5, 6, 7, and 8—make up the PROCEED por-
tion. In Phase 5—implementation—with appropriate resources secured, planners select in-
terventions and strategies and implementation begins. Phases 6, 7, and 8 address process,
impact, and outcome evaluation (see Chapter 13 for definitions), respectively, and are based
on the earlier phases of the model, when objectives were outlined in the assessment process.
Whether all three of these final phases are used depends on the evaluation requirements of
the program. Usually, the resources needed to conduct evaluations of impact (Phase 7) and
outcome (Phase 8) are much greater than those needed to conduct process evaluation (Phase
6) (Green & Kreuter, 2005).
Intervention Mapping
Intervention mapping was designed to fill a gap in health promotion practice by trans-
lating data collected in the PRECEDE phases of PRECEDE-PROCEED (i.e., social, epidemio-
logical, educational, ecological, administrative, organizational, and policy assessments)
into theoretically based and otherwise appropriate interventions (Green & Kreuter, 2005).
Once planners identify program objectives, they are guided by diagrams and matrices
that incorporate outputs of the assessment process with relevant theory (Green & Kreuter,
2005). Intervention Mapping as a planning model has been refined and described more
comprehensively by Bartholomew, Parcel, Kok, Gottlieb, and Fernandez (2011). The model
has been used to develop a breast and cervical cancer screening program for Hispanic farm-
workers (Fernandez, Gonzales, Tortolero-Luna, Partida, & Bartholomew, 2005), to develop
a worksite physical activity intervention (McEachan, Lawton, Jackson, Conner, & Lunt,
2008), to explore the development of existing sex education programs for people with
intellectual disabilities (Schaafsma, Joke, Kok, & Curfs, 2012), and in reducing heavy drink-
ing among college students (Voogt, Poelen, Kleinjan, Lemmers, & Engels, 2014).
Box 3.4 outlines the six phases of Intervention Mapping. The first phase, conduct a needs
assessment, is conducted by using the PRECEDE phases of the PRECEDE-PROCEED model
and includes establishing a participatory planning group, assessing community capacity,
and linking the needs assessment to health outcomes and quality of life goals (Bartholomew
et al., 2011). Phase 2, create matrices of change objectives, specifies who and what will change as
a result of the intervention (Bartholomew et al., 2011). Although the identification of goals
and objectives is common to all planning models, intervention mapping makes a signifi-
cant contribution in this regard and is considered the basic tool of the model. In this phase,

Chapter 3 Program Planning Models in Health Promotion 51
planners create a matrix of change objectives which “state what needs to be achieved in order
to accomplish performance objectives that will enable changes in behavior or environmen-
tal conditions that will in turn improve the health and quality of life program goals identi-
fied in Step 1” (Bartholomew et al., 2011, p. 239). This is perhaps the defining strength and
unique contribution of the model.
Phase 3, theory-based intervention methods and practical applications, guides the planner
through a process of selected theory-based interventions and strategies that hold the great-
est promise to change the health behavior(s) of individuals in the priority population.
Phase 4, organize methods and applications into an intervention program, describes the scope
and sequence of the intervention, the completed program materials, and program protocols
(Bartholomew et al., 2011). In addition, program materials are pretested with the priority
population prior to implementation.
Phase 5 of intervention mapping is plan for adoption, implementation, and sustainabil-
ity of the program. This phase requires the same development of matrices as in Phase 2,
except in these matrices, the focus is on adoption and implementation of performance
objectives (Bartholomew et al., 2011). In other words, instead of focusing on who and
what will change within the priority population, the focus is on what will be done by
whom among planners or program partners. Finally, Phase 6 is generate an evaluation
plan. In this phase, planners decide if determinants were well specified, if strategies were
appropriately matched to methods, what proportion of the priority population was
reached, and  whether or not implementation was complete and executed as planned
(Bartholomew et al., 2011).
Healthy Communities
Healthy Communities (or Healthy Cities) is a movement that began in the 1980s in
Canada and, with the assistance of the World Health Organization, spread to various lo-
cations throughout Europe. As a result, organizations like California Healthy Cities and
Indiana Healthy Cities were created in the United States. The movement is characterized by
community ownership and empowerment and driven by the values, needs, and participa-
tion of community members with consultation from health professionals. Another charac-
teristic of Healthy Communities is diverse partnership. It is not uncommon to see partners
3.4
Box Phases of Intervention Mapping
PHaSE 1 Conduct a Needs Assessment
PHaSE 2 Create Matrices of Change Objectives
PHaSE 3 Select Theory-Based Intervention Methods and Practical Applications
PHaSE 4 Organize Methods and Applications into an Intervention Program
PHaSE 5 Plan for Adoption, Implementation, and Sustainability of the Program
PHaSE 6 Generate and Evaluation Plan
Source: Bartholomew, L.K., Parcel, G.S., Kok, G., Gottlieb, N.H., & Fernandez, M.E. (2011). Planning Health Promotion Programs: An Intervention
Mapping Approach (3rd ed.). San Francisco, CA: Jossey-Bass.
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52 Part 1 Planning a Health Promotion Program
from business or labor, transportation, recreation, public safety, or even politicians partici-
pate in the Healthy Communities process.
In the past few decades, the Centers for Disease Control and Prevention (CDC) has
worked intensively with hundreds of communities to cultivate Healthy Communities
and has reported that the following factors predict success: (1) local investment in com-
munities; (2) providing a venue for local communities to learn about effective strategies;
(3) mobilizing networks for change; and (4) providing tools to communities to achieve
health equity and prevent chronic disease (Giles, Holmes-Chavez,  & Collins, 2009). One
of the lessons learned from Healthy Communities is the idea that the pursuit of shared
values in the context of ownership and empowerment is a viable approach to improving
health in the community. The Healthy Communities Program at the CDC has created the
CHANGE (Community Health Assessment aNd Group Evaluation) tool to enable
stakeholders and community team members to gather data on community strengths
and assets as well as provide opportunities to create policy, systems, and environmental
change through a community action plan (CDC, 2010a). This tool or model represents a
viable planning framework for organizations and communities engaging in the Healthy
Communities approach.
Box 3.5 displays the eight phases (described as action steps by CDC) of the CHANGE
tool. Phase 1, assemble the community team, organizes 10-12 individuals, including key
decision makers, representing diverse sectors from the community who are willing to
collect and analyze data, translate data to an action plan, and oversee implementation of
related interventions (CDC, 2010a). Phase 2, develop a team strategy, directs the community
team to make decisions about how to operate most efficiently and effectively. This might
include reorganizing the larger team into smaller work groups with specific tasks. It also
includes creating decision-making procedures, including how to reach consensus (CDC,
2010a). Phase 3, review all five CHANGE sectors, divides the work of data collection and
analysis into five sectors: (1) the community at large sector; (2) the community institu-
tion/organization sector (i.e. institutions or organizations in the community that provide
human services and access to facilities); (3) the health care sector; (4) the school sector; and
3.5
Box Phases of the CHaNGE Tool
PHaSE 1 Assemble the Community Team
PHaSE 2 Develop a Team Strategy
PHaSE 3 Review All Five CHANGE Sectors
PHaSE 4 Gather Data
PHaSE 5 Review Data Gathered
PHaSE 6 Enter Data
PHaSE 7 Review Consolidated Data
PHaSE 8 Build the Community Action Plan
Source: Centers for Disease Control and Prevention (2010a). Community Health Assessment aNd Group Evaluation Action Guide: Building a Foundation
of Knowledge to Prioritize Community Needs. Atlanta: U.S. U.S. Department of Health and Human Services.
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Chapter 3 Program Planning Models in Health Promotion 53
(5) the worksite sector. Each sector contains specific questions with related data elements
associated with policy, systems, or environmental change that need to be addressed (CDC,
2010a). Phase 4, gather data, begins the assessment phase. Here, “sites” or locations that
have data related to the questions associated with each sector are identified and specific
data collection strategies such as observations, interviews, focus groups and surveys are
used to gather new or existing data (CDC, 2010a). In Phase 5, review data gathered, team
members discuss what was discovered and “rate” (or rank) each item (specific questions
related to each sector) using a five-point scale. This involves making judgments about
whether the condition of each item (e.g. condition and safety of sidewalks that increase or
decrease the likelihood of physical activity, or structured physical activity classes in grades
9-12, etc.) is improving, getting worse, or staying the same (CDC, 2010a). Phase 6, enter
data, incorporates CHANGE Sector Excel files, which organizes data for analysis. Phase
7, review consolidated data, transfers data into “CHANGE summary statements for quick
reference of all sites with related ratings across all five sectors (CDC, 2010a). In essence, this
step summarizes data to accommodate prioritization and decision making. Finally, Phase
8, building the community action plan, involves translating prioritized data from the sum-
mary statements to measurable objectives and action steps with assignments, and creates
strategies for evaluation and reassessment (CDC, 2010a). The CHANGE action guide (CDC,
2010a) provides adequate instructions on how to complete the eight phases of this process.
But in general, it includes pre-planning and visioning, needs assessment, priority setting,
selecting appropriate policy, systems, or environmental interventions, and evaluating the
quality and effectiveness of interventions.
SMART
Although most planning models try to involve members of the priority population in
the planning process at some level and some go so far as to incorporate consumer data
(see MAPP for a good example), planning models such as SMART (Social Marketing
Assessment and Response Tool [Neiger & Thackeray, 1998]), with a social marketing
focus, generally do a better job of orienting program interventions to the preferences of
consumers throughout the entire planning process (see Chapter 11 for more informa-
tion on marketing/social marketing). Consumer data are collected continually, first to
understand the wants and needs of consumers and then to test all aspects of interven-
tion and communication strategies. There is some evidence to suggest that this planning
approach may be more effective than traditional approaches used in health promotion
(Neiger & Thackeray, 2002). SMART is one of the more robust social marketing mod-
els currently in practice; the other being the Community Based Prevention Marketing
Model (Bryant, Forthofer, McCormack-Brown, Landis, & McDermott, 2000). Within the
last few years, the SMART Model has been used in service-learning to teach community
health (Buckner, Ndjakani, Banks, & Blumenthal, 2010), in the development of an edu-
cational intervention to treat schizophrenia (Bradshaw, Lovell, Bee, & Campbell, 2010),
and in developing a support program for patients with diabetic kidney disease (Pagels,
Hylander, & Alvarsson, 2015).
The SMART model, influenced primarily by Walsh and colleagues (1993), is also a com-
posite of several social marketing planning frameworks but differs from most planning

54 Part 1 Planning a Health Promotion Program
models used in health promotion settings due to its multistep focus on the consumer. Unlike
some social marketing planning models, SMART has been used from start to finish in success-
ful social marketing interventions (Neiger & Thackeray, 2002).
As displayed in Box 3.6, SMART is composed of seven phases. Like other social market-
ing planning models, the central focus of SMART is consumers. The heart of this model,
composed of Phases 2 through 4, directs planners to acquire a broad understanding of
the consumers who will be the recipients of a program and its interventions. These three
phases seek to understand consumers before interventions are developed or implemented.
Though these phases (2–4) are displayed in linear fashion, and for clarity will be described
in sequence, they are typically performed simultaneously with members of the priority
population.
3.6
Box
Phase 1: Preliminary Planning
⦁⦁ Identify a health problem and name it in
terms of behavior
⦁⦁ Develop general goals
⦁⦁ Outline preliminary plans for evaluation
⦁⦁ Project program costs
Phase 2: Consumer analysis
⦁⦁ Segment and identify the priority
population
⦁⦁ Identify formative research methods
⦁⦁ Identify consumer wants, needs, and
preferences
⦁⦁ Develop preliminary ideas for preferred
interventions
Phase 3: Market analysis
⦁⦁ Establish and define the market
mix (4Ps)
⦁⦁ Assess the market to identify
competitors (behaviors, messages,
programs, etc.), allies (support systems,
resources, etc.), and partners
Phase 4: Channel analysis
⦁⦁ Identify appropriate communication
messages, strategies, and channels
⦁⦁ Assess options for program distribution
⦁⦁ Identify communication roles for
program partners
⦁⦁ Determine how channels should be used
The SMaRT Model
Phase 5: Develop Interventions,
Materials, and Pretest
⦁⦁ Develop program interventions and
materials using information collected
in consumer, market, and channel
analyses
⦁⦁ Interpret the marketing mix into
a strategy that represents exchange
and societal good
⦁⦁ Pretest and refine the program
Phase 6: Implementation
⦁⦁ Communicate with partners and clarify
involvement
⦁⦁ Activate communication and
distribution strategies
⦁⦁ Document procedures and compare
progress to timelines
⦁⦁ Refine the program
Phase 7: Evaluation
⦁⦁ Assess the degree to which the priority
population is receiving the program
⦁⦁ Assess the immediate impact on the
priority population and refine the
program as necessary
⦁⦁ Ensure that program delivery is
consistent with established protocol
⦁⦁ Analyze changes in the priority
population
Source: Adapted from Walsh et al. (1993) by Neiger & Thackeray (1998).
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Chapter 3 Program Planning Models in Health Promotion 55
The Phases of SMaRT
Phase 1, preliminary planning, is critical for any type of health promotion program and
in this model includes the planning elements of pre-planning and needs assessment as
described earlier. Preliminary planning allows program planners to objectively assess all
health problems and determine which one is most appropriate to address. This is most often
accomplished through analysis of epidemiologic data, including various mortality and mor-
bidity rates and associated risk factor data. It also includes objective priority setting with
predetermined criteria. Sometimes planners do not undergo a process to select a priority
health problem because the decision has already been made or the organization is dedicated
to a specific health problem (e.g., the American Heart Association focuses on heart disease).
Once a single health problem is determined, it is defined in terms of behaviors. Risk factors,
or contributing factors, then become the focus of the social marketing process. This is simi-
lar to most health promotion programs.
Some social marketing practitioners and those who engage in community-based partici-
patory research would argue that the priority population itself should determine the focus of
an intervention or program. Good arguments can be made for this approach, including the
idea that priority populations are capable of identifying their own problems and solutions
and that they will be more vested in long-term involvement if they have ownership in the
process. The SMART model suggests that planners, as trained health professionals, have both
the expertise and responsibility to use various data sets to oversee and determine priority
health problems within a community in partnership with members of the priority popula-
tion. Once a priority or priorities are identified, the remainder of the process becomes almost
exclusively consumer-driven.
While health professionals may determine initial program direction, the SMART model
directs that consumers drive the development and implementation of interventions.
This is not unlike most ventures in commercial marketing where a product or service is
developed internally then tested with consumers and modified prior to distribution. For
example, a company such as Coca-Cola develops its own identity and mission and creates
the basic essence of its products. But it engages in complex marketing campaigns to better
understand how to modify, improve, position, and deliver these products to its consumers
in a way that offers benefits at reasonable costs.
Although goals are outlined in Phase 1, objectives are not. This makes sense from a social
marketing perspective, since consumer research has not yet been performed. The goals are
general statements of intent or direction, but they do not specify program components or
direct the planner into specific courses of action.
Another task in Phase 1 is to develop preliminary plans for evaluation. Theoretically, it will
make sense to most planners to consider evaluation early in the planning process. In reality,
evaluation is too often an afterthought. Preliminary decisions regarding evaluation outcomes
must be made early in the planning process in order to account for personnel, time, and bud-
get requirements. Therefore, it is also important to determine how baseline and post-program
(posttest) data will be collected and to identify valid survey or data collection instruments.
Planners can also control for various kinds of bias or error in data collection if these basic
evaluation concepts are considered before the program is implemented.
Finally, program costs need to be projected before the social marketing project begins.
Social marketing can be an expensive proposition in terms of staff costs and direct expenses.

56 Part 1 Planning a Health Promotion Program
When performed correctly, a social marketing project can take several months or up to a year
before implementation even begins. Program planners and organizations must decide if they
are ready to make these kinds of time and financial commitments.
At the end of Phase 1, the social marketing planners have (1) identified the focus of in-
terest in terms of modifiable behaviors, (2) developed goals that provide general direction,
(3) outlined preliminary plans for evaluation, and (4) estimated total project costs. Based
on this information, the planners and organizations can make an informed decision
about the potential costs and benefits of the project as well as the application of social
marketing.
Phase 2 of SMART is consumer analysis. In social marketing language, the process of per-
forming consumer analysis is called formative research, defined as a process that identi-
fies differences among subgroups within a population, identifies a subgroup, determines the
wants and needs of the subgroup, and identifies factors that influence its behavior, including
benefits, barriers, and readiness to change (Bryant, 1998).
It is important to remember that no single type of data collection technique is necessarily
best in performing formative research. To the contrary, it is helpful to use multiple methods
to gain a better perspective of the priority population. It is a mistake for those who engage in
social marketing to perform one or two focus groups in the name of formative research and
claim they understand their consumers. Ordinarily, however, formative research will involve
the use of focus groups, in-depth interviews, and surveys, and so on, to understand consumer
preferences.
At the conclusion of Phase 2, a priority population is also identified. Adequate formative
research has been performed yielding data about major themes, directions, and consumer
preferences related to the health problem and related interventions. Although Phases 2
through 4 are often performed simultaneously, information collected in Phase 2 can provide
context for the other two phases. For example, knowing about consumer preferences related
to some type of behavior change allows planners to more effectively understand consumer
preferences related to the market mix and communication strategies.
Phase 3, market analysis, examines the fit between the focus of interest (desired behavior
change) and important market variables within the priority population. Marketing mix is
a term that is often used in both commercial and social marketing. It is composed of four
components, also known as the 4Ps: product, price, place, and promotion (see Chapter 11 for
more on the 4Ps).
At the conclusion of this phase, consumer analysis is enriched by a better understanding
of important market variables that influence consumers. Combined with consumer analysis
and channel analysis, market analysis provides a powerful combination of useful informa-
tion about consumers, the environment they live in, and strengths and weakness associated
with potential social marketing interventions.
The fourth phase of SMART is channel analysis. Although communication may not be
the focal point of a social marketing campaign, it will play a secondary role in communicat-
ing important messages about the product. In addition to messages and related strategies,
formative research includes specific questions about the type of communication channels
consumers believe are most appropriate for the behavior change being addressed.
At the conclusion of Phase 4, communication channels are identified that are consistent
with preliminary messages, and product distribution points and potential communication
and intervention partners are identified.

Chapter 3 Program Planning Models in Health Promotion 57
Phase 5 of SMART is develop interventions, materials and pretesting. Once formative research
is performed, it is critical that the data are transferred or infused adequately into the design of
programs, interventions, and communication strategies. To do this, data must be analyzed
and categorized appropriately to assure that planners understand what they have seen, heard,
and observed. As planners meet to design programs and materials, they should keep formative
research data in front of them and refer to them often. Discussion and decisions should reflect
all data and represent a consensus among all planners. In other words, materials and methods
should represent what was learned in formative research.
Once a program prototype is developed, it is imperative to return to the priority popula-
tion and test the concepts before implementing a widespread campaign. In fact, social mar-
keting represents a process of continually returning to the consumers until the program and
all its support mechanisms are consistent with their views and preferences. Several mecha-
nisms are available to perform pretesting. One example is a pilot test where the program can
be implemented with the priority population on a smaller, less expensive scale. Phase 6 of
SMART is implementation. This phase is concerned with clarifying everyone’s role, including
external partners. This means that procedures are communicated and documented, and that
timelines are developed and followed. In this phase, the communication and distribution
plans are activated and the actual program and its interventions are offered. In addition, the
program is refined continually, based on consumer feedback.
The seventh and final phase of SMART is evaluation. The preliminary evaluation strate-
gies that were identified in Phase 1 now take effect. Evaluation always has at least two ma-
jor objectives: improve the quality of the program and determine the effectiveness of the
program. With respect to quality, program planners assess the degree to which the priority
population is actually receiving the program or interventions. Planners also assess the im-
mediate impact the program is having and whether the interventions and related support
strategies are acceptable and engaging to the priority population. In addition, planners
ensure that program delivery is consistent with program protocol or at least consistent with
developed timelines.
Ultimately, social marketing, and all its related work, is of little value unless behavior
change occurs and health is improved. Evaluation also concerns itself with measuring these
outcomes. Effective planners and evaluators also make sure that evaluation results are folded
back into the program so that it can be improved before it is too late. This requires communi-
cating evaluation results effectively to stakeholders.
Other Planning Models
The Evidence-Based Planning Framework for Public Health, MAPP, MAP-IT, PRECEDE-
PROCEED, Intervention Mapping, Healthy Communities (CHANGE tool), and SMART are all
theoretically good models and can each be used to successfully plan, implement, and evaluate
programs. While these specific models may be used more commonly in health promotion
settings, still other models have been useful in various settings including Community-Based
Prevention Marketing (Bryant, Forthofer, McCormack-Brown, Landis, & McDermott, 2000),
PATCH (Lancaster & Kreuter, 2002), the Health Communication Model (National Cancer
Institute, n.d.), Healthy Plan-It (Centers for Disease Control and Prevention, 2000), and SWOT
(Strengths, Weaknesses, Opportunities, and Threats) (Panagiotou, 2003), which is more of a

58 Part 1 Planning a Health Promotion Program
decision-making strategy than a traditional planning model. Technically, its use should be
limited to the preliminary stages of decision making in preparation for more comprehensive
strategic planning (Bartol & Martin, 1991; Johnson, Scholes, & Sexty, 1989).
An Application of the Generalized Model
In practice, planners will often encounter situations where it is not feasible to use a model
in its entirety or where it is necessary to combine parts of different models to meet specific
needs. For this reason, the Generalized Model is used in this book to help you adapt and
respond to complex planning challenges you will experience in professional practice.
With planning expertise associated with your working knowledge of the Generalized
Model, you will be able to more quickly assimilate and interpret varying or competing
stakeholder preferences for planning into a guiding paradigm that will generally keep you
on track. Although there is nothing unique about the Generalized Model itself, its prin-
ciples are the building blocks for all other planning models. This likely became apparent
to you as you reviewed the preceding planning models and noticed their many similari-
ties. Each of these models in one form or another includes: pre-planning, assessing needs,
setting goals and objectives, developing interventions, implementing interventions and
evaluating results.
Another benefit of understanding the Generalized Model is an increased ability to apply
an important process closely related to program planning—grant writing. Requirements
listed in requests for applications (RFAs) or requests for proposals (RFPs) related to grant an-
nouncements will be developed by the funding agency/organization and include their
preferences for language and terminology. But the steps or requirements related to requests
for health funding often relate back to the steps displayed in the Generalized Model.
For example, funding requests from the CDC and other federal or national organizations
generally require applicants to organize proposals with the following types of sections:
background and statement of need; work plan; management plan; evaluation; and budget.
These sections parallel closely with the Generalized Model: the background and statement
of need relate to the needs assessment; the work plan includes goals and objectives as well as
a description of interventions; and the management plan generally includes requirements
for program implementation. The Community Tool Box (see Weblinks at the end of this
chapter), a Website designed to assist health professionals with various tasks, outlines the
standard components of a grant proposal. Sections include the statement of the problem/
needs assessment; project description (goals and objectives and methods/activities); the
evaluation plan; and the budget request and justification (University of Kansas, 2015b).
To help you better understand how the Generalized Model might work in practice, we will
use a hypothetical example to walk you through its five steps. Of course, in practice, stake-
holders may choose a different approach than what is presented here. But at least you can
see how the steps in the model build upon each other. While this example is hypothetical in
nature, it is drawn from the 96 years of combined experience we as authors have with plan-
ning and evaluation in health promotion settings. In other words, it represents a realistic
accumulation of our experience.
Let’s assume Jane Doe, CHES, a recent health promotion graduate, has just been hired
by a medium-sized county health department in California. She has been asked to lead a

Chapter 3 Program Planning Models in Health Promotion 59
planning process to identify a health problem that will become the health department’s key
priority for the next three years.
The first thing Jane decides to do is some pre-planning. She sets out to identify key stake-
holders who can help guide the process as well as partners who will help her carry out the
work. She organizes a few meetings with stakeholders to discuss the collective vision for the
process including purpose, scope, and deliverables as well as the leadership structure (i.e.,
authority, roles, and responsibilities). She ensures that a few partners are community resi-
dents who have volunteered previously with the health department and can help represent
the community in general. Jane begins discussions with her partners to identify and secure
resources to be able to implement a program once a priority health problem and priority pop-
ulation have been identified. Although Jane realizes she does not need to spend months or
even weeks pre-planning, she understands the value of getting all stakeholders on the same
page with respect to vision, leadership, and resources. This will help ensure a more positive
and successful planning approach.
The actual planning and evaluation process begins with a needs assessment.
Stakeholders determine together that they will collect data in three main categories:
chronic diseases, infectious diseases, and injuries. Three teams are assembled to address
each of the categories and each team is charged with identifying 8–10 leading health
problems or diseases within the three categories. Teams agree to use a recent data report
produced by the California Department of Health Services (organized by county) that
describes leading causes of mortality, morbidity, and hospitalizations to select the 8–10
health problems for each of the categories. Stakeholders further determine that they will
collect the following types of data for each of the 8–10 health problems: county-specific
mortality and morbidity data; hospital discharge data; economic data; years of potential
life lost; disability data; data on disparities; social determinants and risk factors for each
health problem; and evidence of successful interventions that relate to the preventable
nature of each health problem. The planning team decides on a presentation template
for each health problem that includes graphs as well as brief descriptions for each of the
predetermined criteria. The three planning teams decide to allow two months to collect
and organize all the data.
After two months have passed, all three teams come together to compile their work in
a single report and to make an oral presentation of their findings. Afterward, Jane and the
community residents are given the assignment to use the basic priority rating (BPR) model
2.0 (Neiger, Thackeray, & Fagen, 2011) to narrow the list of health problems within each
category to five (see Chapter 4 for BPR). Jane serves as the moderator of priority setting to
make sure everyone understands the process. Within a week, five chronic diseases (heart dis-
ease, breast cancer, lung cancer, diabetes, and arthritis), five infectious diseases (HIV/AIDS,
pneumonia, chlamydia, E.coli, and meningitis), as well as five unintentional injuries (falls,
drownings, motor vehicle injuries, bicycle crashes, and auto-pedestrian injuries) surface as
leading health problems in the county.
After preliminary priority setting, the group of stakeholders decides it would like to
supplement its needs assessment with a series of focus groups throughout the county to de-
termine what community residents feel are the most significant health problems among the
initial priorities. Stakeholders decide to hire an evaluation firm to conduct 20 focus groups
across the county and prepare a report. The final bid for services is $8,500, which the com-
munity outreach office of a local hospital agrees to pay.

60 Part 1 Planning a Health Promotion Program
As the evaluation firm begins to organize and conduct focus groups, stakeholders use
the BPR model to further prioritize the remaining 15 health problems. Jane leads all discus-
sions but is assisted by a program coordinator from the local chapter of the American Cancer
Society who has years of experience in health promotion and some experience with the BPR
model. It takes the group two additional meetings to develop a list of their top five priorities:
(1) motor vehicle injuries; (2) heart disease; (3) breast cancer; (4) chlamydia; and (5) diabetes.
Within a month, the contracted evaluation team returns with its findings from the focus
groups. Data indicate that the community believes effective prevention should start with
children and adolescents and that the county should focus on childhood obesity as a risk fac-
tor for heart disease as well as the prevention of sexually transmitted diseases (i.e., chlamydia)
among adolescents.
With these findings, Jane and her stakeholders are faced with a difficult decision. The
BPR model and process produced a convincing case that motor vehicle injuries should be
the county’s top priority. But community residents are not in agreement. After thought-
ful deliberation, stakeholders decide to develop a safe driving program among high school
students throughout the county as well as a childhood obesity prevention program among
elementary and junior high students. They further decide to create two planning teams for
each of the priorities, with each team taking responsibility for grant writing and funding in
general. The teams are also tasked to identify appropriate partners with specific expertise and
resources in each of the two priority areas.
With health problems and priority populations identified, each newly formed team de-
velops goals and objectives for each of the two priorities. Using Healthy People 2020 as a starting
point, the teams develop general goals for each of the priorities as well as process, impact, and
outcome objectives. The teams carefully develop their baseline measurements (i.e., starting
points) for each objective based on the data collected in the needs assessment. Again, using
the targets in Healthy People 2020, each team develops its own targets for each objective, en-
suring that each one is specific, measurable, achievable, realistic, and time-phased.
With goals and objectives developed, the planning teams turn to developing the interven-
tions, the third step in the Generalized Model. Here, planners need to determine if they will
use existing programs and tailor them to their priority population or develop their own
programs. Jane remembers from her undergraduate coursework that interventions need to
be evidence-based. She works with both teams to ensure that the interventions selected will
offer a high probability of success. In the end, the childhood obesity team decides to adapt
a program from Utah titled Gold Medal Schools. This program is selected for its successful
track record and its multifaceted approach combining educational components with poli-
cies leading to healthy school environments. The safe driving team selects a program called
Driving School Home, a successful defensive driving course involving high school students
from Illinois. Both teams then begin the process of fully understanding their programs and
drafting budgets, including an analysis of how many staff members and volunteers would
be required to implement each program, how much funding would be required to purchase
program materials or capital equipment, and how much money might be required for con-
sultants. Program protocols are available for each program and in a matter of weeks, both
teams feel they understand the basic sequence of tasks and activities required to implement
each program.
The fourth phase of the Generalized Model, implementing interventions, is focused on
delivering interventions to the community. Before implementation occurs however, both

Chapter 3 Program Planning Models in Health Promotion 61
teams begin to lay the necessary groundwork with school personnel to establish partner-
ships and to receive approval to proceed as planned. This becomes more complicated than
Jane had anticipated. However, protocols and policies previously developed by the various
school districts need to be observed. For example, one thing all school districts require is that
each program be implemented on a pilot basis first to determine whether the likelihood of
success is high enough to justify full implementation of the programs on a broader basis. In
total, this process takes three months. But afterward, strong partnerships are established and
implementation is approved for each program.
Implementation is equivalent to program management. In this phase, program partners
ensure that programs are implemented as per predetermined protocol. Regular meetings are
held to ensure that everyone is doing his/her job as planned. Managers follow up with their
staff and make sure that timelines are carefully followed and that monies from approved
budgets are accessible for program support. Implementation also focuses on marketing and
communication. It is important that an adequate number of members from the priority
population is reached and that enough people actually participate in the programs. Jane and
her teams conduct in-depth interviews with school administrators to understand how to best
communicate the purpose of the programs to potential participants (e.g., schools, students,
and parents).
Jane helps to coordinate all the work of implementation and discovers that it takes a great
deal of assertiveness and diplomacy to keep people moving forward on schedule. She also
learns that certain aspects of both programs need to be modified in the process of imple-
mentation in order to increase the likelihood of their success. Toward the end of year one of
implementation, Jane realizes that while neither program was implemented perfectly, both
programs are running smoothly with continued enthusiasm and support.
During program implementation, Jane, along with two colleagues from the county health
department conduct formative evaluation to ensure that the quality of program compo-
nents and implementation are being presented as planned and that modifications are made
continually to improve the likelihood of success. This also proves to be a challenge for Jane.
During the course of implementing the Driving School Home program, she has to replace an
ineffective teacher. As the Gold Medal Schools program is evaluated, Jane discovers that the
kick-off assembly is too long and that both teachers and students are losing attention. When
the assembly is shortened by 20 minutes and more incentives and small prizes are distrib-
uted, everyone feels more energized. These come to represent just a few of the many program
improvements that are made during year one.
In addition, both teams had decided prior to implementation that outcome evalua-
tion, which would measure both changes in behavior as well as decreases in the actual
health problems, would be conducted by faculty and graduate students from a nearby
university. University personnel were willing to conduct the research at no cost, provid-
ing they could use all data for publications in scientific journals. While the researchers
required certain things of Jane and her partners, it became a win-win situation in the end.
The researchers collected data immediately after the programs concluded and then again
at three months after the conclusion of the programs. Data indicated that the Gold Medal
Schools program was moderately effective and that the Driving School Home program was
moderately to highly effective. Jane communicated to stakeholders that the programs
were more likely to experience higher levels of success in future implementations based
on continual improvements as part of formative and process evaluation. After data had

62 Part 1 Planning a Health Promotion Program
been collected and analyzed, Jane made several presentations to stakeholders reporting
on what went well and what went poorly. These presentations helped ensure continued
funding for both programs.
To reiterate, the preceding example could have played out in many different ways
based on the vision and competency of those leading the planning efforts. The purpose
of the example was to describe how the phases in the Generalized Model might unfold.
In practice, selecting a specific planning model to apply will be based on many factors:
(1)  the preferences of stakeholders (e.g., decision makers, program partners, consum-
ers); (2) how much time and funding are available for planning purposes; (3) how many
resources are available for data collection and analysis; (4) the degree to which clients are
actually involved as partners in the planning process or the degree to which your planning
efforts will be consumer oriented (i.e., planning is largely based on the wants and needs of
consumers or the planning process is owned by the community itself); and (5) preferences
of a funding agency (in the case of a grant or contract award). Planners must have the
capacity to not only lead a planning process, but also negotiate these important issues
among a diverse set of stakeholders.
Final Thoughts on Choosing a Planning Model
Three important criteria, or the three Fs of program planning: fluidity, flexibility, and
functionality, should also help guide the selection of your model and govern the application
of its use. Fluidity suggests that steps in the planning process are sequential, or that they
build on one another. It is usually a problem if certain steps in the planning process are
performed out of sequence as diagrammed in the Generalized Model. For example, a plan-
ner cannot develop goals and objectives until a needs assessment has been performed and a
priority health problem has been identified.
Flexibility means that planning is adapted to the needs of stakeholders. Due to various
circumstances, planning is usually modified as the process unfolds. For example, some
health problems, such as an outbreak of influenza, require a rapid assessment and scan of the
environment. Strict adherence to a model in light of unique and pressing circumstances will
generally lead to frustration among partners and a less-than-desirable outcome. Functionality
means that the outcome of planning is improved health conditions, not the production of
a program plan itself. A plan is only a tool to help planners accomplish their real work—to
improve health and decrease disease and disability.
In addition to the three Fs, when deciding on a planning model, it is also important to
ensure that the model is conducive to planning a population-based approach and that
it uses an ecological framework. Whereas systematic and strategic planning efforts can
address smaller populations such as those found in a small community or worksite, many
planning processes pertain to large population segments of even larger populations—thus
the term population-based approach.
Planners must also understand the interaction between a priority population and the
communities in which they live. The ecological framework helps planners better appreciate
that families, schools, employers, social networks, organizations, communities, and societies
exert an influence on individuals and priority populations as they attempt to change health

Chapter 3 Program Planning Models in Health Promotion 63
behaviors and improve their health (Bartholomew et al., 2011). Thus, planners must work
with priority populations within the context of broad environments.
In addition, during pre-planning, planners need to determine the extent to which
members of the priority population will be involved in the planning process and in
decision making. This varies widely in practice and may range from no community
involvement on one end of a continuum to an approach like community-based partici-
patory research where the community itself owns the program and is the unit of identity,
solution, and practice involved in all aspects of program development and delivery
(Trickett, 2011). Ideally, planning efforts in health promotion should use a partnership-
based approach in the context of  community empowerment and mobilization where
professionals work in unison with community members in taking actions to improve
health and reduce disease.
Summary
A model can provide the framework for planning a health promotion program. Several differ-
ent planning models have been developed and revised over the years. The planning models
for health promotion presented in this chapter have included:
1. The Generalized Model
2. Evidence-Based Planning Framework for Public Health
3. MAPP (Mobilizing for Action through Planning and Partnership)
4. MAP-IT (Mobilize, Assess, Plan, Implement, Track)
5. PRECEDE-PROCEED
6. Intervention Mapping
7. Healthy Communities (CHANGE tool)
8. SMART (Social Marketing Assessment and Response Tool)
The Generalized Model is recommended as the template for learning the basic principles
of planning and evaluation: (1) assessing needs; (2) setting goals and objectives; (3) develop-
ing interventions; (4) implementing interventions; and (5) evaluating results. Several other
models used in health promotion also continue to make valuable contributions typically
using these same elements.
Review Questions
1. How does an understanding of the Generalized Model help you understand other
planning models?
2. What are the elements or steps in the Generalized Model that are common in most,
if not all, other planning models?
3. Why is it important to use a model when planning?

64 Part 1 Planning a Health Promotion Program
4. How does pre-planning relate to most of the models presented in this chapter?
5. Explain the degree to which you believe consumers or members of the community
should be involved in the planning process. Do you believe they should own or control
the process?
Activities
1. After reviewing the models presented in this chapter, create your own model by
identifying what you think are the common components of the models. Provide a
rationale for including each component. Then draw a diagram of your model so that
you can share it with the class. Be prepared to explain your model.
2. In a one-page paper, defend what you believe is the best planning model presented in
this chapter.
3. Using a hypothetical health problem for a specific priority population, write a paper
explaining the steps/phases for one of the models presented in this chapter.
4. Identify a health promotion program reported as successful in a scientific journal. What
elements of the Generalized Model are described in the paper? Could you engage in an
effective planning process based on the amount of information provided in the article?
Summarize your comments in a one-page paper.
Weblinks
1. http://www.healthypeople.gov/2020/default.aspx
Healthy People
At this Website, Healthy People 2020 is outlined with several helpful links including:
(1) About Healthy People (background and general information); (2) Healthy People 2020
topics and objectives; (3) Data Search; (4) Leading Health Indicators (measurement and
progress); (5) Healthy People in Action (the Healthy People 2020 consortium and stories
from the field); and (6) Tools and Resources. This is a site with which planners in health
promotion should be familiar.
2. http://prcstl.wustl.edu/training/Pages/EBPH-Course-Information.aspx
Evidence-Based Planning for Public Health
This Website displays the evidence-based planning framework for public health
described in this chapter. PowerPoint presentations are provided for each skill and phase
associated with this framework.
3. http://www.naccho.org/topics/infrastructure/mapp/index.cfm
National Association of County and City Health Officials
At this Website, the MAPP model is comprehensively diagrammed and explained.
The four MAPP assessments are described, including how they are implemented, how to
use subcommittees for each assessment, and how to make linkages between assessments.
4. http://www.healthypeople.gov/2020/tools-and-resources/Program-Planning
MAP-IT: A Guide to Using Healthy People 2020 in Your Community

http://www.healthypeople.gov/2020/default.aspx

http://prcstl.wustl.edu/training/Pages/EBPH-Course-Information.aspx

http://www.naccho.org/topics/infrastructure/mapp/index.cfm

http://www.healthypeople.gov/2020/tools-and-resources/Program-Planning

Chapter 3 Program Planning Models in Health Promotion 65
This Website provides a valuable resource to assist health promotion professionals in
implementing Healthy People 2020. The site includes field notes for each of the phases in
MAP-IT with examples or case studies from various health organizations, as well as other
resources and tool kits for each planning phase.
5. http://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/change.htm
CHANGE Model (Community Health Assessment aNd Group Evaluation)
This Website provides a detailed description of CDC’s CHANGE model associated with
the implementation of the Healthy Communities Approach.
6. http://ctb.ku.edu/
Community Tool Box
This Website is an indispensable tool for all planners in health promotion. According to
the site, “The Tool Box offers more than 300 educational modules and other tools, many
of which pertain to planning steps and phases discussed in this chapter.
7. http://www.communityhlth.org/communityhlth/resources/hlthycommunities.html
Association for Community Health Improvement
This Website provides additional information on the Healthy Communities Initiative
including current projects and links.
8. http://www.cdc.gov/healthcommunication/
Gateway to Health Communication and Social Marketing Practice, Centers for Disease
Control and Prevention
This Website provides an overview of health communication and social marketing
practice including how to develop programs, segmenting an audience, and selecting
appropriate channels and tools for program delivery.

http://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/change.htm

http://ctb.ku.edu/

http://www.communityhlth.org/communityhlth/resources/hlthycommunities.html

http://www.cdc.gov/healthcommunication/

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67
Once the planning committee is in place and a planning model has been selected,
the next step in the planning process is to identify the needs of those in the priority popu-
lation. Gilmore (2012) has defined need as “the difference between the present situation
and a more desirable one” (p. 8). These needs can be expressed in many different ways.
For example, there may be a need for better health, or a need for more knowledge, or a
need to possess a certain skill, to name a few. Whether a need of the priority population is
4
Chapter Assessing Needs
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁⦁ Define need and needs assessment.
⦁⦁ Define capacity, community capacity, and capacity
building.
⦁⦁ Explain why a needs assessment is an important
part of the planning process.
⦁⦁ Explain what should be expected from a needs
assessment.
⦁⦁ Differentiate between primary and secondary
data sources.
⦁⦁ List the various methods for collecting
primary data.
⦁⦁ Locate secondary data sources that are in print
and on the World Wide Web.
⦁⦁ Explain how a needs assessment can be
completed.
⦁⦁ Explain what is meant by health impact
assessment.
⦁⦁ Conduct a needs assessment within a given
population.
Key Terms
action research
basic priority rating
(BPR)
bias
BPR model 2.0
capacity
capacity building
categorical funds
community capacity
community forum
Delphi technique
focus group
health assessments
(HAs)
health impact
assessment (HIA)
HIPAA
key informants
mapping
need
needs assessment
networking
nominal group
process
observation
obtrusive observation
opinion leaders
participatory data
collection
participatory research
photovoice
primary data
proxy measure
random-digit dialing
(RDD)
secondary data
self-assessments
self-report
significant others
single-step survey
unobtrusive
observation
walk-through
windshield tour

68 Part 1 Planning a Health Promotion Program
actual (true need) or perceived (reported need) does not matter (Gilmore, 2012). What mat-
ters is being able to identify all needs, actual and perceived, so that they can be addressed
through appropriate program planning.
From an epidemiologic viewpoint, a needs assessment has been defined as “[a] systematic
procedure for determining the nature and extent of problems experienced by a specific
population that affect their health either directly or indirectly” (Porta, 2014, p. 195). From a
program planning viewpoint, a needs assessment is defined as the process of identifying,
analyzing, and prioritizing the needs of a priority population. Other terms that have been
used to describe the process of determining needs include community analysis, community
diagnosis, and community assessment. Conducting a needs assessment may be the most critical
step in the planning process because it “provides objective data to define important health
problems, sets priorities for program implementation, and establishes a baseline for evaluat-
ing program impact” (Grunbaum et al., 1995, p. 54).
There are many reasons why a needs assessment should be completed before the other
steps of the planning process begin. First, it is a logical place to start (Gilmore, 2012). Before
a need can be met, it first must be identified and measured. Second, a needs assessment
can help ensure that scarce resources are allocated where they can give maximum health
benefit (Rowe, McClelland, & Billingham (2001). Without determining and prioritizing
needs, resources can be wasted on unsubstantiated programming. Third, a needs assessment
allows planners to “apply the principles of equity and social justice in practice” (Rowe et al.,
2001) by focusing on those in greatest need. Fourth, failure to perform a needs assessment
may lead to a program focus that prevents or delays adequate attention directed to a more
important health problem. For example, a health problem that tends to create a high emo-
tional response, particularly among parents, is the trauma associated with bicycle injuries
in children. Of course, it is a tragedy when a preventable death occurs. In 2013, 7% of the
743 bicyclists killed in the United States were children age 15 and under (NHTSA, 2015). But
an even more significant determinant of childhood injury and death in the United States is
the inadequate use of safety belts or car seats involved with motor vehicle crashes. In fact,
motor vehicle crashes are the leading cause of death among children in the United States
(Sauber-Schatz, West, & Bergen, 2014). A needs assessment that examined both bicycle
and motor vehicle crashes would lead planners to determine in most locations, in most in-
stances, that restraining children in motor vehicles with safety belts or approved car seats is
a more important issue.
Fifth, a needs assessment can determine the capacity of a community to address specific
needs. Capacity refers to the individual, organizational, and community resources, such
as leadership, relationships, operations, structures, infrastructure, politics, and systems, to
name a few, that can enable a community to take action (Brennan Ramirez, Baker, & Metzler,
2008; Gilmore, 2012). In other words, when related to health promotion, community
capacity is the “characteristics of communities that affect their ability to identify, mobilize,
and address social and public health problems” (Goodman et al., 1998, p. 259) (see Chapter 9
for mapping community capacity). “Assessing community capacity helps you think about
existing community strengths that can be mobilized to address social, economic, and envi-
ronmental conditions affecting health inequities. In general, you should look at the places
(e.g., parks, libraries) and organizations (e.g., education, health care, faith-based groups,
social services, volunteer groups, businesses, local government, law enforcement) in various

Chapter 4 Assessing Needs 69
sectors of the community” (Brennan Ramirez et al., 2008, p. 54). “It is also important to
identify the nature of the relationships across these sectors (e.g., norms, values), with the
community (e.g., civic participation), and among various subgroups within the community
(e.g., distribution of power and authority, trust, identity)” (Sampson & Raudenbush, 1999,
and Trachim, 1989, as cited in Brennan Ramirez et al., 2008, p. 54).
Sixth, a needs assessment can provide a focus for developing an intervention to meet the
needs of the priority population. And finally, knowing the needs of a priority population
provides a reference point to which future assessments can be compared.
Having just stated several reasons why a needs assessment should be completed, it may
seem odd that there are a few planning scenarios in which a needs assessment would not be
used. The first would be if another needs assessment had been conducted recently, possibly
for another related program, and the funding or other resources to conduct a second needs
assessment in such a short period of time were not available. A second scenario in which
a needs assessment may not be used is one where the program planners are employed by
an agency that deals only with a specific need that is already known (e.g., cancer and the
American Cancer Society), or the agency for which they work has received categorical
funds that are earmarked or dedicated to a specific disease (e.g., HIV/AIDS), health determi-
nant (e.g., risk factor), or program (e.g., immunization).
Although a needs assessment has long been an important step in health promotion
process, two recent events have made the public more aware of the importance of a needs
assessment. In 2003, the Institute of Medicine (2003) recommended examination of health
department accreditation as a means of improving public health agency performance. After
such an examination, the Public Health Accreditation Board (PHAB) was created in 2007
to create an accreditation process for governmental public health departments operated by
tribes, states, local jurisdictions, and territories (PHAB, 2013b). In July 2011, PHAB released
the Accreditation Standards and Measures. In order for a health department to become ac-
credited, it must show its work meets the standards and measures that are spread over 12 do-
mains. The first domain, which is a needs assessment, is stated as “Conduct and Disseminate
Assessments Focused on Population Health Status and Public Health Issues facing the
Community” (PHAB, 2013a, p. 13).
The second event that has made needs assessments more visible to the public was the
passing of the Patient Protection and Affordable Care Act (PPACA also known as the ACA)
that added section 501(r) to the Internal Revenue Code. Under section 501(r) of the code,
501(c)(3) organizations that operate one or more hospitals (i.e., non-profit hospitals) must
meet four general requirements in order for the organization to maintain its 501(c)(3) tax-
exempt status. One of the four general requirements is to conduct a community health needs
assessment (CHNA) and adopt an implementation strategy for addressing the needs at least
once every three years (CDC, n.d.b). Further, the IRS guidelines require that these organiza-
tions partner with a public health agency in conducting the CHNA. Each of these events that
require community needs assessments will add to improving the community’s health.
The remaining portions of this chapter will present discussions on what to expect from
a needs assessment, the types and sources of data used to conduct a needs assessment, and a
suggested process for conducting a needs assessment. Box 4.1 identifies the responsibilities
and competencies for health education specialists that pertain to the material presented in
this chapter.

70 Part 1 Planning a Health Promotion Program
What to Expect from a Needs Assessment
Several authors have provided lists of questions that should be answered after completing a
needs assessment. They include:
1. Who makes up the priority population? (Petersen & Alexander, 2011)
2. What are the needs of the priority population? (Petersen & Alexander, 2011)
3. Why do these needs exist? (NACCHO, n.d.)
4. What factors create or determine the need? (NACCHO, n.d.)
5. Which subgroups within the priority population have the greatest need? (Petersen &
Alexander, 2011)
6. Where are these subgroups located geographically? (Petersen & Alexander, 2011)
7. What resources are available to address the needs? (NACCHO, n.d.)
8. What is currently being done to resolve identified needs? (Petersen & Alexander, 2011)
9. How well have the identified needs been addressed in the past? (Petersen & Alexander, 2011)
Indirectly, getting answers to the latter three questions, numbers 7, 8, and 9, provides some in-
formation about the community capacity and whether part of the identified needs may include
the need to build capacity. Capacity building refers to activities that enhance the resources
of individuals, organizations, and communities to improve their effectiveness to take action.
No matter how needs assessment is defined, the concept embedded in the definitions is the
same: identifying the needs of the priority population and determining the degree to which
the needs are being met. If needs are not being met, there may also be a need to enhance capac-
ity of the community.
4.1
Box Responsibilities and Competencies for Health Education Specialists
The content of this chapter is associated with a single area of responsibility. That
responsibility and related competencies include:
RESponSiBility i: Assess Needs, Resources, and Capacity for Health Education/Promotion
Competency 1.1: Plan assessment process for health education/promotion
Competency 1.2: Access existing information and data related to health
Competency 1.3: Collect primary data to determine needs
Competency 1.4: Analyze relationships among behavioral, environmental,
and other factors that influence health
Competency 1.5: Examine factors that influence the process by which
people learn
Competency 1.6: Examine factors that enhance or impede the process of
health education/promotion
Competency 1.7: Determine needs for health education/promotion based
on assessment findings
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc.
(NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc. (NCHEC)
and the Society for Public Health Education (SOPHE).

Chapter 4 Assessing Needs 71
Acquiring Needs Assessment Data
Two types of data are generally associated with a needs assessment: primary data and
secondary data. Primary data are those data you collect yourself (via a survey, a focus
group, in-depth interviews, etc.) that answer unique questions related to your specific needs
assessment. Most methods of collecting primary data are ones in which those collecting
the data interact with (e.g., interviewing) or minimally interact with (e.g., windshield tour)
those from whom the data are being collected. Such methods have been labeled as interac-
tive contact methods or minimal contact observational methods (Marti-Costa & Serrano-Garcia
as cited in Hancock & Minkler, 2012). Secondary data are those data already collected by
somebody else and available for your use. Thus, the methods to collect these data have been
labeled as no contact methods (Marti-Costa & Serrano-Garcia as cited in Hancock & Minkler,
2012). The advantages of using secondary data are that (1) they already exist, and thus
collection time is minimal, and (2) they are usually fairly inexpensive to access compared
to primary data. Both of these advantages are important to planners because programs
are often planned when both time and money are limited. However, a drawback of using
secondary data is that the information might not identify the true needs of the priority
population—perhaps because of how the data were collected, when they were collected,
what variables were considered, or from whom the data were collected. A good rule is to
move cautiously and make sure the secondary data are applicable to the immediate situa-
tion before using them.
Primary data have the advantage of directly answering the questions planners want
answered by those in the priority population. However, collecting primary data can be
expensive and when done correctly, take a great deal of time.
An overview of the means of acquiring primary and secondary data are presented in the
following pages.
Sources of primary Data
Primary data can be collected using a variety of methods. Those most commonly used in
planning health promotion programs are presented in Box 4.2.
SinglE-StEp oR CRoSS-SECtional SuRvEyS
Single-step surveys, or as they are often called cross-sectional (point-in-time) surveys, are a
means of gathering primary data from individuals or groups with a single contact—thus, the
term single-step. Such surveys often take the form of written questionnaires and interviews.
When individuals or groups (also sometimes called respondents or participants) are answering
questions about themselves, the information that is provided is referred to as self-report
data. Thus, respondents are asked to recall (e.g., “When was your last visit to your dentist?”)
and report accurate information (e.g., “On average, how many minutes do you exercise
each day?”). Self-report measures are essential for many needs assessments and evaluations
because of the need to obtain subjective assessments of experiences (e.g., feelings about
available programs, self-assessments of health status, and health behavior, such as eating
patterns) (Bowling, 2005). “For some behaviors, such as safer sex behaviors, this is the only
way one can measure behavior” (Sharma & Petosa, 2014, p. 100). Even marketing data (e.g.,
the best location for a program, the best time to offer a program, and willingness to pay for a

72 Part 1 Planning a Health Promotion Program
program) and capacity data (e.g., “What resources are needed to make this change?) can be
collected through these assessments. In addition, self-report measures have a broad appeal
to those who need to collect data, because “they are often quick to administer and  involve
little interpretation by the investigator” (Bowling, 2005, p. 15). However, planners should
be aware that self-report data do have limitations. One such limitation is bias (Windsor,
2015)—those data that have been distorted because of the way they have been collected.
(See the section in Chapter 5 on bias free data.) To overcome some of these limitations and
to maximize the usefulness of self-report, Baranowski (1985) has developed eight steps to
increase the accuracy of this method of data collection:
1. Select measures that clearly reflect program outcomes.
2. Select measures that have been designed to anticipate the response problems and that
have been validated.
3. Conduct a pilot study with the priority population. (See Chapter 5 for pilot studies.)
4. Anticipate and correct any major sources of unreliability.
5. Employ quality-control procedures to detect other sources of error.
6. Employ multiple methods.
7. Use multiple measures.
8. Use experimental and control groups with random assignment to control for biases in
self-report.
By following these steps, planners can enhance the accuracy of self-report, making this a more
effective method of data collection.
For a variety of reasons, there are times when those in the priority population cannot re-
spond for themselves or do not want to respond. For example, children who have not learned
how to read yet or people with dementia (Streiner, Norman, & Cairrney, 2015). In such
situations, planners will have to collect data indirectly by asking another (i.e., proxy reporter)
(Streiner et al., 2015) or looking for indications of a behavior. Such a method is referred to
4.2
Box
Single-Step or Cross-Sectional Surveys
From priority population—self-report
written questionnaires
telephone interviews
face-to-face interviews
electronic interviews
group interviews
Proxy measures
From significant others
From opinion leaders
From key informants
Multistep Survey: Delphi Technique
Sources of primary Data
Community Forum (Town Hall Meeting)
Meetings
Focus Group
Nominal Group Process
Observation
Direct observation
Indirect observation (proxy measures)
“Windshield” or walk-through (walking
tours)
Photovoice and videovoice
Self-Assessments
Fo
cu
s
O
n

Chapter 4 Assessing Needs 73
as a proxy (or indirect) measure. A proxy measure is an outcome measure that provides
evidence that a behavior has occurred. Or as Dignan (1995) stated, “indirect measures are
unmistakable signs that a specific behavior has occurred” (p. 103). Examples of proxy mea-
sures include (1) lower blood pressure for the behavior of medication taking, (2) body weight
for the behaviors of exercise and dieting, (3) cotinine in the blood for tobacco use, (4) empty
alcoholic beverages in the trash for consumption of alcohol, or (5) another person reporting
on the compliance of his/her partner (Cottrell & McKenzie, 2011). Proxy measurements of
skills or behavior usually require more resources and cooperation to obtain than self-report
or direct observation (Dignan, 1995). The greatest concern associated with proxy measures is
making sure that the measure is both valid and reliable (Cottrell & McKenzie, 2011).
In addition to surveying the priority population, there are other groups of individuals
who are commonly asked to respond to single-step surveys for the purpose of collecting
primary needs assessment data. They include significant others of the priority population,
community opinion leaders, and key informants. Significant others may include family
members and friends. Collecting data from the significant others of a group of heart disease
patients is a good example. Program planners might find it difficult to persuade heart disease
patients themselves to share information about their outlook on life and living with heart
disease. A survey of spouses or other family members might help elicit this information so
that the program planners could best meet the needs of the heart disease patients.
Opinion leaders are individuals who are well respected in a community and who can
accurately represent the views of the priority population. These leaders are:
1. Discriminating users of the media
2. Demographically similar to the priority group
3. Knowledgeable about community issues and concerns
4. Early adopters of innovative behavior (see Chapter 11 for an explanation of these terms)
5. Active in persuading others to become involved in innovative behavior
Opinion leaders include political figures, chief executive officers (CEOs) of companies, union
leaders, administrators of local school districts, and other highly visible and respected indi-
viduals. (See Figure 4.1 for a form for tallying opinion leader survey data.)
Key informants are individuals with unique knowledge about a particular topic. For
example, it may be a person who has had a specific problem like losing weight being able to
talk about the barriers of such an experience, or a person who has tried to get health insur-
ance through an exchange only to be denied coverage. Because their information may only
represent a single experience and thus be biased, planners need to be careful not to base an
entire needs assessment on the data generated from a key informant survey.
Single-step surveys of those in the priority population, significant others, opinion leaders,
and key informants can be administered, as noted earlier, several different ways. The primary
means of collecting data from these individuals include written questionnaires, telephone
interviews, face-to-face interviews, electronic interviews, and group interviews. A discussion
of each follows.
WRittEn QuEStionnaiRES
One of the most often used methods of collecting self-reported data is the written
questionnaire. It has several advantages, notably the ability to reach a large number of

74 Part 1 Planning a Health Promotion Program
respondents in a short period of time, even if there is a large geographic area to be covered.
This method offers low cost with minimum staff time needed. However, it often has the
lowest response rate.
With a written questionnaire, each individual receives the same questions and instruc-
tions in the same format, so that the possibility of response bias is lessened. The corre-
sponding disadvantage, however, is the inability to clarify any questions or confusion
on the part of the respondent. As mentioned, the response rate for mailed questionnaires
tends to be low especially if respondents cannot remain anonymous, but there are several
ways to overcome this problem. One way is to include with the questionnaire a postcard
that identifies the person in some way (such as by name or identification number). The in-
dividual is asked to return the questionnaire in the envelope provided and to send the post-
card back separately. Anonymity is thus maintained, but the planner/evaluator knows who
has returned a questionnaire. The planner/evaluator can then send a follow-up mailing
(including a letter indicating the importance of a response and another copy of the ques-
tionnaire with a return envelope) to the individuals who did not return a postcard from the
first mailing. The use of incentives also can increase the response rate. For example, some
hospitals offer free health risk appraisals to those who return a completed needs assessment
instrument.
The appearance of the questionnaire is also extremely important when collecting data.
It should be attractive, easy to read, and offer ample space for the respondents’ answers. It
should also be easy to understand and complete, because written questionnaires provide no
opportunity to clarify a point while the respondent is completing the questionnaire. In addi-
tion, all mailed questionnaires should be accompanied by a cover letter, to help clarify direc-
tions for completion (see Chapter 5 for more information on questionnaire design).
__________________________________________
Number of interviewersData collection method
______________________________
To: _____From: ______ Total number of people interviewed
Date Collected ________
Number of Persons
Identifying Problem
Percentage of Persons
Identifying ProblemRank Health Problem
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
⦁▲ Figure 4.1 Form to Tally Opinion Leader Survey Data
Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (no date), p. A3–12.

Chapter 4 Assessing Needs 75
Short questionnaires that do not take a long time to complete and questionnaires that
clearly explain the need for the information are more likely to be returned. Planners/evaluators
should give thought to designing a questionnaire that is as easy to complete and return as pos-
sible. For other strategies to increase response rates to written questions delivered via the postal
service see the systematic review conducted by Edwards et al. (2009).
FaCE-to-FaCE intERviEWS
At times, it is advantageous to administer the instrument to the respondents in a face-to-face
interview setting. This method is time consuming because it may require not only time for
the actual interview but also travel time to the interview site and/or waiting time between
interviews. The interviewer must be carefully trained to conduct the interview in an unbi-
ased manner. It is important to explain the need for the information in order to conduct the
needs assessment/evaluation and to accurately record the responses. Methods of probing, or
eliciting additional information about an individual’s responses, are used in the face-to-face
interview, and the interviewer must be skilled at this technique.
This method of self-report allows the interviewer to develop rapport with the respondent.
The flexibility of this method, along with the availability of visual cues, has the advantage of
gaining more complete data from respondents. Smaller numbers of respondents are included
in this method, but the rate of participation is generally high. It is important to establish
and follow procedures for selecting the respondents. There are also several disadvantages
to the face-to-face interview. It is more expensive, requiring more staff time and training of
interviewers. Variations in the interviews, as well as differences between interviewers, can
influence the results.
tElEpHonE intERviEWS
Compared to mailed surveys or face-to-face interviews, the telephone interview offers a
relatively easy method of collecting self-reported data at a moderate cost. But it is not as easy
and inexpensive as it once was “due in part to the increasing use of cell phones” (SHADAC,
2009, p. 1). The number of households in the United States that do not have landline tele-
phone service, known as wireless-only households, continues to grow. It has been estimated
that more than two out of five American homes (44.0%) have only wireless telephones and
another 2.6% do not have any phone service (Blumberg & Luke, 2014). The prevalence of
such ‘wireless-only’ households now markedly exceeds the prevalence of households with
only landline telephones (8.5%), and this difference is expected to grow (Blumberg & Luke,
2014). Those most likely to live in wireless-only households are younger, living with other
nonrelated adults, renting their residence, and being non-white (Blumberg & Luke, 2014).
Therefore, depending on whom planners/evaluators are trying to interview and how they
plan to select the participants for interviews, some individuals may not have a chance of
being selected and/or contacted.
Prior to so many people living in wireless-only households, participants who were to be
interviewed by telephone were selected using some type of random process. One method
was to randomly select people from a “list.” For example, a program participants’ list, a local
telephone book, student directory, church directory, or employee directory. However, select-
ing people randomly from a list misses people with unlisted telephone numbers and/or cell
phones. One way to overcome this problem is a method known as random-digit dialing
(RDD), in which telephone number combinations are chosen at random. This method would

76 Part 1 Planning a Health Promotion Program
include businesses as well as residences and nonworking as well as valid numbers, making it
more time consuming. The numbers may be obtained from a table of random numbers or
generated by a computer. The advantage of random-digit dialing is that it includes the entire
survey population with a telephone in the area, including people with unlisted numbers and
cell phones. However, there are several drawbacks to using RDD. The first is that those with
cell phones may not have a telephone number with an area code in which they live. This is
a problem because in order to use the RDD technique both the area codes and the exchanges
(i.e., the first three digits of the seven-digit telephone number) must be known. Another draw-
back is some peoples’ resistance to answering questions over the telephone or resentment
about being interrupted with an unwanted call. And finally, those conducting the interviews
may also have a difficult time reaching individuals because of unanswered phones or answer-
ing machines.
Like face-to-face interviews, telephone interviewing requires trained interviewers; without
proper training and use of a standard questionnaire, the interviewer may not be consistent
during the interview. Explaining a question or offering additional information can cause a
respondent to change an initial response, thus creating a chance for interviewer bias. The
interviewer does have the opportunity to clarify questions, which is an advantage over the
written questionnaire, but does not have the advantage of visual cues that the face-to-face
interview offers.
ElECtRoniC intERviEWS
With more and more individuals having access to the Internet and email [87% of U.S. adults
use the Internet, and 72% of Internet users say they looked online for health information
during the past year (Pew Research Center, 2014)], it was only a matter of time until planners/
evaluators used them to conduct interviews. Advantages to using this type of interviewing
compared to using a written questionnaire include the reduced response time, cost of materi-
als, ease of data collection, flexibility in the design and format of the questionnaire, control
over the administration such as distribution to the recipients all at the same time on the
same day, and recipient familiarity with the format and technology (Neutens & Rubinson,
2014). In addition, responses received can be formatted to enter directly into a spreadsheet/
statistical package eliminating manual data entry or scanning (Cottrell & McKenzie, 2011).
However, there are several drawbacks to using the Internet for interviewing: not everyone
has access to the Internet, obtaining email addresses of the possible respondents can be diffi-
cult, and some people’s lack of comfort in using a computer. To date, studies in the literature
on the response rate to electronic interviews has been mixed, with some studies reporting
good results and others reporting lower rates similar to written questionnaires sent via the
U.S. mail (Cottrell & McKenzie, 2011).
With the expanded use of the Internet has come an increase in the number of commer-
cial companies (e.g., FluidSurveys, Qualtrics, QuestionPro, SurveyMonkey, surveygizmo,
Zoomerang) that offer services to assist those in using this method of interviewing. This is
how they work. Customers sign up and pay a fee. For the most part, the fee is based on the
amount of service provided and the length of time the service is used. Typical services of-
fered include design and preparation of the questionnaire, translation of the questionnaire
into another language, customizing the questionnaire with organization logo/branding,
personalized email cover letter introducing the questionnaire, personalized email thank-you
letters for those who complete the instrument, data tallying and analysis, various trainings,

Chapter 4 Assessing Needs 77
and customer support. The costs of the services vary depending on the type of customer, but
most companies provide a discount for not-for-profit and educational organizations. Some
companies provide free options for limited use. One drawback of such commercial services
is that they may not meet the security policies of some potential users (e.g., medical centers).
gRoup intERviEWS
Interviewing individuals in groups provides for economy of scale. That is, data can be col-
lected from several people in a short period of time. But there are some drawbacks of such
data collection that primarily revolve around one or more group members’ influencing
the response of others. A specific form of group interview discussed later in this chapter is
focus groups. Focus groups are useful in collecting information for a needs assessment, but
can also be used to determine if programs are being implemented effectively or determine
program outcomes.
MultiStEp SuRvEy
As its title suggests, a multistep survey is one in which those collecting the data contact those
who will provide the data on more than one occasion. The technique that uses this process
is called the Delphi technique. It is a process that generates consensus through a series of
questionnaires, which are usually administered via mail or electronic mail. The process be-
gins with those collecting the data asking the priority population to respond to one or two
broad questions. The responses are analyzed, and a second questionnaire with more specific
questions based on responses to the first questionnaire, is developed and sent to the priority
population. The answers to these more specific questions are analyzed again, and another
new questionnaire is created and sent out, requesting additional information. If consensus is
reached, the process may end here; if not, it may continue for another round or two (Gilmore,
2012). Most often, this process continues for five or fewer rounds.
CoMMunity FoRuM
The community forum, also sometimes referred to as a town hall meeting, approach brings
together people from the priority population to discuss what they see as their group’s problems/
needs. It is not uncommon for a community forum to be organized by a group representing the
priority population, in conjunction with the program planners. Such groups include labor,
civic, religious, or service organizations, or groups such as the Parent Teacher Association
(PTA). Once people have arrived, a moderator explains the purpose of the meeting and then
asks those from the priority population to share their concerns. One or several individuals
from the organizing group, called recorders, are usually given the responsibility for taking notes
or recording the session to ensure that the responses are documented accurately. However,
when moderating a community forum, it is important to be aware that the silent majority may
not speak out and/or a vocal minority may speak too loudly. For example, an individual par-
ent’s view may be wrongly interpreted to be the view of all parents.
At a community forum, participants may also be asked to respond in writing (1) by answer-
ing specific questions or (2) by completing some type of instrument. Figure 4.2 is an example
of an instrument that could be used to collect data from participants in a community forum.
MEEtingS
Meetings are a good source of information for a preliminary needs assessment or various
aspects of evaluation. For example, if a health department is planning to conduct a needs

78 Part 1 Planning a Health Promotion Program
assessment and would like some direction on what health topics to key in on, planners may
meet with a small group from the priority population to find out what they see as health issues
in the community.
The meeting structure can be flexible to avoid limiting the scope of the information
gained. The cost of this form of data collection is minimal. Possible biases may occur when
meetings are used as the sole source of data collection. Those involved may give “socially
acceptable” responses to questions rather than discussing actual concerns. There also may
be limited input if relatively few participants are included, or if one or two participants
dominate the discussion.
FoCuS gRoup
The focus group is a form of qualitative research that grew out of group therapy. Focus
groups are used to obtain information about the feelings, opinions, perceptions, insights,
beliefs, misconceptions, attitudes, and receptivity of a group of people concerning an idea
or issue. Focus groups are rather small, compared to community forums, and usually include
only 8 to 12 people. If possible, it is best to have a group of people who do not know each
other so that their responses are not inhibited by acquaintance. Participation in the group
is by invitation. People are invited about one to three weeks in advance of the session. At
the time of the invitation, they receive general information about the session but are not
given any specifics. This precaution helps ensure that responses will be spontaneous yet ac-
curate. Once assembled, the group is led by a skilled moderator who has the task of obtaining
candid responses from the group to a set of predetermined questions. In addition to elicit-
ing responses to the questions, the moderator may ask the group to prioritize the different
Directions: Please rank the need for each program in the community by placing a number in the
space to the left of the programs. Use 1 to rank the program of greatest need, 2 for the next
greatest need, and so forth, until you have ranked all seven programs. The program with the
highest number next to it should be the one that, in your opinion, is least needed. If you feel that
a program should not be considered for implementation in our community, please place an X in
the space to the left of the program instead of a number. Please note that the number you place
next to each program represents its need in the community, not necessarily your desire to par-
ticipate in it. After ranking the program, place an X to the right of the program in the column(s)
that represent the age group(s) to which you feel the program should be targeted.
Children
5–12
Teens
13–19
Adults
20–64
Older
adults 65�Program All ages
_______ Alcohol education: ________ ________ ________ ________ ________
_______ Exercise/�tness: ________ ________ ________ ________ ________
_______ Nutrition education: ________ ________ ________ ________ ________
_______ Safety belt use: ________ ________ ________ ________ ________
_______ Smoking cessation: ________ ________ ________ ________ ________
_______ Smoking education: ________ ________ ________ ________ ________
_______ Weight loss: ________ ________ ________ ________ ________
⦁▲ Figure 4.2 Instrument for Ranking Program Need
Source: Instrument for Ranking Program Need. Amy L. Bernard. Copyright © 2011 by Amy L. Bernard. Reprinted with permission.

Chapter 4 Assessing Needs 79
responses. As in a community forum, the answers to the questions are recorded through
either written notes and/or audio or video recordings, so that at a later date the interested
parties can review and interpret the results.
Focus groups are not easy to conduct. Special care must be given to developing the ques-
tions that will be asked. Poorly written questions will yield information that is less than use-
ful. In addition, the moderator should be one who is skilled in leading a group. As might be
surmised, the level of skill needed to conduct a focus group increases as the topic of discus-
sion becomes more controversial.
Although focus groups have been shown to be an effective way of gathering data, they
do have one major limitation. Participants in the groups are usually not selected through a
random-sampling process. They are generally selected because they possess certain attributes
(e.g., individuals of low income, city dwellers, parents of disabled children, or chief executive
officers of major corporations). Participants may not be representative of the priority popula-
tion. Therefore, the results of the focus group are not generalizable (CDC, 2008a). For more
detail and information about preparing for and conducting focus groups, see Gilmore (2012),
National Cancer Institute (n.d.), and Teufel-Shone & Williams (2010).
noMinal gRoup pRoCESS
The nominal group process is a highly structured process in which a few knowledgeable
representatives of the priority population (5 to 7 people) are asked to qualify and quantify
specific needs. Those invited to participate are asked to record their responses to a question
without discussing it among themselves. Once all have recorded a response, participants
share their responses in a round-robin fashion. While this is occurring, the facilitator is
recording the responses on a computer screen, chalkboard or flipchart for all to see. The
responses are clarified through a discussion. After the discussion, the participants are asked
to rank-order the responses by importance to the priority population. This ranking may be
considered either a preliminary or a final vote. If it is preliminary, it is followed with more
discussion and a final vote.
oBSERvation
Observation, defined as “notice taken of an indicator” (Green & Lewis, 1986, p. 363), can also
be an effective means of collecting data. Not only can people be observed, but the environment
(i.e., those things around the priority population) can be observed as well. Because those doing
the observation can “see” but do not interact with those in the priority, observation has been
labeled a minimal-contact method of data collection.
Observation can be direct or indirect. Direct observation means actually seeing a situation
or behavior. For example, direct observation may include watching the eating patterns of
children in a school lunchroom, observing workers on an assembly line to see if they are
wearing their protective glasses, checking the smoking behavior of employees on break, and
observing drivers for safety belt use. This method is somewhat time consuming, but it seldom
encounters the problem of people refusing to participate in the data collection, resulting in a
high response rate.
Observation is generally more accurate than self-report, but the presence of the observer
may alter the behavior of the people being observed. For example, having someone ob-
serve smoking behavior may cause smokers to smoke less out of self-consciousness due to
their being under observation. When people know they are being observed it is referred

80 Part 1 Planning a Health Promotion Program
to as obtrusive observation. Unobtrusive observation means just the opposite; the
persons being studied are not aware they are being measured, assessed, or tested. Typically,
unobtrusive observation provides less biased data, but some question whether unobtrusive
observation is ethical.
Differences among observers may also bias the results, because different observers may
not observe and report behaviors in the same manner. Some behaviors, such as safety belt
use, are very easy to observe accurately. Others, such as a person’s degree of tension, are more
difficult to observe. This method of data collection requires a clear definition of the exact
behavior to observe and how to record it (i.e., having an observation checklist), in order to
avoid subjective observations. Observer bias can be reduced by providing training and by
determining rater reliability. If the observers are skilled, observation can provide accurate
needs assessment or evaluation data at a moderate cost.
As noted earlier in this chapter, indirect observation (or proxy measure) can also be used to
determine whether a behavior has occurred. This can be completed by either “observing” the
outcomes of a behavior (e.g., pills left in a bottle) or by asking others (e.g., spouse) to report
on such outcomes (see the earlier discussion on proxy measures). In addition, these measures
can be used to verify self-reports when observations of the actual changes in behavior cannot
be observed.
Some specific methods of observation that have been useful in collecting data for
health promotion programs are windshield tours or walk-throughs and photovoice. When us-
ing a windshield tour or walk-through, the person(s) doing the observation “walks or
drives slowly through a neighborhood, ideally on different days of the week and at differ-
ent times of the day, ‘on the lookout’ for a whole variety of potentially useful indicators of
community health and well-being” (Hancock & Minkler, 2012, p. 164). Potentially useful
indicators may include: “(A) Housing types and conditions, (B) Recreational and commercial
facilities, (C) Private and public sector services, (D) Social and civic activities, (E) Identifiable
neighborhoods or residential clusters, (F) Conditions of roads and distances most travel, (G)
Maintenance of buildings, grounds and yards” (Eng & Blanchard, 1990–1991, p. 96–97).
Photovoice (formerly called photo novella) is the creation of Wang and Burris (1994,
1997). It is a form of participatory data collection (i.e., those in the priority population
participate in the data collection) in which those in the priority population are provided
with cameras and skills training (on photography, ethics, data collection, critical discussion,
and policy), then use the cameras to convey their own images of the community problems
and strengths (Kramer et al., 2010; Minkler & Wallerstein, 2012). “Photovoice has 3 main
goals: (1) to enable people to record and reflect their community’s strengths and concerns;
(2) to promote critical dialogue and enhance knowledge about issues through group discus-
sions of the photographs; and (3) to inform policy makers” (FYVPC, 2006, para. 2).
Photovoice has been used a lot with “marginalized groups of various ages that want their
perspective seen and heard by those in power” (WCPH, 2009, p. 1). More recently it has been
receiving increased attention because of its application to health promotion. There are a
number of reports of its use in the literature that have resulted in successful policy and envi-
ronmental changes (e.g., Goodhard et al., 2006; Kramer et al., 2010; Wang, Morrel-Samuels,
Hutchinson, Bell, & Pestronk, 2004). It has also been used with a variety of community and
public health problems.
The process for using photovoice involves the following steps: (1) defining the goals
and objectives of the project; (2) identifying the community participants; (3) providing

Chapter 4 Assessing Needs 81
participants with the purpose and philosophy behind photovoice; (4) providing partici-
pants with training to carry out the project; (5) providing a theme for taking the pictures
(e.g., “show what is unhealthy about our community”); (6) letting the participants take the
pictures; (7) selecting the photographs that reflect the concerns of the project; (8) in groups,
engaging in meaningful dialogue about the significance of each photograph; (9) contextu-
alizing the photographs by writing captions based on the mnemonic SHOWeD created by
Wallerstein (1987) (i.e., What do you See here? What’s really Happening here? How does
this relate to Our lives? Why does this problem or this strength exist? What can we Do
about this?); (10) codifying the results by identifying the issues, themes, or theories that
emerge; (11) identifying the stakeholders and venues to present the results; (12) making
the presentation(s) to the community stakeholders (e.g., policy makers, decision makers)
and the public; and (13) taking action based on results of the photovoice process (Downey,
Ireson, Scutchfield, 2009; Kramer et al., 2010; STEPS Centre, 2015; University of Kansas,
2014; Wang & Burris, 1997; Wang, Morrel-Samuels, et al., 2004; Wang, Yi, Tao, & Carovano,
1998; WCPH, 2009).
For those interested in learning more about photovoice please see reviews by Catalani and
Minkler (2010) and Hergenrather, Rhodes, and Bardhoshi (2009).
SElF-aSSESSMEntS
Data can also be collected by those in the priority population through self-assessments.
“A majority of these approaches address primary prevention issues, such as the assessment
of risk factors and protective factors in one’s lifestyle pattern, and the secondary prevention
process of the early detection of disease symptoms” (Gilmore, 2012, p. 179). Examples of
such assessments include breast self-examination (BSE), testicular self-examination (TSE),
self-monitoring for skin cancer, and health assessments (HAs). “Health assessments in-
clude instruments known as health risk appraisals or health risk assessments (HRAs), health
status assessments (HSAs), various lifestyle-specific (e.g., nutrition, stress, and physical activ-
ity) assessment instruments, wellness and behavioral/habit inventories” (SPMBoD, 1999,
p.  xxiii), and disease/condition status assessments (e.g., chances of getting heart disease or
diabetes). HAs, specifically HRAs, have been used more in worksite health promotion pro-
grams than in other settings.
Of the different self-assessments, it is the HAs that have been most useful in the needs
assessment process, because from such assessments planners can obtain “group data which
summarize major health problems and risk factors” (Alexander, 1999, p. 5). And of the HAs,
it is the HRAs that are most often included in the needs assessment process. HRAs are instru-
ments that estimate “the odds that a person with certain characteristics will die from selected
causes within a given time span” (Alexander, 1999, p. 5). Even though HRAs are used as part
of needs assessments, this was not their original intent. The original purpose of HRAs was to
engage family physicians and their patients in conversation about risks of premature death
and preventive health behaviors (Robbins & Hall, 1970).
To use an HRA as part of a needs assessment, planners would have those in the prior-
ity population complete a questionnaire. The instruments include questions about health
behavior (e.g., smoking, exercise), personal or family health history of diseases (e.g., can-
cer, heart disease), demographics (e.g., age, sex), and usually some physiological data (e.g.,
height, weight, blood pressure, cholesterol). The resulting risk appraisals, in most cases,
are calculated by computers, but some HRAs are hand-scored by the participant or health

82 Part 1 Planning a Health Promotion Program
professional (Alexander, 1999). Most HRAs generate both individual and group reports. Thus
planners can use the individual reports as part of an educational program for the priority
population and use the group reports as another source of primary needs assessment data.
There are many HA instruments on the market. Before using one, you need to review
information about the instruments that are available. Hunnicutt (2008a) created 10 critical
questions that need to be asked when a health risk appraisal is purchased from a vendor: (1)
How long has the vendor been in business? (2) How many other clients have used the instru-
ment? (3) Who was behind the development of the HRA? (4) What is the best price? (5) Is
the vendor willing to share the names of other clients who have used the HRA? (6) Is there
any litigation pending against the vendor? (7) Is the vendor Health Insurance Portability
and Accountability Act (HIPAA) compliant? (8) Will the vendor store the HRA data at a site
outside the United States? (9) Is customer service/technical assistance included with the pur-
chase of the HRA? (10) Who is the key contact within the company of the vendor and what is
his/her emergency number?
Although this discussion has revolved around the use of HRAs as means of providing
information for a needs assessment, they have also been used to help motivate people to:
act on their health, measure health status, increase productivity, increase awareness, serve
as cues to action, and to contribute to program design and evaluation (Simpson, Hyner, &
Anderson, 2013) (see Hunnicutt, 2008b, for benefits of using personal health assessments
in a worksite). However, it should be noted that the Community Preventive Services Task
Force (CPSTF) has conducted two separate reviews on the use of HRAs among employees.
In the first review, it was found that there was insufficient evidence to recommend the
use of HRAs with appropriate feedback to achieve improvements in health behavior. In
the second review, it was found that there was sufficient evidence to recommend the use
of HRAs with appropriate feedback when combined with health education programs, and
with or without additional interventions for improving health behaviors of employees
(CPSTF, 2006 & 2007).
table 4.1 summarizes the advantages and disadvantages of the various methods of col-
lecting primary data.
Sources of Secondary Data
Several sources of secondary needs assessment data are available to planners. The main
sources include data collected by government agencies at multiple levels (federal, state, or
local), data available from nongovernment agencies and organizations, data from existing
records (e.g., medical records), and data or other evidence that are presented in the literature
(see table 4.2).
Data CollECtED By govERnMEnt agEnCiES
Certain government agencies collect data on a regular basis. Some of the data collection is
mandated by law (e.g., census, births, deaths, notifiable diseases), whereas other data are
collected voluntarily (e.g., usage rates for safety belts). Because the data are collected by the
government, program planners can gain free access to them by contacting the agency that
collects the data, or by finding them on the Internet, or in a library that serves as a United
States government depository. Many college and university libraries and large public librar-
ies serve as such depositories.

Chapter 4 Assessing Needs 83
TAbLe 4.1 Methods of Collecting Primary Data
Method Advantages Disadvantages
Self-Report
Written questionnaire
via mail
Large outreach
No interviewer bias
Convenient
Low cost
Minimum staff time required
Easy to administer
Quick
Standardized
Possible low response rate
Possible problem of representation
No clarification of questions
Need homogenous group if response
is low
No assurance addressee was
respondent
Wait time for returns**
Telephone interview Moderate cost
Relatively easy to administer
Permits unlimited callbacks
Can cover wide geographic areas
Faster than mail or interview
techniques**
Respondent can hang up**
Telemarketers have made it harder**
Possible problem of representation
Possible interviewer bias
Requires trained interviewers
Wireless-only households
Unlisted number households
Face-to-face interview High response rate
Flexibility
Gain in-depth data
Develop rapport
Can observe nonverbal behavior**
No help from others in answering**
Expensive
Requires trained interviewers
Possible interviewer bias
Limits sample size
Time-consuming
Electronic interview Low cost
Ease and convenience
Almost instantaneous
Commercial companies’ services
Wide geographic coverage**
Must have Internet access
Self-selection
May lack anonymity
Respondent can easily delete request
to participate**
Email addresses hard to get sometimes
Group interview High response rate
Efficient and economical
Can stimulate productivity of others
May intimidate and suppress individual
differences
Fosters conformity
Group pressure may influence
responses
Delphi technique* Pooled responses
Spans time and distance
High motivation and commitment
Reduced influence of others
Enhanced response quality and
quantity
Equal representation
Consistent participant contact
High cost and time commitment
Reduced clarification opportunities
Reduced immediate reinforcement
(continued)

84 Part 1 Planning a Health Promotion Program
Data availaBlE FRoM nongovERnMEnt agEnCiES
anD oRganizationS
In addition to the data available from government agencies, planners should also consult
with nongovernment agencies and groups for data. Included among these are health care
systems, voluntary health agencies, business, civic, and commerce groups. For example,
most of the national voluntary health agencies produce yearly “facts and figures” booklets
that include a variety of epidemiological data. In addition, local agencies (e.g., local health
department), health care facilities (e.g., non-profit hospitals) and organizations (e.g., United
Way) often have data they have collected for their own use.
Method Advantages Disadvantages
Community forum
(town hall meeting)*
Relatively straightforward to
conduct
Relatively inexpensive
Access to a broad cross-section
of the community
People participate on own terms
Can identify most interested
Often difficult to achieve good
attendance
Participants in the community forum
may tend to represent special interests
Forum could degenerate into
gripe session
Data analysis can be time consuming
Meetings Good for formative evaluation
Low cost
Flexible
Possible result bias
Limited input from participants
Focus groups* Low cost
Convenience
Creative atmosphere
Ease of clarification
Flexibility
Qualitative information
Limited representativeness
Dependence on moderator skill
Preliminary insights
Participant involvement
Nominal group
process*
Direct involvement of priority
groups
Planned interactivity
Diverse opinions
Full participation
Creative atmosphere
Recognition of common ground
Time commitment
Competing issues
Participant bias
Segmented planning involvement
observation Accurate behavioral data
Can be obtrusive
Moderate cost
Requires trained observers
May bias behavior
Possible observer bias
May be time-consuming
Self-assessments Convenient
No interviewer bias
Moderate cost
Minimum staff time required
Easy to administer
Flexibility
Possible low response rate
Possible problem of representativeness
Self-selection
*From Gilmore (2012); **From Neutens & Rubibson (2014)
TAbLe 4.1 Continued

Chapter 4 Assessing Needs 85
TAbLe 4.2 Sample Sources of Secondary Data Available from Governmental
and Nongovernmental Agencies and Organizations
Type of Agency/Organization Type of Data URL (Web Address)
Government Agencies
U.S. Bureau of Census Demographic
U.S. Census Statistical
Abstract of the United
States
http://www.census.gov
http://www.census.gov/prod/www/
statistical_abstract.html
Centers for Disease Control
and Prevention (CDC)
Health and Vital Statistics
National Center for Health
Statistics (NCHS)
Morbidity Mortality Weekly
Report (MMWR)
CDC WoNDER
http://www.cdc.gov/nchs/
http://www.cdc.gov/mmwr/
http://wonder.cdc.gov
Behavioral Risk Factors
Behavioral Risk Factor
Surveillance System
(BRFSS)
Youth Risk Behavior
Surveillance System
(YRBSS)
http://www.cdc.gov/brfss/
http://www.cdc.gov/healthyyouth
/data/yrbs/index.htm
Food & Drug Administration
(FDA)
Food, Drugs and Medical
Device Data
http://www.fda.gov
Environmental Protection
Agency (EPA)
Environmental Data
and Statistics
http://www.epa.gov
Substance Abuse & Mental
Health Services Administration
(SAMHSA)
Substance & Mental Health
Statistical Information
http://www.samhsa.gov
National Cancer Institute Cancer Statistics http://www.cancer.gov
Nongovernmental Agencies and Organizations
American Cancer Society Cancer Information and
Statistics
http://www.cancer.org
American Heart Association Heart Disease and Stroke
Information and Statistics
http://www.heart.org/HEARToRG/
County Health Rankings Health Data by U.S. Counties http://www.countyhealthrankings.org
Henry J. Kaiser Family
Foundation
Health Data by States http://kff.org/statedata/
Data FRoM ExiSting RECoRDS
These are health data that are often collected as a part of normal operations of an organiza-
tion. These data can also serve as useful secondary needs assessment data. Using such data
may be an efficient way to obtain the necessary information for a needs assessment (or an
evaluation) without the need for additional data collection. The advantages include low cost,
minimum staff needed, and ease in randomization. The disadvantages include difficulty in
gaining access to the necessary records and the possible lack of availability of all the informa-
tion needed for a needs assessment or program evaluation.

http://www.census.gov

http://www.census.gov/prod/www/statistical_abstract.html

http://www.cdc.gov/nchs/

http://www.cdc.gov/mmwr/

http://wonder.cdc.gov

http://www.cdc.gov/brfss/

http://www.cdc.gov/healthyyouth/data/yrbs/index.htm

http://www.fda.gov

http://www.epa.gov

http://www.samhsa.gov

http://www.cancer.gov

http://www.cancer.org

http://www.heart.org/HEARToRG/

http://www.countyhealthrankings.org

State Health Facts

86 Part 1 Planning a Health Promotion Program
Examples of the use of existing records include checking medical records to monitor
blood pressure and cholesterol levels of participants in an exercise program, reviewing
insurance usage of employees enrolled in an employee health promotion program, and
comparing the academic records of students engaging in an after-school weight loss pro-
gram with those who are not. In these situations, as with all needs assessments using ex-
isting records, the cooperation of the agencies that hold the records is essential. At times,
agencies may be willing to collect additional information to aid in the needs assessment for
(or an evaluation of) a health promotion program. Keepers of records are concerned about
confidentiality and the release of private information. The importance of privacy for those
planners working in health care settings was further emphasized in 2003 with the enact-
ment of the Standards for Privacy of Individually Identifiable Health Information section (The
Privacy Rule) of the Health Insurance Portability and Accountability Act of 1996 (officially
known as Public Law 104-191 and referred to as HIPAA, pronounced “hip-a”). The rule sets
national standards that health plans, health care clearinghouses, and health care providers
who conduct certain health care transactions electronically must implement to protect and
guard against the misuse of individually identifiable health information. Failure to imple-
ment the standards can lead to civil and criminal penalties (USDHHS, OCR, n.d.). Planners
can deal with these privacy issues by getting permission from all participants to use their
records or by using only anonymous or de-identified (i.e., information removed so individu-
als cannot be identified) data.
Data FRoM tHE litERatuRE
Planners might also be able to identify the needs of a priority population by reviewing any
available current literature about that priority population. An example would be a planner
who is developing a health promotion program for individuals infected by the human immu-
nodeficiency virus (HIV). Because of the seriousness of this disease and the number of people
who have studied and written about it, there is a good chance that present literature could
reflect the need of a certain priority population.
The best means of accessing data from the literature is by using the available literature
databases. Most literature databases today are available in several different forms, including
electronic databases and the Internet. Depending on the database used, planners can expect
to find comprehensive listings of citations for journal articles, book chapters, and books,
and, in some databases, abstracts of the literature. Within the listings, most databases cite
sources by both author and subject/title. Figure 4.3 provides an example of what planners
might find when searching a database.
Many literature databases are available to planners. Next is a short discussion of those
databases that have proved helpful to health promotion planners.
pSyCinFo
PsycINFO®, which is produced by the American Psychological Association (APA), is an abstract-
ing (not full-text) “and indexing database with more than 3 million records devoted to peer-
reviewed literature in the behavioral sciences and mental health (APA, 2015, para. 1)
MEDlinE
Medline, the primary component of and accessed through PubMed®, is the U.S. National
Library of Medicine’s® (NLM) premier bibliographic database that contains over 22 million

Chapter 4 Assessing Needs 87
references from more than 5,600 journals covering the life sciences with a concentration on
biomedicine. “A distinctive feature of Medline is that the records are indexed with NLM’s
Medical Subject Headings (MeSH®)” (U.S. NLM, 2015, para. 1).
EDuCation RESouRCE inFoRMation CEntER (ERiC)
ERIC is an online digital library of education literature sponsored by the Institute of
Education Sciences (IES) of the U.S. Department of Education. ERIC provides free access to
educational journal articles and other education-related materials.
CuMulativE inDEx to nuRSing & alliED HEaltH litERatuRE (CinaHl)
The CINAHL, which is updated monthly, provides indexing of journals from the fields of
nursing and other allied health disciplines. It also provides indexing for healthcare books,
dissertations from the field of nursing, selected conference proceedings, and standards of
practice. Subject headings follow the NLM’s MeSH® structure.
puBMED
PubMed includes “more that 24 million citations from biomedical literature from MEDLINE,
life science journals, and online books” U.S. NLM (n.d.). Some of the citations provide links
to full-text content.
Steps for Conducting a literature Search
gEnERal SEaRCH pRoCEDuRES
The process of searching a database is not difficult, and with the exception of a few indi-
vidual differences, most indexes are arranged in a similar format. As Figure 4.3 indicated,
most indexes include both an author and a subject/title index. An item that is specific to
each index is its thesaurus, a listing of the key words the indexes used to index the subject/
Author Citation
Authors Article title
T T
Neiger, B. L., Thackeray, R., & Fagan, M. C. Basic priority rating model 2.0: current
applications for priority setting in health promotion practice. Health Promotion Practice.
2011; 12(2), 166–171.
c c c
Journal Volume Pages Journal
(number)
Subject/Title Citation
Article title
T
Basic priority rating model 2.0: current applications for priority setting in health
promotion practice. Neiger, B. L., Thackeray, R., & Fagan, M. C., Health Promotion Practice.
2011; 12(2), 166–171.
⦁▲ Figure 4.3 Sample Citations

88 Part 1 Planning a Health Promotion Program
titles. Planners can find the thesauri online or in a separate volume with or near a hard
copy of the indexes.
Figure 4.4 provides planners with a literature search strategy in the form of a flowchart. The
chart begins by identifying the need of the priority population or topic to be searched. At this
point, planners can search either by subject/title or by author. If planners know of an author
who has done work on their topic, they can search the database using the author’s last name.
If they do not have information on authors, they will need to match their topic with the key
words presented in the thesaurus. Since there are times when a topic is not expressed in the
same terms used in the thesaurus, planners will need to look for related terms. Once they have
a list of key words, they need to search the database for possible matches. In conducting this
search, they need to ensure that they are using the database that covers the years of literature
in which they are interested. This search should identify possible sources and citations.
Once sources are identified, planners may review abstracts (or entire documents) online
or locate a hard copy of the document. Then, planners must determine the quality and use-
fulness of the publication in the needs assessment process. One means by which planners
can judge the quality of the literature is to examine the references at the end of the publica-
tions. First, this reference list may lead planners to other sources not identified in the original
search. Second, if the sources found in the database include all those commonly cited in the
literature, this can verify the exhaustiveness of the search.
SEaRCHing via tHE WoRlD WiDE WEB
The continued development of the World Wide Web (WWW) has enhanced the opportuni-
ties for planners to obtain a variety of needs assessment data with the “touch of a button”
from their home or office. Many of the government and nongovernment agencies and orga-
nizations, as well as the databases, discussed in this chapter have Websites that planners can
access if they have the Web address, also known as the uniform resource locator (URL). If the
Web address is unknown, planners can use a search engine to identify appropriate Websites.
Popular search engines include Yahoo, DuckDuckGo, Ask, AOL, Google, and bing.
Planners can experiment with and select the sites that best fit their needs. If planners are us-
ing a term that has more than one word (i.e., heart disease), it is best to use quotation marks
around the term when entering it on the search engine. “This will let the search engine know
that the exact phrase, as contained in the quotation marks, is to be used when seeking sites
that match. If the quotation marks are not used, the search engine will find sites that contain
any of the words in the query” (Cottrell et al., 2015, p. 300) and thus many of the sites found
may not be of use.
As with any data source, planners need to be aware that not all data found via the Web
are valid and reliable. Thus planners need to scrutinize sources just as they would data
found in hard copies. Librarians at Meriam Library at California State University, Chico
created the Currency, Relevance, Authority, Accuracy, Purpose (CRAAP) Test that is most
useful for evaluating information obtained via the Internet (see the link for the Website in
the Weblinks section at the end of the chapter).
using technology to Map needs assessment Data
As has already been mentioned in this chapter, more and more needs assessment data are
being obtained through the use of technology (i.e., electronic interviews, computerized
searchers of the World Wide Web and databases).

Chapter 4 Assessing Needs 89
Also look to match topic with
related key words not
originally considered
Search the database for the
years in which interested
Identify need or topic
Match topic with key words
in the thesaurus
Subject/Title search
Locate sources
Identify possible sources
Judge quality and quantity
of sources
Organize literature into
useable form
Search database for known
authors using last names for
the years in which interested
Author search
⦁▲ Figure 4.4 Literature Search Strategy Flowchart
Source: Adapted from Deeds (1992) and Marcarin (1995).

90 Part 1 Planning a Health Promotion Program
One other process that is being used more frequently is the use of geographic infor-
mation systems (GIS) to help provide meaning to collected data. “GIS helps us analyze
spatially referenced data and make well-informed decisions based on the association
between data and the geography” (CDC, 2006). In other words, the data are mapped.
Mapping “is the visual representation of data by geography or location, linking informa-
tion to a place to support social and economic change on a community level. Mapping is a
powerful tool for two reasons: (1) it makes patterns based on place much easier to identify
and analyze, and (2)  it provides a visual way of communicating those patterns to a broad
audience, quickly and dramatically” (Kirschenbaum & Corburn, 2012, p. 444). The process
of mapping involves (1)  identifying the geographic area that the map will cover, (2) col-
lecting the necessary data, (3) importing the data into GIS software so that the data can be
placed on maps, and (4) analyzing what is found in the maps. Mapping has taken on more
meaning recently because it has been noted that “when it comes to your health, your zip
code is more important than your genetic code” (Iton, 2014, para. 8). Mapping has been
used to address a number of different health problems. Some examples include blood pres-
sure (Mendy, Perryman, Hawkins, & Dove, 2014), cancer (Beyer & Rushton, 2009; Richards
et al., 2010), diabetes (Ruberto & Brissette, 2014), fruit and vegetable consumption (Lucan,
Hillier, Schechtner, & Glanz, 2014), and lead screening (Graff, 2013). The use of GIS in the
needs assessment process will continue to grow as the development of such software be-
comes more widely available and easier to use.
Conducting a Needs Assessment
A number of different approaches can be used to determine the needs of the priority
population. “Need assessments range from informal approaches, using educated and in-
formed observations to formal, comprehensive research projects. However, the informal
approaches are less reliable than a planned and scientifically developed research approach”
(Timmreck, 2003, p. 89). Often, informal approaches are used because of limited resources,
usually time, personnel, and money. However, as noted in the beginning of this chapter,
needs assessment may be the most critical step in the planning process and should not be
taken lightly. Resources used on need assessments usually pay dividends many times over.
Therefore the authors present a six-step process that is more formal in nature: (1) determin-
ing purpose and defining the scope of the needs assessment, (2) gathering data, (3) analyz-
ing the data, (4) identifying the risk factors linked to the health problem, (5) identifying
the program focus, and (6) validating the need before continuing on with the planning
process (see Figure 4.5).
Step 1
Determining the
purpose and
scope
Step 2
Gathering
data
Step 3
Analyzing
data
Step 4
Identifying risk
factors linked to
health problem
Step 5
Identifying
the program
focus
Step 6
Validating
the need
⦁▲ Figure 4.5 Steps in Conducting a Needs Assessment

Chapter 4 Assessing Needs 91
Step 1: Determining the purpose and Scope of the needs assessment
The initial step in the needs assessment process is to determine the purpose and the scope of
the needs assessment. In other words, what is the goal of the needs assessment? What does the
planning committee hope to gain from the needs assessment? How extensive will the needs
assessment be? What kind of resources will be available to conduct the needs assessment?
In reality, the first challenge associated with conducting a needs assessment is determining
whether an assessment should even be performed, and if so, what type of needs assessment
is appropriate. As noted earlier in the chapter a comprehensive needs assessment may not be
warranted because a need may be obvious or an agency/organization has received categorical
funding to address a specific health problem. However, a more focused needs assessment may
be appropriate to gather more specific information about the need or health problem. For
example, if the priority health problem is breast cancer, it is still necessary to collect current
information on the degree to which women are either dying or suffering from the disease. It
will be important to know how prevalent breast cancer is and where it is most prevalent in the
population, as well as the high-risk subpopulations, economic costs, and general trends over
time. The extent to which a needs assessment is necessary and appropriate should be deter-
mined by stakeholders, including key decision makers.
In other cases, a planner may be in a situation where a needs assessment has never been
performed, not been performed for a long period of time, or where categorical funding does
not dictate what health problem(s) should be addressed. This will require planners and
their partners to collect a wide range of data, compare the importance of multiple health
problems, and set priorities. In a general sense, this is the process that is often referred to as a
community health needs assessment (CHNA). This implies that all significant health problems
are examined to assess their relative significance. Stakeholders and planning groups will
also usually determine how many health problems will be analyzed in the needs assess-
ment. This will be influenced by how much time, and how many resources, can be directed
to the needs assessment.
Another important decision that must be made is the extent to which those in the
community where the needs assessment is being conducted will be involved in the needs
assessment process. The term participatory or action research has gained popular-
ity in recent years, though it is often misunderstood or used inappropriately. Participatory
research has been “defined as systematic inquiry, with the collaboration of those affected
by the issue being studied, for the purposes of education and of taking action or effecting
change” (Mercer et al., 2008, p. 409).
Once the basic purpose and scope of the needs assessment is identified, planners may pro-
ceed to data collection. However, planners must not take this first step too lightly. Although
a natural tendency is to move forward quickly, an understanding of why a needs assessment
is being performed will give proper direction to all other steps that follow.
Step 2: gathering Data
The second step in the needs assessment process is gathering data. As noted earlier in this
chapter, there are many different sources of needs assessment data. A part of the art of
conducting a needs assessment is to be able to identify the most relevant data possible. By
relevant data, we mean those data that are most applicable to the planning situation and
that will do the best job of helping planners to identify the actual needs of the priority

92 Part 1 Planning a Health Promotion Program
population. Because of the cost and availability, it is recommended that planners begin the
data-gathering process by trying to locate relevant secondary data. For example, if a national
program is being planned, then national secondary data should be sought from appropriate
national government and nongovernment agencies. If a local program is being planned,
then appropriate local data should be sought. When planning a local program, it is not un-
usual to find that local data do not exist. If that is the case, planners may need to use state,
regional, or national data (in that order) and apply them to the local area. For example, let’s
assume diabetes mellitus mortality data are needed for local planning and the only data
available are national level data. Planners could use national data (e.g., 21.2 per 100,000
people died of diabetes in 2013) to estimate the number of deaths in a local community.
If the population of a local city is 250,000, planners could infer that the number of deaths
due to diabetes in the city during 2013 totaled 53 (i.e., 21.2 × 2.5). If the city’s population
were older, 53 deaths could be viewed as a low estimate because diabetes deaths are more
prevalent in older populations. Conversely, if the population were younger, 53 deaths could
be viewed as a high estimate. Obviously, as noted at the beginning of this chapter, there are
disadvantages of using secondary data, but good planners use and interpret them in light of
their limitations (McDermott & Sarvela, 1999).
Once relevant secondary data have been identified, planners need to turn their attention to
gathering the appropriate primary data in order to fill in the “data gaps” to better understand
the needs of the priority population. For example, if secondary data show that there is a need for
cancer education programming, but does not specifically identify the type of cancer or segment
the priority population by useful demographic characteristics (e.g., age or sex), then efforts
should be made to collect such data. Or, it may be that all the secondary data are quantitative
data such as how frequently a service is used, and thus it might be very useful to collect primary
data that are qualitative in nature such as detailed explanations of why a service was not used. It
should be noted that primary data collection could have a dual purpose. Not only do primary
data collections provide valuable information about the specific planning situation that cannot
be obtained from secondary data, they also provide an opportunity to get those in the priority
population actively involved and contributing to the program planning process. Thus, planners
need to decide what primary data are needed, from whom they should be collected (e.g., All?
Some? Just certain demographic groups?), and what methods (e.g., Interviews? Questionnaires?
Focus groups? Photovoice?) would be best for not only collecting the needed information but
also in getting active participation from the priority population.
It should also be noted that the planning model used to develop a program might also
drive the types of data collected for the needs assessment. For example, when the Social
Marketing Assessment and Response Tool (SMART) model is used planners would be inter-
ested in collecting data that would assist with Consumer Analysis (Phase 2), Market Analysis
(Phase 3), and Channel Analysis (Phase 4). When the Mobilizing for Action through Planning
and Partnerships (MAPP) model is being used planners should be collecting data that would
provide information for the Assessments (Phase 3) which yield a list of challenges and oppor-
tunities in a community (see Chapter 3 for more information about SMART and MAPP).
In addition to using a planning model to help guide the types of data to be collected, plan-
ners may also want to use theoretical constructs to help guide data collection. For example, it
may be important for planners to know what stages of change (see Chapter 7 for information
on the Transtheoretical Model) the priority population is in for a specific health behavior
(i.e., exercise) in order to create a more focused intervention.

Chapter 4 Assessing Needs 93
As planners conclude the second step in the needs assessment process, they must remember
that each planning situation is different. It is desirable to have both primary and secondary
needs assessment data in order to gain a clear picture of needs; however, depending on the
resources and circumstances, planners may have access to only one or the other. In addition,
there is usually a trade-off between quality and quantity of data. Planners must use the best
data available under the challenges and constraints facing them.
Step 3: analyzing the Data
At this point in the needs assessment process, planners must analyze all the data collected,
with the goal of identifying and prioritizing the health problems. The goal of data analysis
is easily stated, but this step may be the most difficult to complete. There are those rare
occasions when the data analysis is not very complicated because the need is obvious. For
example, the data may clearly show that breast cancer rates have continued to rise in a
community, while the number of breast screenings has dropped, and those in the priority
population recognize the problem. Or, in another setting the data analysis shows a very
clear correlation between the health status of the priority population and the lack of pri-
mary health care received. However, not all analyses of data yield such obvious needs. More
often than not, planners are faced with trying to compare data that are not easily compared.
The data may be mixed (i.e., apples and oranges) or confusing. For example, they may have
mortality data for one health problem, morbidity data for another, and perhaps behavioral
risk factor data for yet another. Or, if planners are working with a multicultural priority pop-
ulation, data analysis may even be more confusing, because health concepts held by one
culture may be very different than the health concepts held by the planners. When work-
ing with diverse communities, it is important to find “out more information about what is
going on and why and how cultural issues may or may not influence a health problem or
related risk behaviors” (Vaughn & Krenz, 2014, p. 178). A failure to understand and appreci-
ate these differences in the priority population can have serious implications for success of
any health promotion/disease prevention effort (Kline & Huff, 1999).
One systematic way to analyze the data is to use the first few phases of the PRECEDE-
PROCEED model for guidance. Start by asking and answering the following questions:
1. What is the quality of life of those in the priority population?
2. What are social conditions and perceptions shared by those in the priority population?
3. What are the social indicators (e.g., absenteeism, crime, discrimination, performance,
welfare, etc.) in the priority population that reflect the social conditions and
perceptions?
4. Can the social conditions and perceptions be linked to health promotion? If so, how?
5. What are the health problems associated with the social problems?
6. Which health problem is most important to change?
The last question in this list is really asking the question: Which problem/need should get
priority? The problems/needs must be prioritized not because the lowest-priority problems/
needs are not important, but because organizations have limited resources to deal with all
identified problems/needs. Thus, “priority setting is critical in narrowing the scope of ac-
tivity to reflect the availability of resources within the context of stakeholders’ values and

94 Part 1 Planning a Health Promotion Program
preferences. In addition, priority setting helps health promotion practitioners stay focused on
problems that actually affect the health status of the population” (Neiger, Thackeray, & Fagen,
2011, p. 166). There are several benefits to effective priority setting. They include: (a) building
consensus among the stakeholders for the allocation of resources in areas most likely to yield
positive and sustainable outcomes; (b) clarifying expectations for the use of resources in a con-
strained environment, (c) helping to establish focus on issues based on objective criteria, and
(d) helping establish a chain of accountability for the stakeholders (Barnett, 2012).
Priority setting is not easy and planners should be aware that there might be conflict
among stakeholders. “Obstacles to the effective implementation of priority setting include,
but are not limited to the following; (a) lack of quality data, (b) conflicting political dynam-
ics and agendas, (c) stakeholder fatigue with assessment process, (d) poorly developed and/
or understood criteria, and (e) lack of equity in stakeholder participation and processes”
(Barnett, 2012, p. 46).
When setting priorities, the planners should seek answers to these questions:
1. What is the most pressing need? Why?
2. Are there resources adequate to deal with the problem?
3. Can the problem best be solved by a health promotion intervention, or could it be
handled better through another means?
4. Are effective intervention strategies available to address the problem?
5. Can the problem be solved in a reasonable amount of time?
The actual process of setting priorities can take many different forms and can range from
subjective approaches such as simple voting procedures, forced rankings, and the nominal
group process with stakeholders to more objective but time-consuming processes such as the
Delphi technique (Gilmore, 2012) and the basic priority rating (BPR) model. The BPR
model, which was first known as the “priority rating process,” was introduced more than
60 years ago (Hanlon, 1954) in an attempt to prioritize health problems in developing coun-
tries. During this span of time, the BPR has been most useful to program planners. Although
the BPR model has provided basic direction in priority setting, it does not represent the broad
array of data available to decision makers today (Neiger et al., 2011). In addition, “elements in
the model give more weight to the impact of communicable diseases as compared to chronic
diseases” (Neiger et al., 2011, p. 166). As such, Neiger and his colleagues have proposed
changes to the BPR model and suggested a new name for the model; BPR Model 2.0. To
provide both background and currency, both the BPR model (Pickett & Hanlon, 1990) and the
BPR model 2.0 (Neiger et al., 2011) are presented here.
BpR MoDEl
The BPR model requires planners to rate four different components of the identified needs
and insert the ratings into a formula in order to determine a priority rating between 0 and
100. The components and their possible scores (in parenthesis) are:
A. size of the problem (0 to 10)
B. seriousness of the problem (0 to 20)
C. effectiveness of the possible interventions (0 to 10)
D. propriety, economics, acceptability, resources, and legality (PEARL) (0 or 1)

Chapter 4 Assessing Needs 95
The formula in which the scores are placed is:
Basic Priority Rating (BPR) =
(A + B)C
3
* D
Component A, size of the problem, can be scored by using epidemiological rates or deter-
mining the percentage of the priority population at risk. The higher the rate or percentage,
the greater the score.
Component B, seriousness of the problem, is examined using four factors: economic loss
to community, family, or individuals; involvement of other people who were not initially
affected by the problem, as with the spread of an infectious disease; the severity of the prob-
lem measured in mortality, morbidity, or disability; and the urgency of solving the problem
because of additional harm. Because the maximum score for this component is 20, raters can
use a 0 to 5 score for each of the four factors.
Component C, effectiveness of the interventions, is often the most difficult of the four
components to measure. The efficacy of some intervention strategies is known, such as im-
munizations (close to 100%) and smoking cessation classes (around 30%), but for many, it
is not. Planners will need to estimate this score based upon the work of others or their own
expert opinions. In scoring this component, planners should consider both the effective-
ness of intervention strategies in terms of behavior change, as well as the degree to which
the priority population will demonstrate interest in the intervention strategy.
Component D, PEARL, consists of several factors that determine whether a particular inter-
vention strategy can be carried out at all. The score is 0 or 1; any need that receives a zero will
automatically drop to the bottom of the priority list because a score of zero (a multiplier) for this
component will yield a total score of zero in the formula. Examples of when a zero may result
are if an intervention is economically impossible, unacceptable to the priority population or
planners, or illegal. Ideally, some of these assessments will be made before a health problem is
considered in the priority setting process.
Once the score for the four components is determined, an overall priority rating for each
need can be calculated, and the prioritizing can take place.
BpR MoDEl 2.0
Building on the BPR model, Neiger and his colleagues (2011) offered the following adapta-
tions to the model and suggested calling the revised model the BPR model 2.0.
A. Size of the problem. “Depending on the availability of data and preferences of the
stakeholders use one of the following:
1. Use incidence and prevalence data and score each on a scale of 0 to 5 for a total of
10 points (it is recognized that incidence represents a proportion of prevalence).
2. Use incidence or prevalence data and score each health problem on a scale of
0 to 10 points.
3. Use age-adjusted cause-specific mortality rates and proportional mortality ratios for
each health problem and score each on a scale of 0 to 5 for a total of 10 points.
4. Use age-adjusted cause-specific mortality rates or proportional mortality ratios and
score each health problem on a scale of 0 to 10 points” (p. 168).
B. Seriousness of the problem. Both the definitions for the components of “seriousness”
and the scoring for the components be changed as follows:
1. Urgency—defined “as the degree to which a health problem is increasing, stabilizing,
or decreasing and that 5-year mortality trend data be used to score it” (p. 168). Scores

96 Part 1 Planning a Health Promotion Program
should be assigned as follows: increasing trend data (5 or 4 points); stabilized trend
data (3 or 2 points); and decreasing trend data (1 or 0 points).
2. Severity—expand the definition of the criterion to include: (a) the lethality of a
health problem (as measured by five-year survival rate), (b) premature mortality (as
measured by years of potential life lost or years of productive life lost), and (c) disability
(as measured by disability-adjusted life years [DALYs]). Scores should be assigned as
follows: 0- to 5-point scale (i.e., 5–4 is high, 3–2 is medium, and 1–0 is low).
3. Economic loss—defined as the accumulation of costs (direct and indirect) borne
by society associated with the health problem. Scores should be assigned as follows:
0- to 5-point scale (i.e., 5–4 is high, 3–2 is medium, and 1–0 is low).
4. Impact on others—expand the definition of the criterion to include: “(a) as
the communicable nature of the health problem (particularly when analyzing
communicable diseases); (b) the behavioral effects related to the health problem
on others (e.g., secondhand smoke, driving while under the influence of alcohol or
other drugs, violence perpetrated on others, etc.); or (c) the emotional and physical
impact the health problem (with attendant disabilities) has on others with respect
to care giving” (p. 169). Scores should be assigned as follows: 0- to 5-point scale
(i.e., 5–4 is high, 3–2 is medium, and 1–0 is low).
C. Effectiveness of the possible interventions. Limit the definition of “effectiveness” to
evidence of a successful intervention and not rate the “reach” of the intervention.
The scoring of effectiveness should be based on the typology of evidence developed
by Brownson, Fielding, and Maylahn (2009). Scores should be assigned as follows:
0- to 10-point scale (i.e., 10–9 reflect evidence-based interventions, 8–7 reflect effective
programs, 6–5 reflect promising interventions, 4–3 reflect emerging interventions, and
2–0 reflect unproven interventions).
D. PEARL. The calculation of PEARL should remain the same. However, if secondary data
are available to calculate the PEARL it should be calculated prior to collecting primary
data so that the needs assessment may be more focused.
For an example application of the BPR model 2.0 readers should refer to Neiger
et al. (2011).
Finally, how will planners know when they have completed Step 3 (Analyzing the Data)
of the needs assessment process? Planners should be able to list in rank order the problems/
needs of the priority population.
Step 4: identifying the Risk Factors linked to the Health problem
Step 4 of the needs assessment process is parallel to the second part of Phase 2 of the PRECEDE-
PROCEED model: epidemiological assessment. In this step, planners need to identify the
determinants of the health problem identified in the previous step. That is, what genetic, be-
havioral, and environmental risk factors are associated with the health problem? Because most
genetic determinants either cannot be changed or interact with the behavior and/or environ-
ment, the task in this step is to identify and prioritize the behavioral and environmental factors
that, if changed, could lessen the health problem in the priority population. Also, it should be
noted that the term environmental factors applies to more than just the physical environment
(e.g., clean air and water, proximity to facilities). Environment is multidimensional and can
include economic environment (e.g., affordability, incentives, disincentives); service environ-
ment (e.g., access to health care, equity in health care, barriers to health care); social environ-
ment (e.g., social support, peer pressure); psychological environment (e.g., emotional learning

Chapter 4 Assessing Needs 97
environment); and the political environment (e.g., health policy). In essence then, modifying
behavioral and/or environmental factors or determinants is the real work of health promotion.
Thus, if the health problem is lung cancer, planners should analyze the health behaviors and
environment of the priority population for known risk factors of lung cancer. For example,
higher than expected smoking behavior may be present in the priority population, and the
people may live in a community where smokefree public environments are not valued. Once
these risk factors are identified, they too need to be prioritized (see Figure 3.4 for a means of
prioritizing these risk factors).
Step 5: identifying the program Focus
The fifth step of the needs assessment process is similar to the third phase of the PRECEDE-
PROCEED model: educational and ecological assessment. With behavioral, environmental,
and genetic risk factors identified and prioritized, planners need to identify those predispos-
ing, enabling, and reinforcing factors that seem to have a direct impact on the risk factors. In
the lung cancer example, those in the priority population may not have (1) the skills necessary
to stop smoking (predisposing factor), (2) access to a smoking cessation program (enabling
factor), or (3) people around them who support efforts to stop smoking (reinforcing factor).
“Study of the predisposing, enabling, and reinforcing factors automatically helps the planner
decide exactly which of the factors making up the three classes deserve the highest priority as
the focus of the intervention. The decision is based on their importance and any evidence that
change in the factor is possible and cost-effective” (Green & Kreuter, 1999, p. 42).
In addition, when prioritizing needs, planners also need to consider any existing health
promotion programs to avoid duplication of efforts. Therefore, program planners should
seek to determine the status of existing health promotion programs by trying to answer as
many questions as possible from the following list:
1. What health promotion programs are presently available to the priority population?
2. Are the programs being utilized? If not, why not?
3. How effective are the programs? Are they meeting their stated goals and objectives?
4. How were the needs for these programs determined?
5. Are the programs accessible to the priority population? Where are they located? When are
they offered? Are there any qualifying criteria that people must meet to enroll? Can the
priority population get to the program? Can the priority population afford the programs?
6. Are the needs of the priority population being met? If not, why not?
There are several ways to seek answers to these questions. Probably the most common way
is through networking with other people working in health promotion and the health care
system—that is, communicating with others who may know about existing programs. (See
Chapter 9 for a more detailed discussion of networking.) These people may be located in the
local or state health department, in voluntary health agencies, or in health care facilities, such
as hospitals, clinics, nursing homes, extended care facilities, or managed care organizations.
Planners might also find information about existing programs by checking with some-
one in an organization that serves as a clearinghouse for health promotion programs or by
using a community resource guide. The local or state health department, a local chamber
of commerce, a coalition, the local medical/dental societies, a community task force, or a

98 Part 1 Planning a Health Promotion Program
community health center may serve as a clearinghouse or produce such a guide. Another
avenue is to talk with people in the priority population. Although they may not know about
all existing programs, they may be able to share information on the effectiveness and acces-
sibility of some of the programs. Finally, some of the information could be collected in Step 2
through separate community forums, focus groups, or surveys.
Step 6: validating the prioritized needs
The final step in the needs assessment process is to validate the identified need(s). Validate
means to confirm that the need that was identified is the need that should be addressed.
Obviously, if great care were taken in the needs assessment process, validation should be a
perfunctory step. However, there have been times when a need was not properly validated;
much energy and many resources have thereby been wasted on unnecessary programs.
Validation amounts to “double checking,” or making sure that an identified need is the
actual need. Any means available can be used, such as (1) rechecking the steps followed in
the needs assessment to eliminate any bias, (2) conducting a focus group with some indi-
viduals from the priority population to determine their reaction to the identified need (if a
focus group was not used earlier to gather the data), and (3) getting a “second opinion” from
other health professionals.
application of the Six-Step needs assessment process
In the previous sections, a six-step approach for conducting a needs assessment was pre-
sented. Now we would like to present an example of how this process may be applied. Let’s
assume that a committee has been appointed by the health administrator of a local health
department to plan a cancer prevention program for the county, and that the composition of
the committee closely represents the greater community. Let’s also assume that the param-
eters for the authority of the planning committee have also been set. Here is how this needs
assessment may be carried out.
Step 1: Determining the Purpose and Scope of the Needs Assessment—After an organi-
zational meeting and a couple subsequent meetings, the planning committee decided that
the purpose of the needs assessment was fourfold. To determine (1) what types of cancers
were of greatest concern in the county, (2) which subpopulations within the county were at
the greatest risk for the cancers identified, (3) what the most common risk factors were for
the cancer(s) and subpopulation(s) identified, and (4) the focus of the proposed program.
The committee members also decided that the scope of the needs assessment would be
defined by the collection of both primary and secondary data, and that they wanted part
of the primary data collection to be participatory in nature. That is, they wanted some of
those in the priority population to participate in the data collection process.
Step 2: Gathering Data—The committee members decided to begin data collection by
identifying available sources of secondary data. Initially they gathered secondary data
for the past five years for both the state and the county in which they lived from the state
health department for the incidence of invasive cancer; cancer mortality rates (i.e., crude
and age-adjusted); mortality rates for various types of cancer broken down by sex, age, and
race/ethnicity; and behavioral risk factors that were known to contribute to or cause the
various types of cancer. In addition, committee members were able to get secondary data

Chapter 4 Assessing Needs 99
from the state environmental agency regarding the levels of air and water pollution in all
92 counties of the state.
The secondary data were good but they did not present a complete picture of the cancer issue
in their county. What was not available in the secondary data were information and data related
to cancer education programs, cancer screening programs, access to health care providers that
specialized in cancer care, and the county residents’ interest in taking part in activities that would
reduce the incidence and prevalence in their community. Therefore, the committee created three
different questionnaires to be administered via single-step surveys. The three questionnaires dealt
with cancer prevention activities (i.e., education and screenings), cancer treatment, and attitudes
toward and willingness to participate in cancer programs if offered in the community.
To make part of the primary data collection a participatory process the committee sought
out two groups of volunteers from the county who were interested in cancer control. The
first group was asked to assist in data collection by administering the surveys to various indi-
viduals in the county by visiting places where residents were likely to gather such as service
group meetings, religious organizations (i.e., churches, mosques, and synagogues), services,
worksites, and neighborhood meetings. The second group of volunteers was asked to collect
data via a photovoice process with a theme of “identify those unhealthy areas of the county
that contribute to cases of cancer.”
Step 3: Analyzing the Data—The committee members decided to analyze the data compar-
ing their county data versus the state data using the informal technique of “eye-balling”
the data. To help make sense of some of the data they created a few cross-tabulation tables
comparing county data to state data. The analysis of the secondary cancer data from the state
health department, the County Health Rankings (University of Wisconsin Population Health
Institute, 2015), and the Kaiser Family Foundation’s state health facts (KFF, 2015) showed:
•⦁ higher county incidence rate for invasive cancers (501/100,000 vs. 426/100,000)
•⦁ both higher county cancer crude mortality rates (177/100,000 vs. 157/100,000) and
age-adjusted mortality rates (170.0/100,000 vs. 161.2/100,000)
•⦁ higher county prevalence rates for colorectal, lung, and pancreas cancers
•⦁ lower county prevalence rates for breast, cervix, and prostate cancers
The analysis of the secondary behavior risk data from the state’s Behavior Risk Factor
Surveillance System data showed:
•⦁ higher percentage of county residents who had not had either a sigmoidoscopy or
colonoscopy in the recommended time period
•⦁ higher percentage of county women who had either a clinical breast examination
(77.1% vs. 74.5%) or mammogram (76.3% vs. 73.1%) in the recommended time period
•⦁ higher percentage of county women who had a Papanicolaou smear (82.6% vs. 77.4%)
in the recommended time period
•⦁ higher percentage of county residents who were physically inactive (55.7% vs. 48.9%)
•⦁ higher prevalence of county residents who smoked (25.3% vs. 21.0%)
The analysis of the primary data from the three surveys conducted by the committee showed
county residents:
•⦁ would participate in free and/or inexpensive cancer screenings if they were convenient
•⦁ were in favor of creating more smokefree public areas
•⦁ felt, and the data showed, that there were too few health care providers in the county
who dealt with cancer.

100 Part 1 Planning a Health Promotion Program
The analysis of the photovoice process identified two major themes in the county:
•⦁ many of the county residents were physically inactive and appeared to be either
overweight or obese, and
•⦁ there were few smokefree public places in the county
Based on all the available primary and secondary data the committee prioritized the list
of cancers using the BPR model 2.0. Those calculations yielded the following BPR scores:
breast (38.7), colorectal (56.8), lung (51.8), cervix (30.4), pancreas (24.0), and prostate (41.7).
Therefore, the committee decided to work to reduce the incidence of colorectal and lung
cancers in the county.
Step 4: Identifying the Risk Factors Linked to the Health Problem—The risk factors associ-
ated with colorectal cancer include age (> 50 years), personal history of colorectal polyps or
cancer, personal history of inflammatory bowel disease (IBD), family history of colorectal
cancer, diets high in red meats, physical inactivity, obesity, smoking, heavy alcohol use, and
type 2 diabetes (ACS, 2015). The risk factors associated with lung cancer include smoking,
exposure to radon, exposure to asbestos, high levels of arsenic in the drinking water, personal
or family history of lung cancer, and air pollution (ACS, 2015).
Step 5: Identifying the Program Focus—Based on the analysis of the data and the risk factors
associated with identified priority cancers the planning committee decided to focus the cancer
prevention program on two areas: working to offer more cancer screening programs in the
county, and working toward a nonsmoking ordinance in the county in order to create smoke-
free public places.
Step 6: Validating the Prioritized Needs—Before moving forward with the planning for the
cancer prevention programs to deal with colorectal and lung cancer, the committee had
representatives from both the state department of health’s cancer prevention program and
the American Cancer Society review their needs assessment to validate their findings. Both
groups agreed with the program focus.
Special Types of Health Assessments
Before leaving the topic of needs assessment we need to introduce two specific types of
health assessments that have gained special attention in the last few years. They are health
impact assessment and organizational health assessment.
Health impact assessment
Health impact assessment (HIA) is an important topic because a HIA could impact
the focus of a needs assessment and it is “a rapidly emerging practice” (CDC, 2015d,
para. 6) in the United States (see NRC, 2011, for examples of its use). A HIA has been
defined as “a systematic process that uses an array of data sources and analytic methods
and considers input from stakeholders to determine the potential effects of a proposed
policy, plan, program, or project on the health of a population and the distribution of
those effects within the population. HIA provides recommendations on monitoring and
managing those effects” (NRC, 2011, p. 5). In other words, a HIA is an “approach that can
help to identify and consider the potential—or actual—health impacts of a proposal on a

Chapter 4 Assessing Needs 101
population. Its primary output is a set of evidence-based recommendations geared to in-
forming the decision-making process. These recommendations aim to highlight practical
ways to enhance the positive aspects of a proposal, and to remove or minimise [sic] any
negative impacts on health, well-being and health inequalities that may arise or exist”
(Taylor & Quigley, 2002, pp. 2–3).
The World Health Organization (2015) has noted that HIAs are based on four values.
They include 1) democracy (i.e., all who are impacted by the proposed change get to partici-
pate in the assessment), 2) equity (i.e., all who will be impacted by the proposed change are
treated fairly in the assessment), 3) sustainable development (i.e., both short- and long-term
impacts of the proposed change are considered are part of the assessment), and 4) ethical
use of evidence (i.e., evidence used in the assessment includes both qualitative and quanti-
tative evidence and is collected using best practices).
There are a number of different frameworks (i.e., guides) that can be used to conduct a HIA
(see Mindell, Boltong, & Forde, 2008 for a review of guides) and they “can range from simple,
fairly easy-to-conduct analyses to more in-depth, complex analyses” (Brennan Ramirez et al.,
2008, p. 46), but most of these guides include the following major steps:
1. Screening (identify plans, projects, or policies for which an HIA would be useful)
2. Scoping (identify which health effects to consider)
3. Assessing risks and benefits (identify which people may be affected and how they may
be affected)
4. Developing recommendations (suggesting changes to proposals to promote positive
health effects or minimize adverse health effects)
5. Reporting (present the results to decision makers), and
6. Monitoring and evaluating (determining the effect of the HIA on the decision) (CDC,
2015d, para. 3)
As planners prepare for a needs assessment they must also consider whether an HIA
should be a part of the process.
organizational Health assessment
Earlier in this chapter mention was made of the impact that the Patient Protection and
Affordable Care Act had on non-profit hospitals and the requirement that the hospitals
had to conduct a CHNA once every three years. Another section (i.e., 1201) of the same law
amended Section 2705 of the Public Health Service Act that encourages employers to imple-
ment comprehensive worksite health promotion programs for their employees. Under the
new law, employers can offer incentives (up to 30% of the total cost of coverage) to encour-
age participation. The program must be reasonably designed to promote health or prevent
disease. A program complies with the reasonably designed provision “if it 1) has a reasonable
chance of improving the health of, or preventing disease in, participating individuals; (2) is
not overly burdensome; (3) is not a subterfuge for discrimination based on a health factor;
and (4) is not highly suspect in the method chosen to promote health or prevent disease”
(CMS,  2015a,  p.  2). “Critics of this provision have voiced concern about the broad defini-
tion of a ‘ reasonably designed’ wellness program” (Goetzel et al., 2013, p. TAHP-2). To deal
with this issue, in recent years several organizational health assessments have been created

102 Part 1 Planning a Health Promotion Program
to determine if best-practices are in place in employer-sponsored worksite health promotion
programs (Goetzel et al., 2013). These organization health assessments can be thought of as
needs assessments for reasonably designed employee-sponsored worksite health promotion
programs. Three of these organizational health assessments—the HERO Employee Health
Management Best Practices Scorecard (Health Enhancement Research Organization, 2014),
the Wellness Impact Scorecard (WISCORE®) (National Business Group on Health, 2015),
Optimal Healing Environment (OHE) Assessment™ (Samueli Institute, 2015) —have been
reviewed by Goetzel et al. 2013.
Summary
This chapter presented definitions of needs assessment and a discussion of primary and
secondary data. The sources of these data along with their pros and cons were discussed at
length. Also, presented in this chapter was a six-step approach that planners can follow in
conducting a needs assessment on a given group of people. It is by no means the only way of
conducting an assessment, but it is one viable option. No matter what procedure is used to
conduct a needs assessment, the end result should be the same. Planners should finish with a
clearly defined program focus. Finally, the terms health impact assessment and organization
health assessment were introduced.
Review Questions
1. What is a need? What does needs assessment mean?
2. What is meant by the terms capacity, community capacity, and capacity building?
3. What should program planners expect from a needs assessment?
4. What is the difference between primary and secondary data?
5. Name several different sources of both primary and secondary data.
6. What advice might you give to someone who is interested in using previously collected
data (secondary data) for a needs assessment?
7. What is the difference between a single-step (cross-sectional) and a multistep survey?
8. Explain the difference between a community forum and a focus group.
9. What are the steps in the photovoice process?
10. What is a health assessment (HA)?
11. Describe the steps used to conduct a literature search.
12. What are the six steps in the needs assessment process, as identified in this chapter?
What is the most difficult step to complete?
13. What is the difference between the BPR model and the BPR model 2.0?
14. What is health impact assessment (HIA) and how could it affect a needs assessment?
15. What is an organizational health assessment? What relationship does it have to the
Affordable Care Act?

Chapter 4 Assessing Needs 103
Activities
1. Assume a local health department (LHD) that serves a rural population of about
100,000 people has hired you. After a few months on the job, your supervisor has given
you the task of conducting a needs assessment. The last one completed by this LHD was
15 years ago. Based on the annual reports of the LHD over the past 5 years, it has been
determined that the needs assessment should focus on the needs of the elderly. For the
purpose of this needs assessment, the LHD has defined elderly as those 65 years of age
and older. Working with the six-step approach to needs assessment presented in this
chapter, complete the first two steps. Complete Step 1 by writing a purpose and scope
for the needs assessment. Complete the first part of Step 2 by identifying at least four
sources of relevant secondary data. Also, describe what you think would be the best
way to go about collecting primary data and defend your choice. Then complete this
activity by creating a list of things you would like to find out by gathering primary data.
2. Visit the Website of a commercial company (e.g., FluidSurveys, Qualtrics, QuestionPro,
SurveyMonkey, surveygizmo, Zoomerang) that is in the business of helping others collect
primary data via the Internet. Once at the site, find out as much as you can about using the
service. What specific services does the company offer? How much do the services cost?
What group of program planners do you think would most benefit from using the services?
Summarize the results of your fact-finding experience in a one-page paper.
3. Using secondary data provided by your instructor or obtained from the World Wide
Web (such as data from a Behavioral Risk Factor Surveillance System, state or local
secondary data, or data from the National Center for Health Statistics), analyze the
data and determine the health problems of the priority population.
4. Using data from the County Health Rankings Website (http://www.countyhealthrankings
.org), examine the data presented for the county in which you grew up or currently live.
After reviewing the data, prepare a written response that summarizes the general health
status of the county.
5. Administer an HHA/HRA to a group of 25 to 30 people. Using the data generated,
identify and prioritize a collective list of health problems of the group.
6. Plan and conduct a focus group on an identified health problem on your campus.
Develop a set of questions to be used, identify and invite people to participate in the
group, facilitate the process, and then write up a summary of the results based on your
written notes and/or an audiotape of the session.
7. Using the data (paper-and-pencil instruments, clinical tests, and health histories)
generated from a local health fair, identify and prioritize a collective list of health
problems of those who participated.
Weblinks
1. http://ctb.ku.edu/en
The Community Tool Box
This site provides excellent resources on community assessment, conducting surveys,
identifying problems, and assessing community needs and resources. Topic sections
include step-by-step instruction, examples, checklists, and related resources.

http://www.countyhealthrankings.org

http://www.countyhealthrankings.org

http://ctb.ku.edu/en

104 Part 1 Planning a Health Promotion Program
2. http://www.csuchico.edu/lins/handouts/eval_websites
CRAAP Test– Meriam Library, California State University, Chico
This link takes you to a handout that presents the CRAAP Test for evaluating materials
found on the World Wide Web.
3. http://www.cdc.gov/nchs/surveys.htm
National Center for Health Statistics
This Webpage of the National Center for Health Statistics (NCHS) provides an overview
of all of the surveys and data collections systems of the NCHS. In addition, it provides
the results of many of the surveys and examples of the questionnaires used to collect
the data.
4. http://www.kff.org/statedata/
Kaiser Family Foundation State Health Facts
This site contains current state-level data on demographics and the economy, health
costs and budgets, health coverage and uninsured, health insurance and managed care,
health reform, health status, HIV/AIDS, Medicaid and CHIP, Medicare, minority health,
providers and service use, and women’s health. Planners can access information as tables,
trend graphs, or color-coded maps.
5. http://wonder.cdc.gov
CDC WONDER
This is the home page for the Centers for Disease Control and Prevention’s (CDC)
Wide-ranging Online Data for Epidemiologic Research (WONDER). CDC WONDER
is an easy-to-use, menu-driven system that provides access to a wide array of secondary
public health information.

http://www.csuchico.edu/lins/handouts/eval_websites

http://www.cdc.gov/nchs/surveys.htm

State Health Facts

http://wonder.cdc.gov

105
5
Chapter Measurement, Measures,
Measurement Instruments,
and Sampling
Chapter Objectives
After reading this chapter and answering the
questions that follow, you should be able to:
⦁⦁ Define measurement.
⦁⦁ Explain the difference between quantitative
and qualitative measures.
⦁⦁ Explain the reasons that measurement is such
an important process as it relates to program
planning and evaluation as well as research.
⦁⦁ Briefly describe the four levels of measurement.
⦁⦁ List the variables that are often measured by
health education specialists.
⦁⦁ List the four desirable characteristics of data.
⦁⦁ Explain the various types of validity.
⦁⦁ Define reliability and explain why it is important.
⦁⦁ Define bias in data collection and discuss how it
can be reduced.
⦁⦁ Briefly describe the steps to identify, obtain, and
evaluate existing measurement instruments.
⦁⦁ Be able to develop questions and response
options for a data collection instrument.
⦁⦁ Briefly describe the process for creating
appropriate presentation for a data collection
instrument.
⦁⦁ Describe how a sample can be obtained from
a population.
⦁⦁ Differentiate between probability and
nonprobability samples.
⦁⦁ Describe how a pilot test is used.
Key Terms
bias
census
cluster sampling
cognitive pretesting
concurrent validity
construct validity
content validity
convergent validity
criterion-related validity
discriminant validity
equivalence reliability
face validity
instrumentation
internal consistency
inter-rater reliability
interval level measures
intra-rater reliability
levels of measurement
measurement
measurement
instrument
nominal level
measures
nonprobability
samples
nonproportional
stratified random
sample
ordinal level
measures
parallel forms
pilot testing
population
predictive validity
preliminary review
pre-pilots
probability sample
proportional stratified
random sample
psychometric qualities
public domain
qualitative measures
quantitative measures
random selection
rater reliability
ratio level measures
reliability
sample
sampling
sampling frame
sampling unit
sensitivity
simple random
sample (SRS)
specificity
stability reliability
strata
stratified random
sample
survey population
systematic sample
universe
validity

106 Part 1 Planning a Health Promotion Program
In this chapter, we will examine critical concepts necessary to maximize the quality of
data, whether for a needs assessment or a program evaluation. Specifically, we will examine
the (1) term measurement, (2) types of data generated from measurement, (3) importance of
measurement, (4) levels of measurement, (5) types of measures, (6) desirable characteristics
of measures, (7) measurement instruments, (8) sampling, and (9) the importance of pilot
testing in the data collection process.
Box 5.1 identifies the responsibilities and competencies for health education specialists
that pertain to the material presented in this chapter.
Measurement
Measurement can be defined as the process of applying numerical or narrative data from
an instrument (e.g., a questionnaire) or other data-yielding tools to objects, events, or people
(Windsor, 2015). For example, if researchers collect data on height and weight from a group
of people then translate those data to body mass index (BMI) values (weight in kilograms
divided by height in meters squared), they can classify participants as either underweight
(usually a BMI of < 18.50), normal (18.50-24.99), overweight (25-29.99) or obese (> 30). In
order to measure something then, planners and evaluators (hereafter referred to collectively
as planners) need to identify what instrument or tool will be used to collect data, how data
5.1
Box Responsibilities and Competencies for Health Education Specialists
Because of the importance of measurement to program planning and evaluation,
the content of this chapter cuts across two different areas of responsibility. Those
responsibilities and related competencies include the following:
RESponSiBility i: Assess Needs, Resources, and Capacity for Health Education/Promotion
Competency 1.2: Access existing information and data related to health
Competency 1.3: Collect primary data to determine needs
Competency 1.4: Analyze relationships among behavioral, environmental,
and other factors that influence health
Competency 1.6: Examine factors that enhance or impede the process of
health education/promotion
Competency 1.7: Determine needs for health education/promotion based
on assessment findings
RESponSiBility iV: Conduct Evaluation and Research Related to Health Education/
Promotion
Competency 4.3: Select, adapt and/or create instruments to collect data
Competency 4.4: Collect and manage data
Competency 4.6: Interpret results
Competency 4.7: Apply findings
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education
Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health
Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE).

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 107
will be categorized using numbers or words, and how these categories of data will be clas-
sified (e.g., for BMI: high risk, medium risk, low risk or excellent health, good health, poor
health, etc.).
The data generated by measurements can be classified into two broad categories, depend-
ing on the method by which they are collected. Quantitative measures “are numeri-
cal data collected to understand individuals’ knowledge, understanding, perceptions, and
behavior” (Harris, 2010, p. 208). Examples of quantitative data could include the mortal-
ity rates for diabetes over the last five years, the aforementioned BMIs of participants in a
weight loss program, the prevalence of cigarette smoking among adolescents, the ratings on
a patient satisfaction survey, and the pretest and posttest scores on a HIV knowledge test.
Qualitative measures are “data collected with the use of narrative and observational ap-
proaches to understand individuals’ knowledge, perceptions, attitudes and behaviors” (Harris,
2010, p. 208). Qualitative data are usually represented as words that are organized into codes
and themes. Examples of qualitative data could include notes generated from observational
studies, transcripts from focus groups, and taped recordings of in-depth interviews with key
informants. Quantitative and qualitative measures both have their individual strengths and
weaknesses, yet their greatest utility may occur when both are used together in the measure-
ment process. While quantitative data with adequate sample sizes can accurately represent
entire populations, qualitative data can provide rich contextual understanding of those same
populations. One way to think about the difference is that quantitative data is like looking at a
picture that is just black and white; all you see are the numbers. Qualitative data adds color and
texture, or richness to those numbers. table 5.1 provides a comparison of many of the qualities
and characteristics of quantitative and qualitative measures.
the importance of Measurement in program planning and Evaluation
As noted earlier in the chapter (see Box 5.1), health education specialists are expected to
have the knowledge and skills to plan and carry out the processes associated with mea-
surement; for example, (1) when reviewing literature in order to justify a program, health
education specialists need to be able to understand the data generated by measurement in
order to determine if they have adequate and appropriate evidence for a proposed program;
(2) when conducting a needs assessment, health education specialists must understand
Table 5.1 Comparison of Quantitative and Qualitative Measures
Source: Cottrell & McKenzie (2011, p. 228) from Debus (1988).
Quantitative Measures Qualitative Measures
Measures level of occurrence Provides depth of understanding
Asks how often? and how many? Asks why?
Studies actions Studies motivations
Is objective Is subjective
Provides proof Enables discovery
Is definitive
Measures levels of actions and trends, etc.
Is exploratory
Allows insights into behavior and trends, etc.
Describes Interprets

108 Part 1 Planning a Health Promotion Program
the basic principles of measurement in order to select and use appropriate data collection
instruments; (3) when health education specialists are planning an evaluation to measure
whether program objectives have been met, they need to be able to measure related program
outcomes; (4) when a funding agency wants evidence that a program it funds is making a dif-
ference in a community, health education specialists must apply appropriate measurement
techniques to generate the needed evidence; or (5) when health education specialists are
asked to interpret the results of a program evaluation to a group of stakeholders, they need
to be competent in determining and communicating whether program components actually
produced the identified results. Each of these examples demonstrates the need for a sound
understanding of the processes associated with measurement. In other words, measurement
is an integral part of program planning, implementation, and evaluation.
levels of Measurement
A fundamental question of measurement is deciding how something should be measured
(McDermott & Sarvela, 1999). For example, consider a scenario in which planners need data
on the income levels of program participants. They could ask about the participants’ income
level in any of the following three ways:
1. Which of the following categories most closely corresponds with your overall
household income: poor, lower middle class, upper middle class, or wealthy?
2. What income category best describes your annual household income? $0 to 10,000;
$10,001 to 25,000; $25,001 to 40,000; $40,001 to 55,000; $55,001 to 70,000; $70,001+
3. What is your annual household income? $ ____________ per year
Although these questions all pertain to household income, each question generates a
different type and level of data. Seventy years ago, Stevens (1946) proposed that four levels
of measurement—nominal, ordinal, interval, and ratio—were the basis for all scientific
measurement. In fact, these four levels of measurement are widely accepted in social and
behavioral research. The four levels of measurement are considered “hierarchical” in nature.
In other words, they progress from more simple or basic to more complex.
1. Nominal level measures constitute the lowest level in the measurement hierarchy
and use names or labels to categorize people, places, or things. While nominal data
represent different categories, they do not represent any particular value or order (i.e.,
they are simply grouped by name). “The two requirements for nominal measures are
that the categories have to be mutually exclusive so that each case fits into one of the
categories, and the categories have to be exhaustive so that there is a place for every
case” (Weiss, 1998, p. 116). For example, a question that would generate nominal data
is, “What is your current student status?” The possible answers include the categories
of “undergraduate student” and “graduate student.” These answers are exhaustive
(contain all possible answers) and mutually exclusive (the respondent has to be one
or the other, but not both). We can then assign numbers to these categories according
to a particular rule we create (e.g., 1 = undergraduate, 2 = graduate).
2. Ordinal level measures, like nominal level measures, allow planners to put data
into categories that are mutually exclusive and exhaustive, but also permit them to
rank-order the categories. The different categories represent relatively more or less
of something. However, the distance between categories cannot be measured. For
example, the question “How would you describe your level of satisfaction with your

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 109
health care? (select one) very satisfied—satisfied—not satisfied” creates categories (very
satisfied—satisfied—not satisfied) that are mutually exclusive (the respondent cannot
select two categories) and exhaustive (there is a category for all levels of satisfaction),
and the categories represent more or less of something (amount of satisfaction), thus
there is a rank order. We cannot, however, measure the distance (or difference) between
the levels of satisfaction. Is the distance between very satisfied and satisfied the same
distance between satisfied and not satisfied? Ordinal data categories are not necessarily
an equal distance apart. Another example is when a patient is asked how much pain
he or she is experiencing on a scale from 1 to 10. While 7 is more severe than 5, this
difference may not be the same as the difference between 3 and 1.
3. Interval level measures enable planners to put data into categories that
are mutually exclusive and exhaustive, and rank-orders the categories, and are
continuous. Furthermore, the widths or differences between categories must all be
the same (Hurlburt, 2003), which allows for the distance between the categories to
be measured. There is, however, no absolute zero value. For example, a question that
generates interval data is, “What was the high temperature today?” We know that a
temperature of 70ºF is different than a temperature of 80ºF, that 80º is warmer than
70º, that there is 10ºF difference between the two, and if the temperature drops to 0º F
there is still some heat in the air (though not much) because 0ºF is warmer than –10ºF.
Examples of health-related variables that are commonly measured on the interval level
include weight, cholesterol, height, blood pressure, age and so forth.
4. Ratio level measures, the highest level in the measurement hierarchy, enable
planners to do everything with data that can be done with the other three levels of
measures; however, those tasks are accomplished using a scale with an absolute zero.
Example questions that generate ratio data include the following: “During an average
week, how many minutes do you exercise aerobically?” “How much money did you
earn last month?” and “How many hours of sleep did you get last night?” An absolute
zero “point means that the thing being measured actually vanishes when the scale
reads zero” (Hurlburt, 2003, p. 17).
Table 5.1 shows the type of questions on a data collection instrument that result in different
levels of measurement. Figure 5.1 shows how different levels of data may be presented as charts
after data analysis has been completed.
Because interval and ratio data are continuous and rank-ordered values with equal distance
between them, and because most statistical procedures are the same for both types of data
(Valente, 2002), some have combined them into a single level of measurement and refer to
the resulting data as numerical data.
The type of data gathered dictates the type of statistical analyses that can be used. Generally
speaking, nominal and ordinal measures are associated with nonparametric tests (less likely
to assume a normal distribution of data, i.e., bell shaped curve) while interval and ratio data
are more often associated with parametric tests (more likely to assume a normal distribution
of data). Parametric statistics are often more powerful in detecting differences between groups
and are therefore preferred by researchers and evaluators (Siegel & Castellan, 1988). Thus,
when planners begin to think about measurement and data collection, they need to consider
both the wording of their questions and the response options and how that wording will im-
pact the data analysis (see Chapter 15).
As presented earlier, many different methods can be used to collect both primary and
secondary data (see Chapter 4). Any method selected will require a measurement instrument

110 Part 1 Planning a Health Promotion Program
to collect the data. By measurement instrument, we mean the item used to measure
the variables (e.g., demographic, psychosocial, behavioral) of interest. Measurement in-
struments are also sometimes referred to as tools or data collection instruments. The term
instrumentation is “a collective term that describes all measurement instruments used”
(Cottrell & McKenzie, 2011, p. 146).
Measurement instruments can take many different forms and sizes. They can range from
the very simple, like a ruler or yardstick, to a questionnaire, to a very complicated piece of
Percent of respondents who have heard of
cytomegalovirus
Number of children currently living
at home
How likely child care providers are
to clean hands with soap and water
or hand sanitizer after serving food
yes
17%
no
83%
300
200
100
0
0 1 2 3 4 5
Nominal data
Ratio/Interval data
Ordinal data
Extremely Likely
Extremely Unlikely
0 50 100 150 200 250
Neutral
⦁▲ Figure 5.1 How to Present Various levels of Data

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 111
machinery that performs DNA sequencing. Although at times health education specialists
may use machines or equipment as instruments (e.g., to check blood cholesterol), more
commonly they employ a sequence of questions to measure variables of interest (Windsor,
2015). These sequences of questions most often take the form of tests, questionnaires, and
scales. The term test is most often used in the context of educational measurement (DiIorio,
2005), such as an HIV/AIDS knowledge test. Questionnaires (sometimes called survey instru-
ments) are instruments that gather information about a variety of factors (e.g., awareness,
skills, behaviors, health status) related to one or more specific topics. For example, a ques-
tionnaire may be developed about sleep habits and include questions about the average
number of hours slept per night, what time a person typically goes to sleep, use of sleep aids,
and techniques used to fall a sleep. A questionnaire can include questions about several
concepts or one or more scales. A scale is a set of questions that asks about one concept or
construct, often related to a psychosocial variable like attitudes, beliefs, or opinions. For
example, health education specialists may be interested in collecting data about attitudes
related to water fluoridation in the priority population. The attitude scale would be a set of
questions related to attitudes. In scales, often the response choice for every question is the
same (e.g., always, sometimes, never). Sometimes the word scale is used in a general sense to
refer to an entire questionnaire or instrument; however, it is not a technically correct use of
the term.
Depending on the nature of the questions being asked, the instrument can vary in length.
Some instruments can be as short as a single question, rating, or item to measure the vari-
able, while others may be multipage instruments. There are advantages and disadvantages to
various instrument lengths. Obvious advantages of a shorter instrument are the time for the
participants to complete it and for the planners to organize and analyze the data. However,
longer instruments may do a better job of measuring less stable (i.e., change over time) vari-
ables like attitudes (DiIorio, 2005), and longer instruments may be more suitable for statisti-
cal calculations (Bowling, 2005).
types of Measures
Many different types of measures are used to conduct needs assessments or evaluate
programs. Typically, health promotion programs focus on one or more of the following
types of measures (also called variables) related to: demographics, awareness, knowledge,
psychosocial characteristics, skills, behaviors, environmental attributes, health status,
and quality of life indicators. table 5.2 illustrates some of these variables and the level of
measurement.
Desirable Characteristics of Data
The results of a needs assessment or program evaluation are only as good as the data that
are collected and analyzed. If a questionnaire is filled with ambiguous questions and the
respondents are not sure how to answer, it is highly unlikely that the data will reflect the
true knowledge, attitudes, and so on, of those responding. Therefore, it is of vital impor-
tance that planners and evaluators make sure that the data they collect are reliable, valid,
and unbiased. Collectively, these characteristics—reliability and validity—are referred to as
an instrument’s psychometric qualities (Cottrell & McKenzie, 2011).

112 Part 1 Planning a Health Promotion Program
Table 5.2 Examples of Questions and Levels of Measurement
Source: Centers for Disease Prevention and Control, 2015a
Variable Question Stem Response Options Level of Measurement
Demographic Height About how tall are you without
shoes?
__/__
ft/inches
Interval
Awareness
Awareness of
smoking cessation
quitlines
A telephone quitline is a free telephone-
based service that connects people who
smoke cigarettes with someone who
can help them quit. Are you aware of
any telephone quitline services that are
available to help people quit smoking?
Yes
No
Nominal
Knowledge
Knowledge of heart
attack symptoms
Do you think pain or discomfort in
the arms or shoulder are symptoms
of a heart attack?
Yes
No
Nominal
Psychosocial
Social and emotional
support
How often do you get the social
and emotional support you
need?
Always
Usually
Sometimes
Rarely
Never
ordinal
Depression During the past 30 days, for about
how many days have you felt sad,
blue, or depressed?
__ __ days Ratio
Behaviors
Visit to healthcare
provider
About how many times in the past
12 months have you seen a doctor,
nurse, or other health professional
for your diabetes?
__ __ times Ratio
Health status
Arthritis diagnosis Has a doctor, nurse, or other health
professional EVER told you that you
had some form of arthritis, rheumatoid
arthritis, gout, lupus, or fibromyalgia?
Yes
No
Nominal
Quality of life
overall measure
of health
Would you say that in general
your health is—
Excellent
Very good
Good
Fair
Poor
ordinal
Reliability
Reliability refers to consistency in the measurement process. That is, reliability “is an
empirical estimate of the extent to which an instrument produces the same result (measure
or score), applied once or two or more times” (Windsor, 2015, p. 196). However, no instru-
ment will ever provide perfect accuracy in measurement because there will always be error.
Reliability coefficients are highest if no error exists (r = 1.0) and lowest when there is only

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 113
error or no association (r = 0.0) between two measures (Windsor, 2015). Error can come from
many sources as will be discussed in the next section about reliability estimates. Planners
need to strive to collect data under the best conditions that will produce reliable data. Several
methods of estimating reliability are available.
Internal consistency is one of the most commonly used reliability estimates (Windsor
et al., 2004). It refers to the intercorrelations among the individual items on a scale, that is,
whether items on the scale are measuring the same domain. This can be done by examining
the scale to ensure that the items reflect what is to be measured and that the level of difficulty
of all items is consistent. Statistical methods can also be used to determine internal consis-
tency by correlating the items on the test with the total score. A Cronbach’s alpha reliability
coefficient measures internal consistency and ranges from 0 to 1 with scores of greater than
0.70 typically classified as acceptable and scores of 0.80 classified as good (George & Mallery,
2003). While alpha coefficients of 0.90 or greater are generally considered to be excellent,
scores this high can also indicate there is redundancy in the instrumentation (i.e., too many
questions may be asking the same thing). If Cronbach’s alpha is low that means there are
errors due to item or content sampling, meaning all the questions on the scale are not in-
terrelated. For example a researcher asked three questions related to people’s perceptions
about weight control (“The health and strength of my body are more important to me than
how much I weigh;” “I honestly don’t care how much I weigh as long as I am physically fit,
healthy, and can do the things I want;” “I mostly exercise because of how it makes me feel
physically”). The three items had a Cronbach alpha of 0.597. The item correlation matrix
showed that last of the three items was not like the others and this contributed to the low
reliability estimate. By removing the last item, the alpha increased to 0.633. This was still not
at the .70 level, but it was improved.
Stability reliability estimates look for consistency over a period of time (Crocker & Algina,
1986). To establish this type of reliability, the same instrument is used to measure the same group
of people under similar, or the same conditions, at two different points in time, and the two sets
of data generated by the measurement are used to calculate a correlation coefficient (Cottrell &
McKenzie, 2011). This is referred to as test-retest. An adequate amount of time should be allowed
between the test and retest so that individuals are not responding on the basis of remember-
ing responses they made the first time, but not be so long that other events could occur in the
intervening time to influence their responses. To avoid the problems of retesting, parallel forms
(equivalent forms) of the test can be administered to the participants and the results can be cor-
related. While a Cohen’s kappa coefficient (Cohen, 1960) equal to or greater to than 0.70 is gen-
erally acceptable, a coefficient of 0.80 is ideal and should be documented (Harris, 2010; Windsor,
2015). There are many sources of error that can contribute to inconsistent scores over time
including changes within the person (they did not get enough sleep the night before), or “errors
due to administration, scoring, guessing, mismarking by examinees, and other temporary fluctu-
ations in behavior” (Crocker & Algina, 1986, p. 133). Stability is important when implementing
interventions over a long period of time and success is evaluated using pre and posttests. If there
should be no change in the variables being measured among participants from pre- to posttest
(i.e., the control group), then stability will be an important reliability estimate.
Rater reliability focuses on the consistency between individuals who are observing or
rating the same item or when one individual is observing or rating a series of items. If two or
more raters are involved, it is referred to as inter-rater reliability. If only one individual
is observing or rating a series of events, it is referred to as intra-rater reliability. There
are several different ways to calculate rater reliability. In a research study, most researchers

114 Part 1 Planning a Health Promotion Program
would use Cohen’s kappa to calculate rater reliability. However, a quicker and easier method
is to calculate it as a percentage of agreement between/among raters or within an individual
rater (DiIorio, 2005). An example of inter-rater reliability would be the percent of agreement
between two observers who are observing passing drivers in cars for safety belt use. If raters
observe 10 cars and the raters agree 8 out of 10 times on whether the drivers are wearing their
safety belts, the inter-rater reliability would be 80%. Intra-rater reliability would be the de-
gree to which one rater agrees with himself or herself on the characteristics of an observation
over time. For example, when a rater is evaluating the CPR skills of participants in his or her
program, the rater should be consistent while observing and evaluating participants.
Estimates of equivalence reliability focus on whether different forms of the same mea-
surement instrument, when measuring the same subjects, will produce similar results (means,
standard deviations, and inter-item correlations). The method used to establish equivalence
is often referred to as parallel forms, equivalent forms, or alternate-forms reliability. One
group is given both versions of an instrument and then the scores are correlated. The useful-
ness of having measurement instruments that possess parallel forms reliability is being able to
test the same subjects on different occasions (e.g., using a pretest-posttest evaluation design)
without concern that the subjects will score better on the second administration (posttest)
because they remember questions from the first administration (pretest) of the instrument.
Another time equivalent forms are used is when a researcher is trying to determine if a shorter
form of a scale is just as reliable as a longer form. For example, the International Physical
Activity Questionnaire (IPAQ) has both a short version (9 items) and a long version (31 items;
Craig et al., 2003). If these instruments have equivalence it would not matter if a person filled
out the short or long form, both instruments would give the same estimate of physical activity
levels. If the forms are not equivalent, there is error due to item or content sampling.
Validity
When designing a data collection instrument, planners must ensure that it measures what
it is intended to measure. This refers to validity. Using an instrument that produces valid
results increases the chance that planners are measuring what they want to measure, thus
ruling out other possible explanations for the results.
Face validity is the lowest level of validity. A measure is said to have face validity if, on
the face, it appears to measure what it is supposed to measure (McDermott & Sarvela, 1999).
Face validity differs from the other forms of validity in that it lacks some form of systematic
logical analysis of the content (Hopkins, Stanley, & Hopkins, 1990). An example of face valid-
ity is when a planner/evaluator asks a group of colleagues to look over a series of questions
to see whether they seem reasonable to include on a questionnaire about the risk for heart
disease. Face validity is a good first step toward creating a valid measurement instrument, but
is not a replacement for the other means of establishing validity (Cottrell & McKenzie, 2011).
Content validity refers to “the assessment of the correspondence between the items
composing the instrument and the content domain from which the items were selected”
(DiIorio, 2005, p. 213). This means that all essential elements of a domain or area are included
in the instrument. For example, a person takes the certification exam to become a health edu-
cation specialist (CHES) they want to be sure that the questions ask about everything a pesron
should know and be able to do as a CHES certified health educator, and not just research and
evaluation or another area of responsibility.

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 115
Content validity is usually established by using a group (jury or panel) of experts to review
the instrument. After such a group is identified, they would be asked to review each element
of the instrument for appropriateness. The collective opinion of the experts is then used to
determine the content of the instrument. McKenzie and colleagues (1999) present a method
of establishing content validity that includes both qualitative and quantitative steps.
With criterion-related validity we are interested in the usefulness of the score as an
indicator of specific trait or behavior presently or in the future. To establish criterion valid-
ity for a scale, there must be a “gold standard” for the comparison with the scale. A gold
standard is a measure that everyone agrees upon is the most accurate and valid measure of a
trait, attribute, or behavior.
Concurrent validity means that the score on a measure (a scale) can predict the pres-
ent standing or status of a trait, attribute or behavior, or even disease status. For example,
a person fills out a survey about mental health and their score on that survey shows they
have major depression. If the instrument has high concurrent validity that score is highly
correlated with a counselor’s diagnosis (the gold standard) of major depression. Predictive
validity means that the score on a measure is able to predict future standing or status. For
example, in prenatal screening a physician wants the amniocentesis test to accurately predict
whether or not a baby will have (or not have) a birth defect when he or she is born. In physi-
cal activity measurement the gold standard is an accelerometer (think Fitbit or Fuel Band).
When establishing validity for a new self-reported measure for how much physical activity a
person got in the last 3 days, the score on the measure would be compared to the results from
the accelerometer the person wore during the same time. If there is good concurrent validity
then the scores from the self-report measure are highly correlated with the accelerometer re-
sults. Both measures are in agreement about a person’s physically activity level.
Construct validity is concerned with whether the instrument is measuring the underly-
ing construct. A construct is a label that we assign a set of attributes or behaviors; it is often
abstract and sometimes theoretical. Examples of constructs in public health and the social sci-
ences are: depression, body-image satisfaction, self-efficacy, worry, social support, perceived
severity, religiosity, chronic disease self-management, anxiety, hopelessness, perceived stress,
school satisfaction, job satisfaction, and so forth (see here for examples of more constructs
http://cancercontrol.cancer.gov/brp/constructs/).
We cannot measure constructs with a simple question or an observation. That is we cannot
ask a person “Are you depressed?” But if a person answers a set of questions (a scale) about their
attitudes, behaviors, thoughts, and so forth, then the construct of depression can be measured.
For example, a person answers the 21-item Beck Depression Inventory (BDI; Beck, Steer, &
Carbin, 1988) and based on their score it can be determined whether or not they are depressed.
If we have construct validity then we can say that the scores from the scale represent the
construct. We are confident that we are actually measuring what we said we are measuring.
For example, we are confident the score on the BDI indicates a person has depression and is
not a measure of a related (or unrelated) construct such as high social anxiety (i.e., the fear of
negative evaluation by others).
Convergent validity is a type of construct validity evidence. It “is the extent to
which two measures which purport to be measuring the same topic correlate (that is, con-
verge)” (Bowling, 2005, p. 12). For example, researchers developing the Reynolds Adolescent
Depression (RAD) scale (Krefetz, Steer, Gulab, & Beck, 2002) gave the RAD and the well-
established BDI to a group on inpatient psychiatric adolescents. The scores revealed high

http://cancercontrol.cancer.gov/brp/constructs/

116 Part 1 Planning a Health Promotion Program
correlation between the RAD and the BDI measures. This provided evidence that the RAD was
in fact measuring depression. Discriminant validity “requires that the construct should
not correlate with dissimilar (discriminant) variables” (Bowling, 2005, p. 12). The BDI is able
to discriminate or distinguish between depression and anxiety (Beck, Steer, & Carbin, 1988).
Again, this gives planners confidence that they are measuring what they intended to measure.
SEnSitiVity and SpECiFiCity
When speaking about validity, planners should also be familiar with the terms sensitivity and
specificity. These terms are used in health care settings as well as epidemiology to express the
validity of screening and diagnostic tests (Cottrell & McKenzie, 2011). Sensitivity is defined
as the ability of the test to identify correctly those who actually have the disease (Friis & Sellers,
2009). It is recorded as the proportion of true positive cases correctly identified as positive on
the test (Timmreck, 1997). The better the sensitivity, the fewer the false positives. Specificity
is defined as “the ability of the test to identify only non-diseased individuals who actually
do not have the disease” (Friis & Sellers, 2009, p. 24). It is recorded as the proportion of true
negative cases correctly identified as negative on the test (Timmreck, 1997). And the better
the  specificity, the fewer the number of false negatives. “An ideal screening test would dem-
onstrate 100% sensitivity and 100% specificity. In practice this does not occur; sensitivity and
specificity are usually inversely related” (Mausner & Kramer, 1985, p. 217).
Both validity and reliability are important. If an instrument does not measure what it is sup-
posed to, then it does not matter if it is reliable (Windsor, 2015). If it is reliable planners may
consistently get the same results, but the results will be of little value. Box 5.2 summarizes the
different types of reliability and validity.
5.2
Box types of Reliability and Validity
Reliability—“an empirical estimate of the extent to which an instrument produces the same
result (measure or score), applied once or two or more times” (Windsor, 2015, p. 196).
internal consistency—the intercorrelations among individual items on the instrument,
that is, whether all items on the instrument are measuring part of the same domain.
Stability—used to generate evidence of consistency over time” (Crocker & Algina, 1986).
Rater (or observer)—associated with the consistent measurement (or rating) of an
observed event by the same or different individuals (or judges or raters) (McDermott &
Sarvela, 1999).
Equivalence—focuses on whether different forms of the same instrument, or a shorter
version of an instrument, when measuring the same participants will produce similar
results. Also referred to as parallel, equivalent or alternate forms reliability.
Validity—whether an instrument correctly measures what it is intended to measure.
Face—if, on the face, the measure appears to measure what it is supposed to measure
(McDermott & Sarvela, 1999).
Content—“the assessment of the correspondence between the items composing the
instrument and the content domain from which the items were selected” (DiIorio, 2005,
p. 213).
Criterion-related—if the score is an indicator of specific trait or behavior presently
(concurrent), in the future (predictive).
Construct—scores on the instrument are measuring the underlying construct. There
can be convergent and discriminant construct validity evidence.
Fo
cu
s
O
n

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 117
Bias Free
Biased data are those data that do not accurately reflect the true level of a measure because of
errors in the measurement process including how data were collected. In addition, bias can
be introduced due to error in the selection of the study participants, in the study’s design, or
in the intervention phase which includes how participants were exposed to the treatment
(Hartman, Forsen, Wallace, & Neely, 2002). In order to effectively plan and evaluate health
promotion programs, planners must work to control bias. Windsor (2015) describes ways in
which bias can occur in data collection—for example, when participants do not feel comfort-
able answering a sensitive question, when participants act differently because they know
they are being watched, when certain characteristics of the interviewer influence a response,
when participants answer questions in a particular way regardless of the questions being
asked, or when a biased sample has been selected from the priority population (see informa-
tion later in this chapter on sampling).
There are a number of steps planners can take to limit bias. For example, if data are being
collected via observation, the observation should be as unobtrusive as possible. If sensitive
questions are being asked of respondents, then those collecting such data need to ensure
that the data are being collected in a confidential way (the identity of the respondent can
be determined but not released), and consider collecting the data via an anonymous means
(there is no way of identifying the respondent). No matter how data are collected, the use of
techniques to reduce bias will increase the accuracy of the results.
Measurement Instruments
Using an Existing Measurement instrument
Before planners create their own measurement instrument, they should search for an exist-
ing instrument that will produce valid and reliable data and that meets their needs. As you
will discover in the next section, it takes a great deal of time, effort, and resources to create a
measurement instrument with good psychometric qualities. The main advantages of using an
existing instrument include less planning time and thus lower costs. The major disadvantage—
one that prevents the use of many existing instruments—is that the items on the existing
instrument may not be relevant or appropriate for the program being planned or evaluated.
Cottrell and McKenzie (2011) offer four steps for identifying, obtaining, and evaluating exist-
ing measurement instruments.
Step 1: Identifying measurement instruments. Start by searching the literature to see
what others have used. You may not find an actual copy of the measurement instruments
in the literature, but you may find a reference to the original source. As you are aware by
now, the U.S. government has created many health-related data collection instruments.
Conducting a search of applicable Websites (e.g., National Center for Health Statistics) can
be useful. Remember, government publications are in the public domain (available for
anyone to use) and thus free of charge and need no permission to use. Also, be aware that
a number of commercial companies sell measurement instruments [e.g., Psychological
Assessment Resources, Inc. (PAR)]. In addition, you may not find a measurement instru-
ment that you can use in whole, but you may find specific questions or a scale that may
work for you.

118 Part 1 Planning a Health Promotion Program
Step 2: Getting your hands on the instrument. Once you have identified potential
measurement instruments, you then have to obtain a hard copy. Unless an instrument is
copyrighted, or there are plans to do so in the future, most sources are willing to share their
measurement instruments. A phone call, letter, or email requesting a copy of an instrument
is usually all that it takes to get a copy. Once the source of the measurement instrument is
known, be aware that you may have to pay for an instrument, and have to meet certain cri-
teria (e.g., being a licensed psychologist, or agree to certain terms) to be able to obtain and
use some measurement instruments.
Step 3: Is it the right instrument? Here are some questions to ask to determine whether an
instrument is the right one for your purposes:
(1) Is there sufficient evidence of the psychometric qualities (validity and reliability) of
the instrument? (2) Has it been used with participants similar to yours? (3) Are standard
or normative scores available for various participants? (4) Is the instrument culturally
appropriate for your participants? (5) Has the reading level of the instrument been deter-
mined? (6) Is there a cost to administer or have the instrument scored? Can you afford it?
(Cottrell & McKenzie, 2011, p. 164)
Step 4: Final steps before proceeding. If you think you have found the right instrument,
before proceeding make sure you have done everything necessary to be able to use it.
Remember, for instruments that are not in the public domain, “you need the permission
of the author for any use of the instrument, usually in writing, and particularly if you need
to make any changes” (Dignan, 1995, p. 67). You also may need to fulfill other conditions
placed on the use of the instrument by the owner of the copyright before you use it.
Creating a Measurement instrument
Only when planners are unable to use or adapt another instrument for their use should they
undertake the process of developing their own (Janz, Champion, & Strecher, 2002). The
process for creating an instrument, particularly scales, with good psychometric qualities that
will yield valid and reliable data is complex and beyond the scope of this text. For a detailed
discussion of steps in this process, see Cottrell and McKenzie (2011) or Crocker and Algina
(1986). However, often planners and evaluators will need to create questions for an instru-
ment to conduct formative research or to measure program success. Next we will present a
general discussion about the wording, sequencing, and presentation of questions on a mea-
surement instrument.
WoRding QUEStionS
The way in which questions are worded is extremely important in gaining the needed infor-
mation. The result of a poorly worded question was evident to one health promotion planner
who was planning a smoking cessation program for employees. When asked “Do you feel we
need a smoking cessation program?” most employees said yes. The planner realized later that
he should have also asked the question, “If offered, would you attend a smoking cessation
program?” since very few employees participated. In general, always try to avoid questions
that can be answered with a simple yes or no.
The following are guidelines to help you in wording structured questions, referred to as
the question stem, with fixed response options.

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 119
First, avoid leading questions that guide the respondent’s answer or suggest that you are
looking for a specific type of response. For example, “Most people choose to get their health
care at Intermountain Health Care. Where do you go when you need to get health care?”
Second, ask only about one thing at a time. Two-part questions, also called double-
barreled, should also be avoided (e.g., “Do you brush and floss your teeth?”). The respon-
dent may brush their teeth, but not floss.
Third, avoid jargon or use of words that people do not understand. (e.g., “What cardiovas-
cular benefits do you feel are gained from aerobic exercise?”). If you need to use a technical
term, like “cardiovascular” or “aerobic” define it before asking the question. For example,
“The next questions will as about aerobic exercise. By aerobic we mean activities that are
done for at least 30 minutes at a time, use large muscles, and cause you to breathe harder
than normal.”
Fourth, be specific. For example instead of asking, “How helpful was the diabetes education
class,” ask “How helpful were the classes in teaching you how to test your blood sugar.” The first
question is too broad and general. There may be many things about the class that was helpful.
The second question asks about specific aspect of the class.
RESponSE optionS
In addition to the question stem, planners must determine the format for response options.
Planners must give consideration to whether the type of question and the response options
will generate the needed data. For example, assume planners were interested in identifying
the ages of those in the priority population. A question like “How old are you?” could gener-
ate the best data (i.e., ratio level data), but some may not want to share their actual age and
thus planners may not collect enough data to describe the priority population. In this case,
a question that generates ordinal level data with response options such as: 15–24 years old;
25–44 years old; 45–64 years old; 65+ years old” may be a better choice.
For ease of data entry and analysis, close-ended or fixed response are the best. The draw-
backs are that these types of questions do not allow individuals to elaborate on their answers.
They may also force a person into a choice because of the limited number of responses to each
question. One way to ensure that the most common responses to questions are included in
the possible choices is to involve several individuals (especially those in the priority popula-
tion) in the formation of the instrument and in pilot testing, discussed later in this chapter.
Common forced response options often include Likert scales. Likert scales allow respon-
dents to select an answer choice along a continuum, generally ranging from a 5- to a 7-point
scale. Likert scales can measure agreement, likelihood, frequency, importance, quality, and
so forth. For example, responses to the question “How much do you agree with the following
statement: I feel that it is important to limit my use of salt” might be rated on a 5-point scale
ranging from “strongly disagree” (1) to “strongly agree” (5).
Always make sure that the question and the response options match. For example, if a
question asks “How likely are you to attend another exercise class in the next month” the
response options should not be “yes” and “no.” Instead options should be on a Likert-type
scale from very unlikely (1) to very likely (5) as the question is asking about “how likely” they
are to do a behavior.
Response options should be mutually exclusive and exhaustive. By mutually exclusive
we mean that the options do not overlap and only one can be selected. For example, “Do
you currently live in a: house, condo, or apartment?” Someone may live in a basement

120 Part 1 Planning a Health Promotion Program
apartment of a house and thus select both house and apartment as response options. These
options are not mutually exclusive. The list could be expanded to make it exhaustive.
Exhaustive response options means that all the possible choices have been included. For
example, if a question asked about race and only included Black and White, the list would
not be exhaustive.
pRESEntation
A survey instrument can have good questions, but if they are not presented in a way that is
easy to read and understand there may be errors in the data or the response rate may be low.
Therefore, presentation is just as important as wording of questions.
Every survey, whether administered in-person, by mail, or via the Internet should have
the following six components.
1. A cover page. The cover page should include the title of the survey, indicate the survey
sponsor, and contain an image that reflects the survey topic.
2. A survey title. The title should tell the reader what the survey is about. For example:
“Live for Life Weight Loss Class Evaluation”
3. A purpose statement. This tells the respondent the reason for the survey. Do not be too
specific so as to bias participant responses. For example, “The purpose of this survey is
to learn about your experience with the Live for Life classes” is better than “The purpose
of this survey is to find out about how often you eat fruit and vegetables and how often
you exercise.”
4. A statement about confidentiality of answers. This means that nobody will know what
they put as answers and their responses will not be linked to them as a person.
5. Instructions for how they should fill out the survey. For example, “For each question,
mark the one box that best reflects your opinion.” These instructions may also
appear throughout the survey before a set of questions. In that case, they are called
“transition statements.” For example, “The next group of questions asks about your
opinion on the Live for Life curriculum. Mark whether you agree or disagree with
each statement.”
6. Instructions for what they are to do with the survey once they are completed. For
example, “When you are finished with the survey, please place it in the box at the front
of the room.”
The visual appearance of the survey is very important. This allows respondents to easily
answer the questions increasing accuracy and response rates. Here are six basic guidelines:
1. Allow for ample white space. There should be plenty of white space between response
options and between the question stem and the response options.
2. Indent the response options from the question stem. This sets the responses apart from
the question stem and makes them easy to identify.
3. Bold the question stem. This will make the question stem stand out from the response
options.
4. Indicate skip patterns. Skip patterns are words that direct them to go to a specific
question based on how they respond.
5. List all questions and response options vertically, from top to bottom. Our eyes naturally
scan top to bottom, so it is easier and faster to read the options. Do not try to fit a lot of

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 121
questions on one page. Remember, white space is good. Layout can include two columns
on a page, but make sure to separate the columns with a line.
6. Group related questions together. For example, when asking about foods a person
eats, place all the food questions together. Also, group all questions that have similar
response options together. For example, if there are several questions on a Likert scale
of strongly agree to strongly disagree, place them together in the survey.
Lastly, ensure that the survey is designed and coded for easy data entry and analysis. If the
survey is Internet-based many of these things will be done automatically. Specifically:
1. Use check boxes next to response options. It is better to have a box that they check
rather than a “circle” your answer to reduce error due to mis-marking.
2. Code the response options. Coding means that there is a number associated with every
response option. It is usually a number using 6-8 point font (or superscript or subscript
number) to the left of the check box. Numbers are better than letters, because data entry
can be done using the number key pad on a computer keyboard; it is much faster!
3. Never ask respondents to “check all that apply.” Rather have them answer yes or no for
each response option. This makes them evaluate each response option individually and
again makes data entry and analysis much easier.
The first questions on an instrument should be ones that capture the respondent’s at-
tention, are easy to answer, and get them interested in answering the rest of the questions.
For example, it is better to ask: “Which of the following did you like best about the Live for
Life program?” than to ask, “How much do you currently weigh?” Questions that deal with
sensitive topics should be posed at the end of the questionnaire or interview. Answers to
questions about drug use, sexuality, or even demographic information, such as income level,
are more readily answered when the respondents understand the need for the information,
are assured of confidentiality or anonymity, and feel comfortable with the interviewer or the
questionnaire. If the respondent ends the interview or does not complete the instrument
when asked sensitive questions, the other information collected can still be used. To reduce
the number of questions on an instrument, ask “is this a nice-to-know question or a need-
to-know question?” Planners may be interested many questions but the answers to those
questions do not fit the purpose for why the data are being collected. For example, it might
be nice to know if people thought the chairs in the classrooms were comfortable but that an-
swer does not help evaluate the success of the program.
Figure 5.2 includes sample survey questions and illustrates the key points for questions,
response options, and presentation.
Sampling
The need to select participants from whom data will be collected can occur at several times
during the process of program planning or evaluation. Depending on the size of the priority
population, planners may want to collect data from all participants, a census, or from only
some of the participants, a sample. Each of the participants is referred to as a sampling unit. A
sampling unit is the element or set of elements considered for selection as part of a sample
(Babbie, 1992). A sampling unit “may be an individual, an organization, or a geographical
area” (Bowling, 2005, p. 166).

122 Part 1 Planning a Health Promotion Program
1. Have you ever heard of the following viruses,
bacteria, or parasites? (Choose yes or no for
each one)
4. On a typical day, for how many children does your
child care facility provide care?
(Include in your count children that are unrelated
and related to you)
5. Not including yourself, do you employ another staff
member (full-time or part-time) at your facility?
6. How many years have you been working as a
child care provider?
7. What is your age?
8. What is the highest level of education that you have
attained?
2. In your opinion, how likely is it that you will
be exposed to the cytomegalovirus at your
child care facility?
3. As far as you know, when should the diaper
changing surface be sanitized? (Choose one)
a. Adenovirus Yes No
Yes No
1−4
5−8
9−12
13−16
Yes No
Yes No− Go to
1
1
1
1
2
2
2
2
b. Enterovirus
c. Giardia
d. Cytomegalovirus
1
2
3
4
Yes
No
1
2
Less than 1 year1
1−5 years2
6−10 years3
18−191
20−292
30−393
40−494
50−595
60 or older6
High school diploma/GED, or less1
Some college2
Associate’s degree3
Bachelor’s degree or higher4
More than 10 years4
Extremely unlikely1
Somewhat unlikely2
Unlikely3
Likely4
Somewhat likely5
Extremely likely6
During the day, as needed1
At the end of the day2
Once a week3
Once a month4
As needed5
After every child6
Question 3
Line separates
columns
Plenty of white
space
Coding number to
the left of each
box
Use italics or
underline for
emphasis
Use “Yes” or “No” and
not “check all that apply”
Skip
pattern
noted
Questions that go on
to two lines are
aligned flush left
Indent response
options
Bold question
stem
Age categories are
mutually exclusive
⦁▲ Figure 5.2 example of Survey Questions, Response Options, and Presentation
Figure 5.3 illustrates the relationship between groups of individuals. All individuals, un-
specified by time or place, constitute the universe—for example, all U.S. citizens, regardless
of where they reside in the world. Within the universe is a population of individuals speci-
fied by time or place, such as all U.S. residents in the 50 states on January 1, 2016. Within this

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 123
Universe
Population
Su
rve
y population
Sample
⦁▲ Figure 5.3 Relationship of Study Populations
population is a survey population, composed of all individuals who are accessible to the
researchers. The key term here is accessible. For example, all U.S. citizens who are accessible and
can be reached by telephone would be a survey population. Obviously, this would not include
those without telephones, such as those who choose not to own them, those institutionalized,
and the homeless.
A survey population may still be too large to include in its entirety. For this reason, a sample
is chosen from the survey population, a process called sampling. Those in the sample are the
individuals who will be included in the data collection process. Using a sample rather than an
entire survey population helps contain costs. For example, using a sample reduces the amount
of staff time needed to conduct interviews, the cost of postage for written questionnaires, and
the time and cost of travel to conduct observations.
How the sample is chosen is critical to the result of the needs assessment or evaluation:
Does the information gained from the sample reflect the knowledge, attitudes, and behav-
iors of the survey population? According to Green and Lewis (1986), the sampling bias is the
difference between the sampling estimate and the actual population value. Sampling bias
can be reduced by controlling the sampling procedure—that is, how the sample is chosen.
Furthermore, the ability to generalize the results to the survey population is greater when the
sampling bias is reduced.
probability Sample
Increasing the likelihood that the sample is representative of the survey population is achieved
by random selection. Randomness minimizes the likelihood that a systematic source of
selection bias will occur among the sample, thereby influencing the degree of representativeness

124 Part 1 Planning a Health Promotion Program
of the population (Windsor, 2015). When random selection is used, each person in the survey
population has an equal chance or probability of being selected, thus creating a probability
sample.
There are a number of different methods for selecting a probability sample. The most
basic of the probability sampling methods is selecting a simple random sample (SRS).
In order to select an SRS, or for that matter any probability sample, the planner must have a
list or “quasi-list” (Babbie, 1992) of all sampling units in the survey population. This list is re-
ferred to as the sampling frame. Oftentimes, sampling frames have the names and contact
information for everyone in the survey population such as with membership lists, patients
of a clinic, and parents of children enrolled in a certain school or program. Other times the
frame may simply be the title of an individual or organization, such as the director of envi-
ronmental services in the 92 local health departments in Indiana, or a list of all the voluntary
health agencies in the county (Cottrell & McKenzie, 2011).
Once the sampling frame has been identified, the planner can proceed with the process
of selecting an SRS. It begins with assigning a number with an equal number of digits to
each sampling unit in the frame. Suppose, for example, we have a frame of 200 individuals.
The first person in the frame would be given the number 000. The rest of the individuals in
the frame would be assigned consecutive numbers and the last person in the frame would
be assigned the number 199. Once it is decided how large the sample should be, the sample
can be selected. For the purpose of this example let’s suppose a sample size of 20 is desired.
To select these 20 individuals, a computer could be used to randomly select 20 numbers
between 000 and 199, or it could be done manually by using a table of random numbers
(Cottrell & McKenzie, 2011) (see table 5.3).
In order to use a table of random numbers, the manner in which the table will be used
needs to be set forth. Since these tables are generated randomly (by computer), it really does
not matter which way one moves through the table as long as it is done in a consistent man-
ner. For example, the process set forth could be to (1) use the first three digits in the columns
of numbers (because all individuals in the example frame have a three-digit number, that is,
000 to 199); (2) proceed down the columns (as opposed to up or across the rows); (3) at the
Table 5.3 Abbreviated Table of Random Numbers
Row/Column A B C D E
1 75 51 02 17 71 04 33 93 36 60
2 42 75 76 22 23 87 56 54 84 68
3 00 47 37 59 08 56 23 81 22 42
4 74 01 23 19 55 59 79 09 69 82
5 66 22 42 40 15 96 74 90 75 89
6 09 24 34 42 00 68 72 10 71 37
7 89 22 10 23 62 65 78 77 47 33
8 51 27 23 02 13 92 44 13 96 51
9 17 18 01 34 10 98 37 48 93 86
10 02 28 54 60 01 11 28 35 54 32

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 125
bottom of the column proceed to the top of the next column to the right; and (4) proceed in
this same manner until the 20 individuals are selected. To ensure that this process is indeed
random, the process must begin with a random start. That is, the planner cannot just pick
the first number at the top of column one and proceed down through the column because
every individual in the survey population would not have an equal chance of being selected.
The planner can accomplish the random start by closing his or her eyes and pointing to a
place on the table of random numbers then proceeding through the table in the way that was
set forth above (Cottrell & McKenzie, 2011).
A systematic sample also uses a frame and takes every Nth person (determined by
dividing the survey population size by the sample size, N/n), beginning with a randomly
selected individual. For example, suppose that we want to choose a sample of 10 people from
a survey population of 100. We start by randomly choosing a number between 001 and 100,
such as 026, using a table of random numbers. We then choose every tenth (N/n = 100/10 =
10) person (036, 046, 056, 076, 086, 096, 006, 016) until we have the 10 subjects for the sam-
ple. In this way, everyone in the survey population has an equal chance of being selected. A
simple random sample or systematic sample can also be used to select “naturally occurring
groups or clusters, such as schools, clinics, worksites, or census tracks” (Gilmore, 2012, p. 74).
When this occurs, it is called cluster sampling.
If it is important that certain groups be represented in a sample, a stratified random
sample can be selected. Such a method would be used if the planners felt that a certain
independent variable (e.g., size, income, or age, etc.) might have an influence on the data
collected from the participants. A stratified random sample might also be used if it is believed
that, due to small numbers of a certain group in the survey population, representatives from
that group may not be selected using a simple random sample. That is, you may have a sur-
vey population of 100 participants and in that 100 there are only 8 of one group. If you were
to select a sample of 10 from the 100, there is a good chance that none of the 8 from the small
group might be selected (Cottrell & McKenzie, 2011).
Here is an example of the use of a stratified random sample. To begin, the planner first
must divide the survey population into subgroups, or strata, then select a simple random
sample from each stratum. Suppose we were interested in collecting data from companies
within a particular state concerning the number of health education programs offered for
employees. Based on past experience, we suspect the size of the business (i.e., number of
employees) would affect the data we want to collect. That is, small companies might have
fewer health education programs in general than large companies. Also, we know that
relatively few companies in the state have a large number of employees. We could then
divide the companies into strata by size, for example small (1–100 employees), medium
(101–1,000), and large (1,001+). Once the planners decide how many to select from each
stratum, they next decide whether to conduct a proportional stratified random sample
or  nonproportional stratified random sample. A proportional stratified random
sample would be used if the planners wanted the sample to mirror, in proportion, the
survey population. That is, draw out the companies in the same proportions that they are
represented in the survey population. Say our example has 600 small companies, 350 me-
dium companies, and 50 large companies, and the desired sample size is 100. Planners
would then select simple random samples of 60 small, 35 medium, and 5 large companies
(Cottrell & McKenzie, 2011).

126 Part 1 Planning a Health Promotion Program
A nonproportional stratified random sample may be used if the planners want
equal representation from the different strata within the survey population. For example,
suppose we want to collect information about the opinions of college students on a medium-
size regional campus (the survey population) about a new alcohol use policy that was put in
place by the administration and we want to hear equally from the different levels of students
(freshmen [n = 4,000], sophomores [n = 3,000], juniors [n = 2,000], and seniors [n = 1,000])
because it is thought that the policy will affect each class differently. If a sample size of 200 is
desired, we would randomly select (using a simple random sample method) 50 students from
each of the classes (Cottrell & McKenzie, 2011). (See table 5.4 for a summary of probability
sampling procedures.)
nonprobability Sample
There are times when a probability sample cannot be obtained or is not needed. In such
cases, planners can take nonprobability samples in which all individuals in the survey
population do not have an equal chance or probability of being selected to participate in the
needs assessment or evaluation. Participants can be included on the basis of convenience
(because they have volunteered, are available, or can be easily contacted) or because they
possess a certain characteristic.
Nonprobability samples have limitations in the extent to which the results can be
generalized to the total survey population. Bias may also occur because those who are not
included in the sample may differ in some way from those who are included. For example,
including only the individuals who complete a health promotion program may bias the
results; the findings might be different if all participants, including those who attended but
did not complete the program, were surveyed.
Nonprobability samples can be used when planners are unable to identify or contact all
those in the survey population. These samples can also be used when resources are limited and
Table 5.4 Summary of Probability Sampling Procedures
Source: Adapted from E. R. Babbie, The Practice of Social Research, 6th ed. (Belmont, CA: Wadsworth, 1992); P. C. Cozby, Methods in Behavioral Research, 3rd ed.
(Palo Alto, CA: Mayfield, 1985); P. D. Leedy, Practical Research: Planning and Design, 5th ed. (New York: Prentice Hall); and R. J. McDermott and P. D. Sarvela,
Health Education Evaluation and Measurement: A Practitioner’s Perspective, 2nd ed. (New York: McGraw-Hill, 1999).
Sample Primary Descriptive Elements
Simple Random Each subject has an equal chance of being selected if table
of random numbers and random start are used.
Systematic Using a list (e.g., membership list or telephone book), subjects
are selected at a constant interval (N/n) after a random start.
Nonproportional Stratified The population is divided into subgroups based on key
characteristics (strata), and subjects are selected from the
subgroups at random to ensure representation of the
characteristic.
Proportional Stratified Like the nonproportional stratified random sample, but
subjects are selected in proportion to the numerical strength
of strata in the population.
Cluster or Area Random sampling of groups (e.g., teachers’ classes) or areas
(e.g., city blocks) instead of individuals.

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 127
a probability sample is too costly or time consuming. It is important that planners understand
the limitations of this type of sample when reporting the results. (See table 5.5 for a summary
of nonprobability sampling procedures.)
Sample Size
An often-asked question associated with sampling involves how many individuals are
needed for planners to feel confident that sampling error is within an acceptable range so
that reasonable conclusions can be drawn from the data collected. There is no easy answer
to this question. Appropriate sample size is determined by both practical and statistical con-
siderations. From a practical standpoint, often the resources (e.g., personnel, financial) avail-
able to collect data are the determining factor on how large the sample will be. Asked another
way, is the desired sample size affordable?
When analyzing sample size from a statistical standpoint, three major theoretical consid-
erations are used: central limit theorem (CLT), precision and reliability, and power analysis
(Norwood, 2000). The CLT can provide the quickest answer to the sample size question.
Mathematically, it has been shown that when a sample size approaches 30 in number, char-
acteristics of that group approach the normal distribution of the group from which it was
drawn. Thus, while a sample size of 30 may not properly estimate a research parameter or
distinguish research results between groups, a general rule for comparison purposes is, no
group should be smaller than 30.
Determining sample size using precision and reliability, or power analysis, is much more
complicated (and is not within the scope of this book). table 5.6 is offered as an example
of the application of these considerations. Detailed explanations of these concepts are pre-
sented in many statistics textbooks.
Pilot Testing
Pilot testing (sometimes referred to as piloting or a pilot study) is a set of procedures used
by planners to try out the program on a small group of participants prior to actual imple-
mentation. In other words, pilot testing can be thought of as a dress rehearsal for planners
Table 5.5 Summary of Nonprobability Sampling Procedures
Sample Primary Descriptive Elements
Convenience Selecting people who are readily available and easy to reach; may be
members of an intact group or people present at public location.
Homogeneous People are selected who share similar characteristics or traits of interest.
Snowball Method by which respondents are asked to identify others who fit study
criteria; often used with difficult to find priority populations or to find
information-rich respondents.
Quota Choosing people based on whether they meet pre-established criteria;
aiming to have certain number of respondents with specific characteristics.
Maximum
variation
Ensuring diverse representation of the priority population by selecting a
wide variety of people possessing characteristics or experiences.

128 Part 1 Planning a Health Promotion Program
(McDermott & Sarvela, 1999). The purpose of using pilot testing is to identify and, if nec-
essary, correct any problems prior to implementation with the priority population. Thus,
pilot testing permits a thorough check of all planned processes to help increase the chances
of having a successful program. Throughout the program planning process, planners may
use pilot testing to detect any problems with sampling, data collection instruments, data
collection procedures, data analysis procedures, interventions, curricula, and program
evaluation (McDermott & Sarvela, 1999). Because this chapter has focused on measure-
ment and measures, the remaining portions of this discussion will focus on the pilot test-
ing of data collection. Pilot testing will be discussed in later chapters, as it relates to the
implementation of a program as well as its role in formative evaluation (see Chapter 12 and
Chapter 14).
Once the data collection method has been determined and the instrument has been
selected or created, a trial run of the instrument, data collection procedures, and analyses
should be conducted. During the piloting process, it would not be uncommon for the
planners to find problems, such as ambiguous questions, difficulty with coding sheets,
and misunderstood directions. Further, the data collected during pilot testing should be
statistically analyzed or compiled to make sure there is no difficulty with this step in the
data collection process. Revising the data collection process using the information gained
from the pilot testing helps ensure that the actual data collection will proceed smoothly.
Several authors have suggested processes for pilot testing (Borg & Gall, 1989; McDermott
& Sarvela, 1999; Parkinson & Associates, 1982; Stacy, 1987). They have been combined
here into a single process. Several of the preceding authors have presented hierarchies for
pilot testing: preliminary review, pre-pilot, and pilot tests. The first and lowest level in the
pilot testing hierarchy is a preliminary review. A preliminary review is conducted when
those responsible for the data collection process ask colleagues, not people from the prior-
ity population, to review the data collection instrument. At a minimum, all data collec-
tion instruments should be subjected to this type of review. Specifically, in a preliminary
review, colleagues would be asked to complete the instrument as if they were participants
in hopes of identifying problems, and also respond to several other questions about the
instrument, such as the appropriateness of (1) the instrument’s title, (2) the introductory
statement explaining the purpose of the data collection, (3) the directions, (4) the order or
Table 5.6 Sample Sizes for Studies Describing Population Proportions When
the Population Size Is Known
* = In these cases the assumption of normal approximation is poor, and the formula used to derive them does not apply.
Source: Statistics: An Introductory Analysis. Taro Yamane. Copyright © 1973 by Pearson Education. Adapted with permission.
Population Size
95% Confidence Interval Sample Size for Precision of
∙1 ∙3 ∙5
500 * * 222
1,000 * * 286
5,000 * 909 370
10,000 5,000 1,000 385
100,000 9,091 1,099 398
S ∞ 10,000 1,111 400

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 129
grouping of the questions, (5) the questions (e.g., unclear or too personal), (6) the length of
the instrument, and (7) the method of returning the instrument, to name a few.
Next, pretesting is completed with members of the priority population. Respondents fill
out the survey and then give feedback either orally or in writing about which questions and
response options they found confusing. When you invite someone to come meet with you and
fill out the survey this process is referred to as cognitive pretesting (Collins, 2003). In this
process you ask the participant to talk out loud as they take the survey, tell you what they are
thinking as they read the question and the responses. For example, if a question asked “How
many residences have you lived in since you were born.” The respondent might say, “I am
thinking whether residences means houses or cities. I think it means cities, so I am going to
write down five.” You may actually be looking for number of houses, so you know you need to
change the wording of that question. The same cognitive pretesting process can be used after
a respondent fills out the survey instead of during the process. The planner holds a debriefing
session after the respondent completes the instrument where inquiries are made about word-
ing of questions, understanding, response options and so forth.
Pre-pilots (or mini-pilots) are used by planners with five or six members of the priority
population to assess the quality of materials, instruments, and data collection techniques. The
pilot test requires the actual implementation of the instrument. A representative sample of
the priority population is used to determine the quality of the instrument. If enough subjects
are used during the pilot study, it may be possible to check the validity and reliability of the
instrument. If at all possible, the use of this sequence of pilot testing techniques is desirable,
but planners are often limited by time and resources, and so not all the steps may be reasonable
to complete.
Ethical Issues Associated with Measurement
Whenever people are being measured as part of a needs assessment or an evaluation, plan-
ners need to be aware that many of their decisions made and actions taken throughout these
processes could have ethical ramifications. Further, planners are obligated by law—via the
Health Insurance Portability and Accountability Act of 1996—to guard against the misuse of
individual identifiable health information.
Ethical issues associated with measurement begin with getting people to voluntarily par-
ticipate in the process. Before people get involved they should be well informed about the
nature of the process and what is expected when they do participate. Further, potential par-
ticipants should not be coerced or deceived to participate. And, once participation has begun,
planners should make it clear that participants have the right to discontinue participation at
any time without penalty. A second issue is that of private and/or sensitive data. If planners
need to ask questions that reveal private and sensitive data, they need to ensure anonymity or
confidentiality. During data collection, planners may hear about illegal acts, such as drug use
or other crimes, or they may be provided with access to confidential data. The planners must
consider the ethical issues and the legal ramifications of such issues.
Once the data have been collected, several ethical issues could arise when the data are an-
alyzed and reported. Inappropriate data analyses can lead to personal harm to participants,
the continuation of inappropriate programs, policies or procedures, and the waste of time,
effort, and resources (Cottrell & McKenzie, 2011). Regardless of the purposes for which the

130 Part 1 Planning a Health Promotion Program
analyzed data are used, planners have an ethical obligation to ensure they do not mislead
anyone who relies on them (Dane, 1990). Finally, when the results of a needs assessment
or an evaluation are reported, planners must ensure not to reveal the identity of those who
participated, or individual results of participants, without their permission.
Summary
This chapter focused on helping you understand the terms measurement, measures, measure-
ment instruments, sampling, and pilot testing. A brief overview of measurement and measures
was provided, along with the four levels of measurement: nominal, ordinal, interval, and
ratio. Several different examples of questions used at each of the levels were also presented.
Next, desirable characteristics of data were discussed, including reliability, validity, and
the importance of being bias free. Background information was provided to assist you with
processes to identify existing measurement instruments and create new ones. Information
was also presented on writing measurement instrument questions. This was followed by a
discussion of techniques used to draw the various probability and nonprobability samples,
and when the various sampling techniques might be most useful. The chapter concluded
with short presentations on the importance of using pilot testing and the ethical issues as-
sociated with measurement.
Review Questions
1. What is meant by measurement, and qualitative and quantitative measures?
2. What are the reasons that measurement is such an important process when it comes to
program planning and evaluation?
3. Name and give an example of each of the four levels of measurement.
4. What are the most common types of measures (variables) used in needs assessments
and evaluations? Give an example of each type of variable.
5. What are sources of validity evidence? What are the different types of reliability
estimates? What are reasons that validity and reliability are important to measurement?
6. What is bias in data collection? Name three ways in which it can be controlled.
7. What are the steps one can follow when identifying, obtaining, and evaluating existing
measurement instruments?
8. What are the advantages and disadvantages of using an existing measurement
instrument?
9. What are the guidelines for wording questions and response options?
10. What are the guidelines for presentation when designing a data collection instrument?
11. Define census, sample, sampling, and sampling frame.
12. Using a table of random numbers, explain how a simple random sample is selected.
13. Describe three types of probability samples.

Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling 131
14. When, if ever, should nonprobability samples be used?
15. What is the purpose of a preliminary review, a pre-pilot (or mini-pilot), a pilot test,
and cognitive pretesting? How is each conducted?
16. What ethical issues are associated with measurement?
Activities
1. Assume that your college or university has hired you to conduct a needs assessment on
the student body for a new health promotion program. Because there are few secondary
data on this group of people, other than national data on college students, you have
decided to survey a random sample of students using a written instrument. Your
task now is to develop the instrument. Create a draft of an instrument that includes
questions that will collect data about the students’ health behavior and demographic
characteristics. Follow the guidelines in this chapter for wording questions as well as
presentation.
2. Conduct a cognitive pretesting of your instrument developed in activity 1 on five or
six of your friends, colleagues, or classmates. Make changes based on the feedback you
receive. Next, pilot test the survey by asking 5–10 people to fill it out. Identify any flaws
you see in the questionnaire or data collection process.
3. Assume that you are charged with the responsibility of collecting data from all the
students on your campus who are interested in taking non-traditional physical activity
classes such as yoga, spinning, or kickboxing. You do not have access to a list of students
on campus that you can use as a sampling frame. Explain how you would obtain a
representative sample from this population. Would probability or non-probability
sampling be best? What are drawbacks and advantages of the method you selected?
4. Look in the peer reviewed literature or the Websites listed in this chapter to find a scale
to measure a construct such as physical activity, social support, self-efficacy for stopping
smoking, resilience, or something similar. Evaluate the quality of the scale by looking for
evidence of validity and reliability in the scholarly literature (start with Google Scholar).
Write a recommendation as to whether or not it would be an appropriate scale to use for
a program evaluation or needs assessment.
Weblinks
1. http://ctb.ku.edu/tools/en/sub_main_1044.htm
Community Toolbox
This page from the Community Toolbox Website, created and maintained by the Work
Group on Health Promotion and Community Development at the University of Kansas,
defines and describes the process of developing baseline measures.
2. http://www.cdc.gov/nchs
National Center for Health Statistics (NCHS)
The NCHS Website is a rich source of data and measurement instruments used to collect
the data about America’s health.

http://ctb.ku.edu/tools/en/sub_main_1044.htm

http://www.cdc.gov/nchs

132 Part 1 Planning a Health Promotion Program
3. http://www.surveysystem.com/resource.htm
Creative Research Systems
The Creative Research Systems Website includes a lot of information about survey
instrument development data collection and includes a calculator for determining
appropriate sample size.
4. http://www.socialresearchmethods.net/
Web Center for Social Research Methods
This Website is designed for people involved with social science research. Topics covered
include measurement, statistics, study design, sampling, and more. There are several easy
to understand examples provided.
5. http://www.qualtrics.com
Qualtrics
Qualtrics is one of the leading firms for conducting online surveys. You can set up an
account and practice creating surveys.
6. http://www.eval.org/
American Evaluation Association
The American Evaluation Association is a professional association dedicated to
improving the practice of evaluation in various sectors. There is an annual conference,
an email list-serv, and several online resources. Student membership is relatively
inexpensive.
7. http://cancercontrol.cancer.gov/brp/constructs/
Health Behavior Constructs: Theory, Measurement and Research
This Website provides definitions and measurement sources for major theoretical
constructs related to behavioral research. This is a good place to start looking for
measurement instruments.

http://www.surveysystem.com/resource.htm

http://www.socialresearchmethods.net/

http://www.qualtrics.com

http://www.eval.org/

http://cancercontrol.cancer.gov/brp/constructs/

133
To plan, implement, and evaluate effective health promotion programs, planners must
have a solid foundation in place to guide them through their work. The mission statement,
goals, and objectives of a program can provide such a foundation. If prepared properly, a mis-
sion statement, goals, and objectives should not only give the necessary direction to a pro-
gram but also provide the groundwork for the eventual program evaluation (Box 6.1). There
are two old sayings that help express the need for a mission statement, goals, and objectives.
The first is: If you do not know where you are going, then any road will do—and you may
end up someplace where you do not want to be, or you may eventually end up where you
want to be, but after wasted time and effort. The second is: If you do not know where you are
going, how will you know when you have arrived? Without a mission statement, goals, and
objectives, a program may lack direction, and at best it will be difficult to evaluate. Figure 6.1
shows the relationship between a mission statement, goals, and objectives. The size of the
6
Chapter Mission Statement, Goals,
and Objectives
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁⦁ Explain what is meant by the terms mission
statement and vision statement.
⦁⦁ Define goals and objectives and distinguish
between the two.
⦁⦁ Identify the different levels of objectives as
presented in the chapter.
⦁⦁ Describe a SMART objective.
⦁⦁ State the necessary elements of an objective as
presented in the chapter.
⦁⦁ Specify an appropriate criterion for objectives.
⦁⦁ Write program goals and objectives.
⦁⦁ Describe the use for Healthy People 2020.
Key Terms
attitude objectives
awareness objectives
behavioral objectives
condition
criterion
environmental
objectives
goal
impact objectives
knowledge objectives
learning objectives
mission statement
objectives
outcome
outcome objectives
process objectives
skill development
objectives
SMART objectives
vision statement

134 Part 1 Planning a Health Promotion Program
rectangles presented in Figure 6.1 has special meaning. The rectangle that represents the mis-
sion statement is the largest, while the rectangle representing the objectives is the smallest,
meaning that ideas presented go from broad to narrow in scope.
Goals ObjectivesMission
statement
⦁▲ Figure 6.1 Relationship of Mission Statement, Goals, and Objectives
6.1
Box Responsibilities and Competencies for Health Education Specialists
The content of this chapter focuses on the mission, goals, and objectives of a program.
Because the mission, goals, and objectives provide the foundation on which programs
are developed and the criteria used to evaluate the programs, the information presented
in this chapter is applicable to three areas of responsibility:
RESponSiBility ii: Plan Health Education/Promotion
Competency 2.2: Develop goals and objectives
Competency 2.3: Select or design strategies/interventions
RESponSiBility iii: Implement Health Education/Promotion
Competency 3.2: Train staff members and volunteers involved in
implementation of health education/promotion
Competency 3.4: Monitor implementation of health education/promotion
RESponSiBility iV: Conduct Evaluation and Research Related to Health Education/Promotion
Competency 4.1: Develop evaluation plan for health education/promotion
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education
Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health
Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE).
Mission Statement
Sometimes referred to as a program overview or program aim, a mission statement is a short
narrative that describes the purpose and focus of the program. The statement not only describes
the current focus of a program but also may reflect the philosophy behind it. The mission state-
ment also helps to guide planners in the development of program goals and objectives. table 6.1
presents examples of mission statements for programs offered in several different settings.
Some people mistake a vision statement for a mission statement. They are different.
Whereas a mission statement provides a description of the current efforts of a program, a
vision statement is a brief description of where the program will be in the future; typi-
cally, in three to five years. A vision statement answers the questions, “What do we want
to be?” and “What will we look like in three to five years?” Vision statements are often part
of a strategic planning process in which organizations define a strategy or direction for the

Chapter 6 Mission Statement, Goals, and Objectives 135
future. Items that are considered when creating a vision statement are future products (i.e.,
information, ideas, goods, services, events, and behavior), markets, customers, location, and
staffing. Most programs do not include a vision statement. However, if a vision statement
were added to Figure 6.1, it would be found in a larger rectangle to the left of the mission
statement rectangle.
Program Goals
Although some individuals use the terms goals and objectives interchangeably, they are not
the same: There are important differences between them. Goals are broad statements that
describe the expected outcomes of the program. They are less specific than objectives and
are used to explain the general intent of a program to those not directly involved in the pro-
gram (Cottrell & McKenzie, 2011; Neiger & Thackeray, 1998). “Goals set the fundamental,
long-range direction” (NCCDPHP, n.d., p. 1). “Objectives break the goal down into smaller
parts that provide specific, measurable actions by which the goal can be accomplished”
(NCCDPHP, n.d., p. 1). In comparison to objectives, goals are expectations that: provide
overall direction for the program, are more general in nature, do not have a specific deadline,
usually take longer to complete, and are often not measured in exact terms.
Program goals are not difficult to write and need not be written as complete sentences.
They should, however, be simple and concise, and should include two basic components:
who will be affected, and what will change as a result of the program. Goals typically include
verbs such as evaluate, know, improve, increase, promote, protect, minimize, prevent, reduce, and
understand (Jacobsen, Eggen, & Kauchak, 1989). A program need not have a set number of
stated goals. It is not uncommon for some programs to have a single goal while others have
several. Box 6.2 presents some examples of goals for health promotion programs.
Table 6.1 Examples of Mission Statements
Setting Mission Statement
Community Setting The mission of the Walkup Health Promotion Program is to provide
a wide variety of primary prevention activities for residents of the
community.
Heath Care Setting This program is aimed at helping patients and their families
to understand and cope with physical and emotional changes
associated with recovery following cancer surgery.
School Setting School District #77 wants happy and healthy students. To that end,
the district’s personnel strive, through a Whole School, Whole
Community, Whole Child model program, to provide students
with experiences that are designed to motivate and enable them
to improve or maintain their health.
Worksite Setting The purpose of the employee health promotion program is
to develop high employee morale. This is to be accomplished
by providing employees with a working environment that is
conducive to good health and by providing an opportunity for
employees and their families to engage in behavior that will
improve and maintain good health.

136 Part 1 Planning a Health Promotion Program
Objectives
Objectives are precise statements of intended outcome (Gilbert, Sawyer, & McNeill, 2015).
Objectives represent smaller steps than program goals—steps that, if completed, will lead
to reaching the program goal(s) (Ross & Mico, 1980). Stated another way, objectives specify
intermediate accomplishments or benchmarks that represent progress toward a goal (CDC,
2003). Objectives outline in measurable terms the specific changes that will occur in the pri-
ority population at a given point in time as a result of exposure to the program. “Objectives
are crucial. They form a fulcrum, converting diagnostic data into program direction and
resource allocation over time” (Green & Kreuter, 2005, p. 100). Objectives can be thought of
as the bridge between needs assessment and a planned intervention. Knowing how to con-
struct objectives for a program is a most important skill for planners.
Different levels of objectives
Several different levels of objectives are associated with program planning. The different
levels are sequenced or placed in a hierarchical order to allow for more effective plan-
ning (Cleary & Neiger, 1998; Deeds, 1992; Parkinson & Associates, 1982). Objectives are
created at each level in order to help attain the program goal. The “objectives should
also be coherent across levels, with objectives becoming successively more refined and
more explicit, and usually multiplied from one level to the next” (Green & Kreuter, 2005,
p.  102). Achievement of the lower-level objectives will contribute to the achievement of
the higher-level objectives and goals. table 6.2 presents the hierarchy of objectives and
indicates their relationship to program outcomes and evaluation. Because the hierarchy
of objectives was created from the work of several, the labels (names) given to the different
levels of objectives have not been consistent. Thus, as we present the description of each
type of objective, we identify various labels that have been used.
pRoCESS oBjECtiVES
The process objectives are the daily tasks, activities, and work plans that lead to the ac-
complishment of all other levels of objectives (Deeds, 1992). They help shape or form the
program and thus focus on all program inputs/resources (all that are needed to carry out a
program), implementation activities (actual presentation of the program), and stakeholder
reactions. More specifically, these objectives focus on such things as program resources
6.2
Box Examples of program Goals
⦁⦁ Reduce the incidence of cardiovascular disease in the employees of the Smith Company.
⦁⦁ Eliminate all cases of measles in the City of Kenzington.
⦁⦁ Prevent the spread of HIV in the youth of Indiana.
⦁⦁ Reduce the cases of lung cancer caused by exposure to secondhand smoke in
Elizabethtown, PA.
⦁⦁ Reduce the incidence of influenza in the residents of the Delaware County Home.
⦁⦁ Increase the survival rate of breast cancer patients through the optimal use of
community resources.
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Chapter 6 Mission Statement, Goals, and Objectives 137
(materials, funds, space); appropriateness of intervention activities; priority population
exposure, attendance, participation, and feedback; feedback from other stakeholders such
as the funding and sponsoring agencies; and data collection techniques, to name a few.
They also form the groundwork for process evaluation (see the last column in Table 6.2).
impaCt oBjECtiVES
The second level of objectives in the hierarchy is impact objectives. This level of objectives
comprises three different types of objectives: learning objectives, behavioral objectives, and
environmental objectives. They are called impact objectives because they describe the imme-
diate observable effects of a program (e.g., changes in awareness, knowledge, attitudes, skills,
behaviors, or the environment) and they form the groundwork for impact evaluation (see
the last column in Table 6.2).
Learning Objectives. Learning objectives are the educational or learning tools needed
in order to achieve the desired behavior change. They are based upon the analysis of educa-
tional and ecological assessment of the PRECEDE-PROCEED model.
Within this category of objectives, there is another hierarchy (Parkinson & Associates,
1982). This hierarchy includes four types of objectives, beginning with the least complex
and moving toward the most complex. Complexity is defined in terms of the time, effort,
and resources necessary to accomplish the objective. The learning objectives hierarchy be-
gins with awareness objectives and moves through knowledge, attitude, and skill
development objectives. This hierarchy indicates that if those in the priority population
Table 6.2 Hierarchy of Objectives and Their Relation to Evaluation
Source: Adapted from Deeds (1992), Cleary & Neiger (1998), and Parkinson & Associates (1982).
Type of Objective Program Outcomes Possible Evaluation Measures Type of Evaluation
Process objectives Activities presented
and tasks completed
Number of sessions held,
exposure, attendance,
participation, staff performance,
appropriate materials, adequacy
of resources, tasks on schedule
Process (form
of formative)
Impact objectives
Learning
objectives
Change in awareness,
knowledge, attitudes,
or skills
Increase in awareness,
knowledge, attitudes, or skill
development/ acquisition
Impact (form
of summative)
Behavioral
objectives
Change in behavior Current behavior modified or
discontinued, or new behavior
adopted
Impact (form
of summative)
Environmental
objectives
Change in the
environment
Measures associated with
economic, service, physical,
social psychological, or political
environments, e.g., protection
added to, or hazards or barriers
removed from, the environment
Impact (form
of summative)
Outcome objectives Change in quality of life
(QOL), health status, or
risk, and social benefits
QOL measures, morbidity data,
mortality data, measures of risk
(e.g., HRA)
outcome (form
of summative)

138 Part 1 Planning a Health Promotion Program
are going to adopt and maintain a health-enhancing behavior to alleviate a health concern
or problem, they must first be aware of the health concern. Second, they must expand their
knowledge and understanding of the concern. Third, they must attain and maintain an
attitude that enables them to deal with the concern. And fourth, they need to possess the
necessary skills to engage in the health-enhancing behavior.
Behavioral Objectives. Behavioral objectives describe the behaviors or actions in which
the priority population will engage that will resolve the health problem and move you to-
ward achieving the program goal (Deeds, 1992). Behavioral objectives are commonly written
about adherence (e.g., regular exercise), compliance (e.g., taking medication as prescribed),
consumption patterns (e.g., diet), coping (e.g., stress-reduction activities), preventive actions
(e.g., brushing and flossing teeth), self-care (e.g., first aid), and utilization (e.g., appropriate
use of the emergency room).
Environmental Objectives. Environmental objectives outline the nonbehavioral causes of
a health problem that are present in the social, physical, psychological, economic, service, and/
or political environments. Environmental objectives are written about such things as the state
of the physical environment (e.g., clean air or water, proximity to facilities, removal of physical
barriers), the social environment (e.g., social support, peer pressure), the psychological environ-
ment (e.g., the emotional learning climate), the economic environment (e.g., affordability,
incentives, disincentives), the service environment (e.g., access to health care, equity in health
care), and/or the political environment (e.g., health policy).
outComE oBjECtiVES
Outcome objectives are the ultimate objectives of a program and are aimed at changes in health
status, social benefits, risk factors, or quality of life. “They are outcome or future oriented” (Deeds,
1992, p. 36). If these objectives are achieved, then the program goal will be achieved. These objec-
tives are commonly written in terms of health status such as the reduction of risk, physiologic
indicators, signs and symptoms, morbidity, disability, mortality, or quality of life measures.
Consideration of the time needed to Reach the outcome of an objective
In addition to objectives being written at different levels within the hierarchy, they can also
be written with consideration to the amount of time needed to reach the objective. Thus,
the terms short-term objective, intermediate objective, and long-term objective have been used.
Short-term objectives include a time frame in which an outcome is “expected immediately
and can occur soon after the program or intervention is implemented, very often within a
year” (NCCDPHP, n.d., p. 2). “Intermediate objectives result from and follow short-term
outcomes” (NCCDPHP, n.d., p. 2), while “long-term objectives state the ultimate expected
impact of the program or intervention” (NCCDPHP, n.d., p. 2). As an example, a short-term
objective may be a process objective that focuses on capacity building indicating the num-
ber of health care providers would be increased. A corresponding intermediate objective
may be written as an impact objective focusing on the number of people screened because
of the increase in providers. And, the long-term objective, an outcome objective, could fo-
cus on risk reduction based on individuals being treated for a problem that was identified
via the screening.

Chapter 6 Mission Statement, Goals, and Objectives 139
Developing objectives
Does every program require objectives from each of the levels just described? The answer is
no! However, too often, health promotion programs have too few objectives, all of which
fall into one or two levels. Many planners have developed programs hoping solely to change
the health behavior of a priority population. For example, a smoking cessation program may
have an objective of getting 30% of the participants to stop smoking. Perhaps this program
is offered, and only 10% of the participants quit smoking. Is the program a failure? If the
program has a single objective of changing behavior, its sponsors would have a good case
for saying that the program was not effective. However, it is quite possible that as a result of
participating in the smoking cessation program, the participants increased their awareness of
the dangers of smoking. They probably also increased their knowledge, maybe changed their
attitudes, and developed skills for quitting or cutting back on the number of cigarettes they
smoke each day. These are all very positive outcomes—and they could be overlooked when
the program is evaluated, if the planner did not write objectives that cover a variety of levels.
Questions to be answered When Developing objectives
In addition to making sure that the objectives are written in an appropriate manner, plan-
ners also need to be consistent with other planning parameters. In this section we present six
questions that planners should consider when writing objectives:
1. Can the objective be realized during the life of the program or within a reasonable time
thereafter? It would be quite realistic to assume that a certain number of people will
not be smoking one year after they have completed a smoking cessation program, but
it would not be realistic to assume that a group of elementary school students could be
followed for life to determine how many of them die prematurely due to inactivity.
2. Can the objective realistically be achieved? It is probably realistic to assume that 30%
of any smoking cessation class will stop smoking within one year after the program has
ended, but it is not realistic to assume that 100% of the employees of a company will
participate in its fitness program.
3. Does the program have enough resources (personnel, money, and space) to obtain a
specific objective? It would be ideal to be able to reach all individuals in the priority
population, but generally there are not sufficient resources to do so.
4. Are the objectives consistent with the policies and procedures of the sponsoring agency? It
may not be realistic to expect to incorporate a no-smoking policy in a tobacco company.
5. Do the objectives violate any of the rights of those who are involved (participants or
planners)? Right-to-know laws make it illegal to withhold information that could cause
harm to a priority population.
6. If a program is planned for a particular ethnic/cultural population, do the objectives
reflect the relationship between the cultural characteristics of the priority group and the
changes sought? It would not be realistic to have an objective that eliminates the use of
tobacco in a priority population that is comprised of Native Americans because of the
ceremonial pipe use in the Native American culture.
Elements of an objective
For an objective to provide direction and be useful in the evaluation process, it must be
written in such a way that it can be clearly understood, states what is to be accomplished,

140 Part 1 Planning a Health Promotion Program
and is measurable. To ensure that an objective is indeed useful, it should include the
following elements:
1. The outcome to be achieved, or what will change
2. The conditions under which the outcome will be observed, or when the change will occur
3. The criterion for deciding whether the outcome has been achieved, or how much change
4. The priority population, or who will change
The first element, the outcome, is defined as the action, behavior, or something
else that will change as a result of the program. In an objective written as a sentence,
the outcome is usually identified as the verb of the sentence. Thus words such as apply,
argue, build, compare, demonstrate, evaluate, exhibit, judge, perform, reduce, spend, state,
and test would be considered outcomes (see Box 6.3 for a more comprehensive listing of
6.3
Box outcome Verbs for objectives
abstract copy gather offer round
accept count (information) order score
adjust create generalize organize seek
adopt criticize generate pair select
advocate deduce group participate separate
analyze defend guess partition share
annotate define hypothesize perform show
apply delay (response) identify persist simplicity
approximate demonstrate illustrate plan simulate
argue derive imitate practice solve
(a position) describe improve praise sort
ask design infer predict spend
associate determine initiate prepare (money)
attempt develop inquire preserve state
balance differentiate integrate produce structure
build discover interpolate propose submit
calculate discriminate interpret prove subscribe
categorize dispute invent qualify substitute
cause distinguish investigate query suggest
challenge effect join question summarize
change eliminate judge recall supply
choose enumerate justify recite support
clarify estimate keep recognize symbolize
classify evaluate label recommend synthesize
collect examine list record tabulate
combine exemplify locate reduce tally
compare exhibit manipulate regulate test
complete experiment map reject theorize
compute explain match relate translate
conceptualize express measure reorganize try
connect extend name repeat unite
construct extract obey replace visit
consult extrapolate object represent volunteer
contrast find (to an idea) reproduce weigh
convert form observe restructure write
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Chapter 6 Mission Statement, Goals, and Objectives 141
appropriate outcome words). It should be noted that not all verbs would be considered
appropriate outcomes for an objective; the verb must refer to something measurable and
observable. Words such as appreciate, know, internalize, and understand by themselves do
not refer to something measurable and observable, and therefore are not good choices
for outcomes. Some verbs work better than others for specific types of objectives. For
example, the verb list is an appropriate verb for an awareness-level objective, but not for a
knowledge-level objective. The verb explain would be much better suited for a knowledge-
level objective.
The second element of an objective is the condition under which the outcome will
be  observed, or when it will be observed. “Typical” conditions found in objectives might
be “upon completion of the exercise class,” “as a result of participation,” “by the year
2020,” “after reading the pamphlets and brochures,” “orally in class,” “when asked to
respond by the facilitator,” “by year two of the program,” “by May 15th,” or “during the
class session.”
The third element of an objective is the criterion for determining when the outcome
has been achieved, or how much change will occur. The purpose of this element is to
provide a standard by which the planners/evaluators can determine if an outcome has
been performed in an appropriate and/or successful manner. Examples might include “to
no more than 105 per 1,000,” “by 10% over the baseline,” “300 pamphlets,” “33% of the
county residents,” “75% of the motor vehicle occupants,” “at least half of the participants,”
“according to CDC guidelines,” or “all people who preregistered.” One of the most dif-
ficult parts of creating appropriate objectives for a program is to determine what would be
the appropriate criterion for an objective. Should program planners expect a 10% increase
over baseline? Should they anticipate half of the employees to participate? What should
be expected? There is no hard-and-fast rule for determining the criterion, but remember
the criterion should be realistic and based on evidence whenever possible. Several different
criterion-(target)-setting methods have been used in writing the objectives for the Healthy
People initiative over the past three plus decades. Box 6.4 provides a brief description of the
target-setting methods used.
The last element that needs to be included in an objective is mention of the priority popu-
lation, or who will change. Examples are “teachers of Smith Elementary,” “employees of the
company,” “the people who participated in the program,” and “those residing in the Muncie
and Provo areas.” Figure 6.2 summarizes the key elements of a well-written objective. There
is one exception to the priority population always being the who of an objective. That excep-
tion applies to process-level objectives. Because some of these objectives guide the work of the
program planners and/or implementers. In those cases, the who is the staff or group entrusted
with instituting the program instead of the priority population (Cottrell & McKenzie, 2011).
(See Box 6.5 for examples of objectives that would include the four primary elements.)
Objectives that include the elements described in this section are referred to as SMART.
SMART stands for specific, measurable, achievable, realistic, and time-phased (CDC, 2003).
Every objective planners write for their programs should be SMART! (See Box 6.6 for a SMART
Objectives Checklist.)
In summary, well-written objectives will always answer the question “WHO is going to
do WHAT, WHEN, and TO WHAT EXTENT?” (NCCDPHP, n.d., p. 2). Although it is easy to
describe the components of well-written objectives, it is not always easy to write them. Box 6.7
provides a template to help program planners write objectives.

142 Part 1 Planning a Health Promotion Program
6.4
Box
⦁⦁ Better than best—When no baseline
data were available, target was set
based on a comparison to racial/
ethnic group with best, or most
favorable rate.
⦁⦁ Consistent with another program—
Target was set based on the results
of an already completed program.
⦁⦁ Consistent with national strategy—
Target was set based on the national
strategy to improve health.
⦁⦁ Consistent with regulations/policies/
laws—Target was set based on data
included in the regulations/policies/
laws.
⦁⦁ Evidence-based approach—Target
set based on results of completed
research.
⦁⦁ Expert opinion—If no other data were
available, the target was set based on
the opinion of experts.
⦁⦁ Minimal statistical significance—
Target was set using the smallest
improvement that results in a
statistically significant difference when
tested against the baseline value.
target Setting methods for the objectives of the Healthy People initiative
⦁⦁ Modeling/projection of trend (or trend
analysis)—Target was set using a
model or based on trend data.
⦁⦁ No increase from baseline (maintain
baseline)—Target was set based on
the belief there would be no change
from baseline.
⦁⦁ One state per year—Target was set
based on getting one state (or the
District of Columbia) to meet a criterion
each year.
⦁⦁ Percent improvement—Target was
based on a reasonable expected percent
change in the priority population
compared to previous improvement.
⦁⦁ Retain previous set of objectives
target—Target was retained if the
previous target was not reached and
was still appropriate.
⦁⦁ Threshold analysis—Target was set
after analyzing at what point change
would begin to produce an effect.
⦁⦁ Total coverage or elimination—Target
was set based on the belief that a
criterion of 100% could be achieved.
Sources: Gurley (2007, April), USDHHS (2007), USDHHS (2015c).
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Goals and Objectives for the Nation
A chapter on goals and objectives would not be complete without at least a short discussion
of the health goals and objectives of the nation. These goals and objectives have been most
helpful to planners throughout the United States.
The goals and objectives of the nation, which have been referred to as the health agenda
or the blueprint of public health planning for the United States, are the primary component
of the U.S. Healthy People initiative. The Healthy People initiative was launched in 1978 and
a year later released the publication of Healthy People: The Surgeon General’s Report on Health
Outcome
(what)
+
Priority
population
(who)
+ Conditions
(when)
+ Criterion
(how much)
= A well-written
objective
⦁▲ Figure 6.2 elements of a Well-Written Objective

Chapter 6 Mission Statement, Goals, and Objectives 143
6.5
Box Examples of objectives to Support the program Goal “to Reduce
the prevalence of Heart Disease in the Residents of Franklin County”
process objectives
a. By 2020, the program planners will increase the number of heart healthy educational
sessions offered to the county residents from the baseline of 15 to 25 per year.
Outcome (what): Increase the number of heart healthy educational sessions
Priority Population (who): Program planners
Conditions (when): By 2020
Criterion (how much): From the baseline of 15 to 25 per year
B. By August 4, the volunteers will distribute the informational brochure to 33% of
the county residents.
Outcome (what): Will distribute the informational brochure
Priority Population (who): Volunteers
Conditions (when): By August 4
Criterion (how much): 33% of the county residents
C. During the pilot testing, the program facilitators will receive a “good” rating from
at least half of the participants.
Outcome (what): Will receive a “good” rating
Priority Population (who): Program facilitators
Conditions (when): During the pilot testing
Criterion (how much): At least half of the participants
D. Prior to the start of the program, the program staff will deliver the program notebooks
to all people who preregistered for the program.
Outcome (what): Will deliver the program notebooks
Priority Population (who): Program staff
Conditions (when): Prior to the start of the program
Criterion (how much): All people who preregistered
impact – learning objectives
a. Awareness level: After the American Heart Association’s pamphlet on cardiovascular
health risk factors has been placed in grocery bags, at least 20% of the shoppers will
be able to identify two of their own risks.
Outcome (what): Identify their own risks
Priority population (who): Shoppers
Conditions (when): After distribution of the pamphlet
Criterion (how much): 20%
B. Knowledge level: When asked over the telephone, one out of three viewers of
the heart special television show will be able to explain the four principles of
cardiovascular conditioning.
Outcome (what): Able to explain the four principles of cardiovascular conditioning
Priority population (who): Television viewers
Conditions (when): When asked over the telephone
Criterion (how much): One out of three
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144 Part 1 Planning a Health Promotion Program
6.5
Box
continued
C. Attitude level: During one of the class sessions, 50% of the participants will defend
their reason for regular exercise.
Outcome (what): Defend their reason for regular exercise
Priority population (who): Class participants
Conditions (when): During one of the class sessions
Criterion (how much): 50%
D. Skill development level: After viewing the video “How to Exercise,” half of those
participating will be able to locate their pulse and count it every time they are asked
to do it.
Outcome (what): Locate their pulse and count it
Priority population (who): Those participating
Conditions (when): After viewing the video
Criterion (how much): Half of those participating
impact—Behavioral objectives
a. One year after the formal exercise classes have been completed, 40% of those
who completed a majority of the classes will still be involved in a regular aerobic
exercise program.
Outcome (what): Will still be involved
Priority population (who): Those who completed a majority of the classes
Conditions (when): One year after the classes
Criterion (how much): 40%
B. During the telephone interview follow-up, 50% of the residents will report having
had their blood pressure taken during the previous six months.
Outcome (what): Will report having their blood pressure taken
Priority population (who): Residents
Conditions (when): During the telephone interview follow-up
Criterion (how much): 50%
impact—Environmental objectives
a. By the year 2020, 10% of the clinic patients will have been able to schedule an
appointment either after 5 p.m. or on a Saturday.
Outcome (what): Will have been able to schedule
Priority Population (who): Clinic patients
Conditions (when): By the year 2020
Criterion (how much): 10%
B. By the end of the year, all senior citizens who want it will be provided transportation
to the congregate meals.
Outcome (what): Provided transportation
Priority population (who): Senior citizens
Conditions (when): By end of year
Criterion (how much): All who want it

Chapter 6 Mission Statement, Goals, and Objectives 145
6.5
Box
continued
outcome objectives
a. By the year 2020, heart disease deaths will be reduced to no more than 100 per 100,000
in the residents of Franklin County.
Outcome (what): Reduce heart disease deaths
Priority population (who): Residents of Franklin County
Conditions (when): By the year 2020
Criterion (how much): To no more than 100 per 100,000
B. By 2020, increase to at least 25% the proportion of men in Franklin County with
hypertension whose blood pressure is under control.
Outcome (what): Blood pressure under control
Priority population (who): Men in Franklin County with hypertension
Conditions (when): By 2020
Criterion (how much): At least 25%
C. Half of all those in the county who complete a regular, aerobic, 12-month exercise
program will reduce their “risk age” on their follow-up health risk assessment by
a minimum of two years compared to their preprogram results.
Outcome (what): Will reduce their “risk age”
Priority population (who): Those who complete an exercise program
Conditions (when): After the 12-month exercise program
Criterion (how much): Half
D. Two-thirds of those who participate in a formal exercise program will use 10% fewer
sick days during the life of the program than those who do not participate.
Outcome (what): Use 10% fewer sick days
Priority population (who): Those who participate
Conditions (when): During the life of the program
Criterion (how much): Two-thirds
6.6
Box
Criteria to assess objectives
yes no
1. Is the objective SMART?
⦁⦁ Specific: Who? (priority population
and persons doing the activity)
and What? (action/activity)
⦁⦁ measurable: How much change
is expected
⦁⦁ achievable: Can be realistically
accomplished given current
resources and constraints
SmaRt objective Checklist
⦁⦁ Realistic: Addresses the
scope of the health problem
and proposes reasonable
programmatic steps
⦁⦁ time-phased: Provides a timeline
indicating when the objective will
be met
2. Does it relate to a single result?
3. Is it clearly written?
Source: CDC (2009b).
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146 Part 1 Planning a Health Promotion Program
6.7
Box template for Writing objectives for Health promotion programs
(Insert one when from list A here), (insert one how much from list B here)
of the (insert one who from list C here), will (insert one what from list D here).
Column a—When? Column B—How much?
⦁⦁ By December 2020 ⦁⦁ 10% improvement
⦁⦁ After the program ⦁⦁ half
⦁⦁ By year two of the program ⦁⦁ a majority
⦁⦁ One year after the classes ⦁⦁ at least 25
Column C —Who? Column D—What?
⦁⦁ participants ⦁⦁ be able to demonstrate how to prepare a low-fat meal
⦁⦁ employees
⦁⦁ adolescents
⦁⦁ university students
⦁⦁ be able to explain the difference between exercise
and physical activity
⦁⦁ have stopped smoking
⦁⦁ list the risk factors for skin cancer
A
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Promotion and Disease Prevention (USDHEW, 1979). Shortly thereafter, the first set of goals
and objectives, Promoting Health/Preventing Disease: Objectives for the Nation (USDHHS, 1980)
were published. The goals and objectives were written to cover the 10-year period from 1980
to 1990 and were divided into three main areas—preventive services, health protection, and
health promotion—and included a total of 226 objectives. Since the creation of the first
set of goals and objectives, three additional sets have been developed and published under
the titles of Healthy People 2000: National Health Promotion and Disease Prevention Objectives
(USDHHS, 1990), Healthy People 2010 (USDHHS, 2000), and Healthy People 2020 (USDHHS,
2015c). Formal reviews (i.e., measured progress) of these objectives are conducted both at
midcourse half way through the 10-year period (i.e., “The Midcourse Review”) and again
at the end of 10 years. The midcourse review provides an opportunity to measure progress
towards the 10-year targets and determine whether there are trends that need to be reversed.
For example, in Healthy People 2010, a number of objectives were changed, updated, or
deleted because of the events 9/11 and Hurricanes Katrina and Rita. Both the results of the
midcourse and end reviews along with other available data are used to help create the next
set of goals and objectives. Each set of goals and objectives has become more detailed than
the previous. “The evolution from the first decade’s objectives to each subsequent set of
objectives reflected changing societal concerns, evidence-based technologies, theories, and
discourses of those decades. Such accommodations changed the contours of the initiative
over time in attempts to make it more relevant to specific partners and other stakeholders”
(Green & Fielding, 2011, p. 451). At the time this text was being revised the “Healthy People
2020” midcourse review was just beginning.
Healthy People 2020, which was released at the end of 2010, will guide U.S. public health
practice and health education specialists through 2020. Healthy People 2020 includes a vision
statement, a mission statement, four overarching goals, and almost 1,200 science-based
objectives (see Box 6.8) spread over 42 different topic areas (see Box 6.9) (USDHHS, 2015c).
On the Healthy People.gov Website each topic has its own Webpage. At a minimum each

Chapter 6 Mission Statement, Goals, and Objectives 147
page contains a concise goal statement, a brief overview of the topic that provides the back-
ground and context for the topic, a statement about the importance of the topic backed up
by appropriate evidence, and references.
The importance of the Healthy People initiative serving as a blueprint for the nation’s
health agenda is evidenced by their widespread use. Since the publication of the first
Healthy People goals and objectives in 1980, a number of other documents have been cre-
ated that can help planners develop or adopt appropriate goals and objectives for their
programs. A number of states and U.S. territories have taken the national objectives and
created similar documents specific to their own residents. In addition, a number of agen-
cies/organizations have taken similar steps to create documents that could be used by their
members and clients in various planning efforts.
The national goals and objectives have been important components in the process of
health promotion planning since 1980. It is highly recommended that planners review these
objectives before developing goals and objectives for programs. The national objectives may
also be helpful in providing a rationale for a program and in focusing program goals and objec-
tives toward the areas of greatest need, as planners work toward the year 2020.
6.8
Box Example Goal and objectives from Healthy People 2020
Educational and Community-Based programs (ECBp)
Goal: Increase the quality, availability, and effectiveness of educational and community-
based programs designed to prevent disease and injury, improve health, and enhance
quality of life.
objective: ECBp-10 Increase the number of community-based organizations (including
local health departments, tribal health services, nongovernmental organizations, and state
agencies) providing population-based primary prevention services in the following areas
ECBp 10.8 nutrition
Target: 94.7%.
Baseline: 86.1% of community-based organizations (including local health
departments, tribal health services, nongovernmental organizations, and state
agencies) provided population-based primary prevention services in nutrition in 2008
Target setting method: 10% improvement.
Data source: National Profile of Local Health Departments (NPLHD), National
Association of County and City Health Officials (NACCHO)
ECBp 10.9 physical activity
Target: 88.5%.
Baseline: 80.5% of community-based organizations (including local health
departments, tribal health services, nongovernmental organizations, and state
agencies) provided population-based primary prevention services in physical activity
in 2008.
Target setting method: 10% improvement.
Data source: National Profile of Local Health Departments (NPLHD), National
Association of County and City Health Officials (NACCHO)
Source: USDHHS (2015c).
Fo
cu
s
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n

148 Part 1 Planning a Health Promotion Program
6.9
Box
1. Access to Health Services
2. Adolescent Health
3. Arthritis, Osteoporosis, and Chronic
Back Conditions
4. Blood Disorders and Blood Safety
5. Cancer
6. Chronic Kidney Disease
7. Dementias, Including Alzheimer’s
Disease
8. Diabetes
9. Disability and Health
10. Early and Middle Childhood
11. Educational and Community-Based
Programs
12. Environmental Health
13. Family Planning
14. Food Safety
15. Genomics
16. Global Health
17. Health Communication and Health
Information Technology
18. Health-Related Quality of Life and
Well-Being
19. Healthcare-Associated Infections
20. Hearing and Other Sensory or
Communication Disorders
Healthy People 2020 topic areas
21. Heart Disease and Stroke
22. HIV
23. Immunization and Infectious
Diseases
24. Injury and Violence Prevention
25. Lesbian, Gay, Bisexual, and
Transgender Health
26. Maternal, Infant, and Child Health
27. Medical Product Safety
28. Mental Health and Mental Disorders
29. Nutrition and Weight Status
30. Occupational Safety and Health
31. Older Adults
32. Oral Health
33. Physical Activity
34. Preparedness
35. Public Health Infrastructure
36. Respiratory Diseases
37. Sexually Transmitted Diseases
38. Sleep Health
39. Social Determinants of Health
40. Substance Abuse
41. Tobacco Use
42. Vision
Source: USDHHS (2015c).
Fo
cu
s
O
n
Summary
The mission statement provides an overview of a program and is most useful in the develop-
ment of goals and objectives. It should not be confused with a vision statement. The terms
goals and objectives are sometimes used interchangeably, but they are quite different. Together,
the two provide a foundation for program planning and evaluation. Goals are more general in
nature and often are not measurable in exact terms, whereas objectives are more specific and
consist of the steps used to reach the program goals. Objectives can and should be written for
several different levels. For objectives to be useful, they should be written so as to be observable
and measurable. At a minimum, an objective should include the following elements: a stated
outcome (what), conditions under which the outcome will be observed (when), a criterion
for considering that the outcome has been achieved (how much), and mention of the prior-
ity population (who). If an objective is written with the above stated elements it will conform
to the SMART format. As planners develop their goals and objectives for their programs, they
should find the Healthy People 2020 document and other information at its Website very useful.

Chapter 6 Mission Statement, Goals, and Objectives 149
Review Questions
1. What is a mission statement? Why is it important? How is it different from a vision
statement?
2. What is (are) the difference(s) between a goal and an objective?
3. What is the purpose of program goals and objectives?
4. What are the different levels of objectives?
5. What are the four different types of objectives found in “learning objectives
hierarchy”?
6. What are the necessary elements of an objective?
7. What are the characteristics of a SMART objective?
8. Briefly explain the Healthy People initiative.
9. What are the goals and objectives for the nation? How can they be used by program
planners?
10. How can planners use the Healthy People 2020 goals and objectives in their program
planning efforts?
Activities
1. Write a mission statement, a goal, and eight supporting objectives (one of each of the
different types) for a program you are planning.
2. Which of the following statements include all four elements necessary for a complete
objective? Revise those objectives that do not include all the elements.
a. After the class on objective writing, the students will know the difference between
a goal and an objective.
b. The students will understand how a skinfold caliper works.
c. After completing this chapter, the students will be able to write objectives for each of
the levels based on the four elements outlined in the chapter.
d. Given appropriate instruction, the employees will be able to accurately take blood
pressure readings of fellow employees.
e. Program participants will be able to list the reasons why people do not exercise.
3. Using data available from the County Health Rankings (http://www
.countyhealthrankings.org) for the county in which you currently reside, write
a goal aimed at improving a health behavior and write one process, three impact
(i.e., one each for knowledge, behavior, and environment), and one outcome objective
to help reach the goal.
4. Using data available from the Kaiser State Health Facts Website (http://kff.org
/statedata) for the state in which you currently reside, write a goal aimed at improving
a health status topic and write one process, three impact (i.e., one each for awareness,
skill, and environment), and one outcome objective to help reach the goal.

http://www.countyhealthrankings.org

http://www.countyhealthrankings.org

State Health Facts

State Health Facts

150 Part 1 Planning a Health Promotion Program
5. Assume that you are a health education specialist working in a primary care clinic.
Based on some data provided by personnel at the local hospital regarding birth
outcomes for the clinic patients, your supervisor has asked that you create a new
program to decrease the percentage of female patients of childbearing age who smoke.
After completing a needs assessment you have found that the highest rate of smokers
was among those patients who were 18–24 years of age, covered by a health insurance
plan, and have more than one child. In addition, the average number of cigarettes
smoked per day by the patients was 22. Write a mission statement, a goal, and at least
six objectives to help reach the stated goal.
Weblinks
1. http://www.cdc.gov/phcommunities/resourcekit/evaluate/index.html
Communities of Practice (CoP) for Public Health: Evaluate a CoP
On this page of the Centers for Disease Control and Prevention Website, you will find
more information about SMART objectives and some related resources that provide
templates for writing SMART objectives.
2. http://www.healthypeople.gov/2020/default
Healthy People 2020
This is the home page for Healthy People 2020. At this site you can navigate to
background information about Healthy People 2020, a listing of the 42 topic areas and
the objectives, and suggestions for implementing Healthy People 2020.
3. http://ctb.ku.edu/en
Community Tool Box
On the home page of the Community Tool Box (CTB), you can use the “Search” function
to locate information on creating mission statements, goals, and SMART objectives.

http://www.cdc.gov/phcommunities/resourcekit/evaluate/index.html

http://www.healthypeople.gov/2020/default

http://ctb.ku.edu/en

151
7
Chapter Theories and Models Commonly
Used for Health Promotion
Interventions
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁⦁ Define theory, model, constructs, concepts, and
variables.
⦁⦁ Explain why health promotion interventions
should be planned using theoretical frameworks.
⦁⦁ Describe how the concept of the ecological
perspective applies to using theories.
⦁⦁ Explain the difference between a continuum
theory and a stage theory.
⦁⦁ Briefly explain the theories and models
presented in this chapter.
Key Terms
action stage
attitude toward the
behavior
aversive stimulus
behavior change theories
behavioral capability
collective efficacy
community readiness
concepts
construct
contemplation stage
continuum theory
decisional balance
diffusion theory
direct reinforcement
early adopters
early majority
efficacy expectations
elaboration
emotional–coping
response
expectancies
expectations
innovators
intention
laggards
lapse
late majority
likelihood of taking
recommended
preventive health
action
locus of control
maintenance stage
model
negative punishment
negative reinforcement
outcome expectations
perceived barriers
perceived behavioral
control
perceived benefits
perceived seriousness/
severity
perceived susceptibility
perceived threat
planning models
positive punishment
positive reinforcement
precontemplation stage
preparation stage
processes of change
punishment
recidivism
reciprocal determinism
reinforcement
relapse
relapse prevention (RP)
self-control
self-efficacy
self-regulation
self-reinforcement
social capital
social context
social network
socio-ecological approach
(ecological perspective)
stage
stage theory
subjective norm
temptation
termination
theory
variable
vicarious reinforcement

152 Part 1 Planning a Health Promotion Program
Whenever there is a discussion about the theoretical bases for health education and
health promotion, we often find the terms theory and model used. We begin this chapter with
a brief explanation of these terms to establish a common understanding of their meaning.
One of the most frequently quoted definitions of theory is one in which Glanz, Lewis,
and Viswanath (2008b) modified an earlier definition written by Kerlinger (1986). It states,
“A theory is a set of interrelated concepts, definitions, and propositions that presents a
systematic view of events or situations by specifying relations among variables in order to
explain and predict the events of the situations” (p. 26). In other words, “a theory presents a
systematic way of understanding events, behaviors and/or situations” (Glanz, n.d., p. 5). For
health education specialists, theory helps “to develop an organized, systematic, and efficient
approach to investigating health behaviors. Once these investigations produce satisfactory
results and are replicated the findings can be used to inform the design of theory-based inter-
vention programs” (Crosby, Salazar, & DiClemente, 2013, p. 32).
Nutbeam and Harris (1999) have stated that a fully developed theory would be character-
ized by three major elements: “It would explain:
⦁⦁ the major factors that influence the phenomena of interest, for example those factors
which explain why some people are regularly active and others are not;
⦁⦁ the relationship between these factors, for example the relationship between knowledge,
beliefs, social norms and behaviours [sic] such as physical activity; and
⦁⦁ the conditions under which these relationships do or do not occur: the how, when, and
why of hypothesised [sic] relationships, for example, the time, place and circumstances
which, predictably lead to a person being active or inactive” (p. 10).
In comparison, a model “is a composite, a mixture of ideas or concepts taken from any
number of theories and used together” (Hayden, 2014, p. 2). Stated a bit differently: “Models
draw on a number of theories to help understand a specific problem in a particular setting
or content. They are not always as specific as theory” (Rimer & Glanz, 2005, p. 4). Unlike
theories, models do “not attempt to explain the processes underlying learning, but only to
represent them” (Chaplin & Krawiec, 1979, p. 68).
Though we just went to some effort to make a distinction between the words theory and
model, when the terms theory-based, theory-driven, and theory-informed are used (such as in
theory-based/driven/informed planning, theory-based/driven/informed practice, or theory-based/
driven/informed research), it is commonly understood in our profession that the word theory
is used in a general way to mean either theory or model. In fact, some of the best-known and
often used theories in health education/health promotion use the word model in their title
(e.g., Health Belief Model). Goodson (2010) provides an explanation for the discrepancy in
the use of term model for things we refer to as “theory.” She has indicated that when some of
these models were created they were properly titled as models. They were created using theo-
retical constructs to explain specific phenomena. They had little empirical testing to prove
their worth. Over time, these models have been tested and refined and thus have gained
theory status. Goodson (2010) concludes by saying in our work “because we tend to borrow
the theories we employ from other disciplines and fields and because our concern usually
centers in applying these theories (or models) to practice or research, it seems to matter little
to us whether we deal with theories or with models; it seems to matter even less what labels

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 153
we attach to them” (p. 228). Thus, as we use the terms theory and theory-based/driven/informed
throughout the remainder of this book, we use them to be inclusive of endeavors based on
either a theory or a model.
Concepts are the primary elements or building blocks of a theory (Glanz et al., 2008b).
When a concept has been developed, created, or adopted for use with a specific theory, it is
referred to as a construct (Kerlinger, 1986). “The key concepts of a theory are its constructs”
(Rimer & Glanz, 2005, p. 4). The operational (practical use) form of a construct is known as a
variable. Variables “specify how a construct is to be measured in a specific situation” (Glanz
et al., 2008b, p. 28). Thus, variables need to be matched “to constructs when identifying
what needs to be assessed during evaluation of a theory-driven program” (Rimer & Glanz,
2005, p. 4).
Consider how these terms are used in practical application. A personal belief is a concept related
to various health behaviors. For example, people are more likely to behave in a healthy way—
say exercise regularly—if they feel confident in their ability to actually engage in a healthy form
of exercise. Such a concept is captured in a construct of the Social Cognitive Theory (SCT) called
self-efficacy. (See the discussion of the SCT later in this chapter.) If health education specialists
want to develop an intervention to assist people in exercising, the ability to measure the
peoples’ self-efficacy toward exercise will help create the intervention. The measurement may
consist of a few questions that ask people to rate their confidence in their ability to exercise.
This measurement, or operational form, of the self-efficacy construct is a variable. However,
because of the complexity of getting a non-exerciser to become an exerciser, the health
education specialist may need to use a model, composed of constructs from several theories, to
plan the intervention (Cottrell et al., 2015, p. 98).
Based on these descriptions, it seems logical to think of theories as the backbone of the
processes used to plan, implement, and evaluate health promotion interventions. They
can help by (1) identifying why people behave as they do and why they are not behaving in
healthy ways, (2) identifying information needed before developing an intervention, (3) pro-
viding a conceptual framework for selecting constructs to develop the intervention, (4) pro-
viding direction and justification for program activities, (5) providing insights into how best
to deliver the intervention, (6) identifying what needs to be measured to evaluate the impact
of the intervention, and (7) helping to guide research identifying the determinants of health
behavior (Cowdery et al., 1995; Crosby, Kegler, & DiClemente, 2009; Glanz et al., 2008b;
Simons-Morton, McLeroy, & Wendel, 2012). Theory also “provides a useful reference point
to help keep research and implementation activities clearly focused” (Crosby et al., 2009,
p.  11), and it infuses ethics and social justice into practice (Goodson, 2010). In addition,
“[u]sing theory as a foundation for program planning and development is consistent with
the current emphasis on using evidence-based interventions in public health, behavioral
medicine, and medicine” (Rimer & Glanz, 2005, p. 5). Getting people to engage in health
behavior change is a complicated process that is very difficult under the best of conditions.
Without the direction that theories provide, planners can easily waste valuable resources in
trying to achieve the desired behavior change. Therefore, program planners should ground
their planning process in the theories that have been the foundation of other successful
health promotion efforts.
There are many theories that health education specialists can use to guide their practice
however, there is no best theory. “The ‘best theory’ is a function of how well it serves the
objectives that must be met to achieve sustainable protective behaviors among a specified

154 Part 1 Planning a Health Promotion Program
population. In essence, the range of behavioral and social science theories available for both
health promotion practice and research affords the practitioner and researcher an oppor-
tunity to select the theories that are the most appropriate, feasible, and practical for a par-
ticular setting or population” (Crosby et al., 2009, p. 15). In addition, “No single theory or
conceptual framework dominates research or practice in health promotion and education
today” (Glanz et al., 2008b, p. 31). In a review of 10 leading health, medicine, and psychology
journals, Painter, Borba, Hynes, Mays, and Glanz (2008) found that “dozens of theories and
models” (Glanz, 2008b, p. 31) had been used in the reported literature. We have no intention
of introducing all of them. However, approximately 10 theories and models are used regu-
larly to plan programs. In the remaining sections of this chapter, and parts of several other
chapters, we present an overview of the theories that are most often used in creating health
promotion interventions. As you read about and study the various theories, you will find
that some express the same general ideas, but employ “a unique vocabulary to articulate the
specific factors considered to be important” (Glanz et al., 2008b, p. 28). Also, be aware that the
presentation of theories that follows is by no means comprehensive in nature. For those read-
ers who would like to examine these and other theories in more depth, we would recommend
eight books: Health Behavior and Health Education: Theory, Research and Practice (Glanz, Rimer,
& Viswanath, 2008a); Emerging Theories in Health Promotion Practice and Research: Strategies
for Improving Public Health (DiClemente, Crosby, & Kegler, 2009); Theory in Health Promotion
Research and Practice (Goodson, 2010); Behavior Theory in Health Promotion Practice and Research
(Simons-Morton et al., 2012); Theoretical Foundations of Health Education and Health Promotion
(Sharma & Romas, 2012); Health Behavior Theory for Public Health (DiClemente, Salazar,
& Crosby, 2013); Introduction to Health Behavior (Hayden, 2014); and Essentials of Health
Behavior: Social and Behavioral Theory in Public Health (Edberg, 2015). Box 7.1 identifies the
responsibilities and competencies for health education specialists that pertain to the material
presented in this chapter.
Types of Theories and Models
There are several ways of categorizing the theories and models associated with health
education/promotion practice. One way of doing so is to divide them into two groups.
The first group includes those theories and models used for planning, implementing, and
evaluating health promotion programs. This group has been called planning models.
The planning models were presented earlier (Chapter 3). The second group is referred
to as behavior change theories. Behavior change theories help explain how change
takes place.
Behavior Change Theories
As noted earlier, there are many behavior change theories that health education specialists
could use to plan programs. Because of the peculiarities of the theories and multitude of
factors that could impact a specific planning situation, some theories work better in some
situations than others. Before we present the theories focusing on behavior change, it is im-
portant to introduce the concept of the socio-ecological approach.

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 155
The socio-ecological approach, which is grounded in the work of development psychologist
Urie Bronfenbrenner (1979), gained traction in health promotion in the 1980s with the move-
ment toward using a systems-approach for interventions. The underlying concept of the socio-
ecological approach (sometimes referred to as the ecological perspective) is that human
behavior shapes and is shaped by multiple levels of influences. “Individuals influence and are
influenced by their families, social networks, the organizations in which they participate (work-
places, schools, religious organizations), the communities of which they are a part, and the
society in which they live” (IOM, 2001, p. 26). In other words, the health behavior of individuals
is shaped in part by the social context in which they live. Social context has been “defined as the
sociocultural forces that shape people’s day-to-day experiences and that directly and indirectly
affect health and behavior (Burke, Joseph, Pasick, & Barker, 2009, p. 56S). Therefore, a central con-
clusion of the socio-ecological approach is that interventions must be aimed at multiple levels of
influence in order to achieve substantial changes in health behavior (Sallis, Owen, & Fisher, 2008).
McLeroy, Bibeau, Steckler, and Glanz (1988) identified five levels of influence: (1) intra-
personal or individual factors, (2) interpersonal factors, (3) institutional or organizational
factors, (4) community factors, and (5) public policy factors. More recently, Simons-Morton
et al. (2012, p. 45) added two additional levels “(6) the physical environment and (7) culture.”
Table 7.1 defines each of the seven levels, and Box 7.2 provides an example of how the levels
can impact health behavior.
7.1
Responsibilities and Competencies for Health Education Specialists
The content of this chapter focuses on theories and models used in the practice of health
promotion. Specifically, theories and models provide a “road map” for planners to use
when creating interventions and evaluating the effectiveness of those interventions. The
responsibilities and competencies related to these tasks include:
RESponSiBiliTy i: Assess Needs, Resources, and Capacity for Health Education/
Promotion
Competency 1.1: Plan assessment process for health education/
promotion
RESponSiBiliTy ii: Plan Health Education/Promotion
Competency 2.3: Select or design strategies/interventions
Competency 2.4: Develop a plan for the delivery of health education/
promotion
RESponSiBiliTy iii: Implement Health Education/Promotion
Competency 3.3: Implement health education/promotion plan
RESponSiBiliTy iV: Conduct Evaluation and Research Related to Health Education/
Promotion
Competency 4.1: Develop evaluation plan for health education/
promotion
RESponSiBiliTy Vii: Communicate, Promote, and Advocate for Health and Health
Education/Promotion, and the Profession
Competency 7.1: Identify, develop, and deliver messages using a
variety of communication strategies, methods, and techniques
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education
Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health
Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE).
Box

156 Part 1 Planning a Health Promotion Program
Table 7.1 An Ecological Perspective: Levels of Influence
Sources: Rimer & Glanz (2005, p. 11); Simons-Morton et al., (2012, p. 45)
Concept Definition
Intrapersonal Level Individual characteristics that influence behavior, such as
knowledge, attitudes, beliefs, and personality traits
Interpersonal Level Interpersonal processes and primary groups, including family,
friends, and peers that provide social identity, support, and role
definition
Community Level
Institutional Factors Rules, regulations, policies, and informal structures that may
constrain or promote recommended behaviors
Community Factors Social networks and norms, or standards, that exist as formal or
informal among individuals, groups, and organizations
Public Policy Local, state, and federal policies and laws that regulate or support
healthy actions and practices for disease prevention, early detection,
control, and management
Physical Environment Natural and built environment
Culture Shared beliefs, values, behaviors and practices of a population
7.2
Box Application of the Socio-Ecological Approach
A good example of the use of the socio-ecological approach (ecological perspective) is
the comprehensive method used to reduce cigarette smoking in the United States. At
the intrapersonal (or individual) level, a large majority of smokers know that smoking is
bad for them and a slightly smaller majority have indicated they would like to quit. Many
have tried—some have tried on many occasions. At the interpersonal level, many smokers
are encouraged by their physician and/or family and friends to quit. Some smokers may
attempt to quit on their own or join a formal smoking cessation group to try to quit. At
the institutional (or organizational) level, a number of institutions (e.g., churches and
worksites) have developed policies that prohibit smoking in and/or on institution property
(i.e., buildings and grounds). At the community level, a number of towns, cities, and
counties have passed ordinances that prohibit smoking in public places. At the public
policy level, a number of states have passed clean indoor air acts that limit smoking, and
have passed laws increasing the tax on a package of cigarettes. Also at this level, the
U.S. government has spent many dollars for public service announcements (PSAs) and
other forms of media advertising the dangers of tobacco use. At the physical environment
level new structures have been built to eliminate exposure to secondhand smoke with
appropriate filtration systems and separate structures have been built to physically
separate the smokers from the non-smokers. At the culture level a focus has been placed
on establishing and reinforcing non-smoking as the cultural norm. Attacking the smoking
problem from all levels has contributed to the decrease in the percentage of smokers in
the United States.
A
pp
lic
at
io
n
Because of the underlying concepts that are captured in the constructs of individ-
ual theories, certain theories are more useful in developing programs aimed at spe-
cific levels of influence. For example, some theories were developed to help explain
behavior change in individuals, while others were developed to help explain change

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 157
at the community level. To assist program planners with matching theories appropriate to
level of influence, we present our discussion of the theories using the simplified version of the
socio-ecological model that condensed the multiple levels into three—intrapersonal, interper-
sonal, and community (Glanz & Rimer, 1995; Rimer & Glanz, 2005). “In practice, addressing
the community level requires taking into consideration institutional and public policy factors,
as well as social networks and norms” (Rimer & Glanz, 2005, p. 11). To this community level
we add the sixth and seventh levels of influence–– physical environment and culture.
In addition to theories being placed into a level of influence at which they may be most use-
ful, theories can also be categorized by the approach—continuum or stage theories—they use
to explain behavior. Continuum theories are those behavior change theories that identify
variables that influence actions (e.g., beliefs, attitudes) and combine them into a single equa-
tion that predicts the likelihood of action (Weinstein, Rothman, & Sutton, 1998; Weinstein,
Sandman, & Blalock, 2008). “These theories acknowledge quantitative differences among
people in their positions on different variables” (Weinstein et al., 2008, p. 124) and “thus, each
person is placed along a continuum of action likelihood” (Weinstein et al., 1998, p. 291).
A stage theory is one that is comprised of an ordered set of categories into which people can
be classified, and which identifies factors that could induce movement from one category to the
next (Weinstein & Sandman, 2002a). More specifically, stage theories have four principal ele-
ments: (1) a category system to define the stages, (2) an ordering of stages, (3) common barriers
to change facing people in the same stage, and (4) different barriers to change facing people in
different stages (Weinstein et al., 1998; Weinstein & Sandman, 2002a). Advocates of stage theories
“claim that there are qualitative differences among people and question whether changes in health
behaviors can be described by a single prediction equation” (Weinstein et al., 2008, pp. 124–125).
Table 7.2 lists the theories presented in this book by level of influence and theory approach.
intrapersonal level Theories
The theories presented in this section of the chapter focus primarily on individual health
behavior. The intrapersonal or “individual level is the most basic one in health promotion
practice, so planners must be able to explain and influence the behavior of individuals”
(Rimer & Glanz, 2005, p. 12). Intrapersonal theories focus on factors within the individual
such as knowledge, attitudes, beliefs, self-concept, feelings, past experiences, motivation,
skills, and behavior. Many health education specialists will use the theories we discuss in this
section to assist individuals with behavior change, But be aware that some of these theories
do not take into account social context and thus they may need to be combined with theo-
ries found in other levels of influence to reach their program goals.
STimuluS RESponSE (SR) THEoRy
One of the theories used to explain and modify behavior is the stimulus response, or SR,
theory (Thorndike, 1898; Watson, 1925; Hall, 1943). This theory reflects the combination
of classical conditioning (Pavlov, 1927) and instrumental conditioning (Thorndike, 1898)
theories. These early conditioning theories explain learning based on the associations
among stimulus, response, and reinforcement (Parcel & Baranowski, 1981; Parcel, 1983). “In
simplest terms, the SR theorists believe that learning results from events (termed ‘reinforce-
ments’) which reduce physiological drives that activate behavior” (Rosenstock, Strecher, &
Becker, 1988, p. 175). The behaviorist B. F. Skinner believed that the frequency of a behavior
was determined by the reinforcements that followed that behavior.

158 Part 1 Planning a Health Promotion Program
In Skinner’s view, the mere temporal association between a behavior and an immediately
following reward is sufficient to increase the probability that the behavior will be repeated.
Such behaviors are called operants; they operate on the environment to bring about changes
resulting in reward or reinforcement (Rosenstock et al., 1988). Stated another way, operant
behaviors are behaviors that act on the environment to produce consequences. These conse-
quences, in turn, either reinforce or do not reinforce the behavior that preceded.
There are two broad categories of environmental consequences: reinforcement or punish-
ment (McDade-Montez, Cvengros, & Christensen, 2005): Individuals can learn from both.
Reinforcement has been defined by Skinner (1953) as any event that follows a behavior,
which in turn increases the probability that the same behavior will be repeated in the future.
Stated differently, reinforcement has “a strengthening effect that occurs when operant be-
haviors have certain consequences” (Nye, 1992, p. 16). Behavior has a greater probability of
occurring in the future: (1) if reinforcement is frequent and (2) if reinforcement is provided
soon after the desired behavior. This immediacy clarifies the relationship between the rein-
forcement and appropriate behavior (Skinner, 1953). Simons-Morton and colleagues (2012)
Table 7.2 Theories by Level of Influence and Category
Level of Influence Where Found in This Book
• Intrapersonal Level
Continuum Theories
Stimulus Response Theory Chapter 7
Theory of Planned Behavior Chapter 7
Health Belief Model Chapter 7
Protection Motivation Theory Chapter 7
Elaboration Likelihood Model of Persuasion Chapter 7
Information-Motivation-Behavioral Skills Model Chapter 7
Stage Theory
Transtheoretical Model Chapter 7
Precaution Adoption Process Model Chapter 7
• Interpersonal Level
Continuum Theories
Social Cognitive Theory Chapter 7
Social Network Theory Chapter 7
Social Capital Theory Chapter 7
• Community Level
Continuum Theories
Communication Theory Chapters 8 & 11
Community organizing Chapter 9
Community Building Chapter 9
Diffusion of Innovations Chapter 7
Stage Theory
Community Readiness Model Chapter 7

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 159
have stated that when a behavior is sufficiently reinforced it tends to recur. If a behavior
is complex in nature, smaller steps working toward the desired behavior with appropriate
reinforcement will help to shape the desired behavior. This was found to be true in getting pi-
geons to play Ping-Pong, and it can be useful in trying to change a complex health behavior
like smoking or exercise. Whereas reinforcement will increase the frequency of a behavior,
punishment will decrease the frequency of a behavior. However, both reinforcement and
punishment can be either positive or negative. The terms positive and negative in this context
do not mean good and bad; rather, positive means adding something (effects of the stimulus)
to a situation, whereas negative means taking something away (removal or reduction of the
effects of the stimulus) from the situation.
If individuals act in a certain way to produce a consequence that makes them feel good or
that is enjoyable, it is labeled positive reinforcement (or reward). Examples of this would
be an individual who is involved in an exercise program and “feels good” at the end of the
workout, or one who participates in a weight loss program and receives verbal encourage-
ment from the facilitator, again making that person “feel good.” Stimulus response theorists
would note that in both of these situations, the pleasant experiences (internal feelings and
verbal encouragement, respectively) should occur right after the behavior, which in turn
increases the chances that the frequency of the behavior will increase.
While positive reinforcement helps individuals learn by shaping behavior, behavior
that avoids punishment is also learned because it reduces the tension that precedes the
punishment (Rosenstock et al., 1988). “When this happens, we are being conditioned by
negative reinforcement: A response is strengthened by the removal of something from the situ-
ation. In such cases, the ‘something’ that is removed is referred to as a negative reinforcer or
aversive stimulus (these two phrases are synonymous)” (Nye, 1979, p. 33). A good example
of negative reinforcement is a weight loss program that requires weekly dues. When
participants stop paying dues because they have met their goal weight, this removal of an
obligation should increase the frequency of the desired behavior (weight maintenance). Or
in the case of exercise, “negative reinforcements would include decreased poor self-image
and decreased fatigue” (McDade-Montez et al., 2005, p. 64).
Some people think of negative reinforcement as a form of punishment, but it is not.
While negative reinforcement increases the likelihood that a behavior will be repeated,
punishment typically suppresses behavior. Skinner suggested “two ways in which a response
can be punished: by removing a positive reinforcer or by presenting a negative reinforcer (aversive
stimulus) as a consequence of the response” (Nye, 1979, p. 43). Punishment is usually linked
to some uncomfortable (physical, mental, or otherwise) experience and decreases the fre-
quency of a behavior. An aversive smoking cessation program that circulates cigarette smoke
around those enrolled in the program as they smoke is an example of positive punishment. It
decreases the frequency of smoking by presenting (adding) a negative reinforcer or aversive
stimulus (smoke) as a consequence of the response. Examples of negative punishment
(removing a positive reinforcer) would include not allowing employees to use the employees’
lounge if they continue to smoke while using it, or reducing the health insurance benefits
of employees who continue to participate in health-harming behavior such as not wearing
a safety belt. Stimulus response theorists would note that taking away the privilege of using
the employees’ lounge or reducing health insurance benefits would decrease the frequency
of smoking among the employees and increase the wearing of safety belts, respectively.
Figure 7.1 illustrates the relationship between reinforcement and punishment.

160 Part 1 Planning a Health Promotion Program
Finally, if reinforcement is withheld—or, stating it another way, if the behavior is
ignored—the behavior will become less frequent and eventually will not be repeated.
Skinner (1953) refers to this as extinction. Teachers frequently use this technique with dis-
ruptive children in the classroom. If a child is acting up in class, the teacher may choose to
ignore the behavior in hopes that the nonreinforced behavior will go away.
THEoRy oF plAnnEd BEHAVioR (TpB)
The theory of planned behavior (TPB) is the first of several value-expectancy theories presented
in this section. Value-expectancy theories were developed to explain how individuals’ be-
haviors were influenced by beliefs and attitudes (Simons-Morton et al., 2012). Thus, the ten-
dency to perform a particular act is a function of the expectancy that the act will be followed
by certain consequences (e.g., ‘How vulnerable am I to the danger?’) and the value of those
consequences (e.g., ‘How severe is the danger?’)” (Prentice-Dunn & Rogers, 1986, p. 157).
The theory of planned behavior has its foundation in the theory of reasoned action (TRA)
(Fishbein, 1967). The TRA was developed to explain volitional behaviors, “that is, behaviors
that can be performed at will” (Luszczynska & Sutton, 2005, p. 73). The TRA has proved to
be useful when dealing with purely volitional behaviors, but complications are encountered
when the theory is applied to behaviors that are not fully under volitional control. A good
example of this is a smoker who intends to quit but fails to do so. Even though intent is high,
nonmotivational factors—such as lack of requisite opportunities, skills, and resources—
could prevent success (Ajzen, 1988).
The TPB (see Figure 7.2) is an extension of the TRA that addresses the problem of incom-
plete volitional control. Both the TRA and the TPB focus on determinants of behavioral
intentions. In the TRA, Fishbein and Ajzen (1975) distinguished among attitude, belief, inten-
tion, and behavior. Intention “is an indication of a person’s readiness to perform a given
behavior, and it is considered to be an immediate antecedent of behavior” (Ajzen, 2006).
According to this theory, individuals’ intentions to perform given behaviors are functions of
their attitudes toward the behavior and their subjective norms associated with the behaviors.
Attitude toward the behavior “is the degree to which performance of the behavior is
positively or negatively valued. According to the expectancy-value model, attitude toward a
behavior is determined by the total set of accessible behavioral beliefs linking the behavior to
various outcomes and other attributes” (Ajzen, 2006). Thus a person who has strong beliefs
about positive attributes or outcomes from performing the behavior will have a positive
Positive
(adding to)
Negative
(taking away)
Positive
reinforcement
(reward)
Negative
reinforcement
Positive
punishment
Increase in frequency
Decrease in frequency Negative
punishment
Consequences
B
e
h
a
v
io
r
⦁▲ Figure 7.1 2 × 2 Table of the Stimulus Response Theory

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 161
attitude toward behavior (Montaño & Kasprzyk, 2008). For example, if a person feels strongly
about exercise being able to help control weight, then that person will have a positive at-
titude toward exercise. The converse is true as well. Weak beliefs about the outcomes or at-
tributes of exercise will produce a negative attitude toward it.
Subjective norm “is the perceived social pressure to engage or not engage in a behavior”
(Ajzen, 2006). For many health behaviors, the social pressure comes from a person’s peers,
parents, partner, close friends, teachers, role models, boss, and co-workers, as well as experts
or professionals like physicians or lawyers. Thus individuals who believe that certain people
think they should perform a behavior and are motivated to meet the people’s expectations
will hold a positive subjective norm (Montaño & Kasprzyk, 2008). Similar to behavioral be-
liefs, the converse is also true. An example of a positive subjective norm are employees who
see their co-workers as important people in their lives and believe that these people approve
of them participating in a company exercise program.
The major difference between TPB and TRA is the addition of a third (the first being atti-
tude toward the behavior and the second being subjective norm), conceptually independent de-
terminant of intention—perceived behavioral control. Perceived behavioral control is similar to
the Social Cognitive Theory’s concept of self-efficacy. Perceived behavioral control “re-
fers to people’s perceptions of their ability to perform a given behavior” (Ajzen, 2006). Stated
differently, perceived behavioral control refers to the perceived ease or difficulty of perform-
ing the behavior and is assumed to reflect past experience as well as anticipated impediments
and obstacles. As a general rule, the more favorable the attitude and subjective norm with
respect to a behavior, and the greater the perceived behavioral control, the stronger should
be the individual’s intentions to perform the behavior under consideration (Ajzen, 1988).
Figure 7.2 illustrates two important features of this theory. First, perceived behavioral
control has motivational implications for intentions. That is, without perceived control,
intentions could be minimal even if attitudes toward the behavior and subjective norm were
Behavioral
beliefs
Attitude
toward the
behavior
Control
beliefs
Perceived
behavioral
control
Normative
beliefs
Subjective
norm
Intention Behavior
Actual
behavioral
control
⦁▲ Figure 7.2 Theory of Planned behavior Diagram
Source: Theory of Planned Behavior Diagram. Icek Ajzen. Copyright © 2006 by Icek Ajzen. Reprinted with permission.

162 Part 1 Planning a Health Promotion Program
strong. Second, there may be a direct link between perceived behavioral control and behav-
ior. Behavior depends not only on motivation but also on actual control. Actual behavioral
control “refers to the extent to which a person has the skills, resources, and other prerequi-
sites needed to perform a given behavior. Successful performance of the behavior depends
not only on a favorable intention but also on a sufficient level of behavioral control. To the
extent that perceived behavioral control is accurate, it can serve as a proxy of actual control
and can be used for the prediction of behavior” (Ajzen, 2006). To use the example of smoking
once again as a behavior not fully under volitional control, TPB predicts that individuals will
give up smoking if they:
⦁⦁ Have a positive attitude toward quitting
⦁⦁ Think others whom they value believe it would be good for them to quit
⦁⦁ Perceive that they have control over whether they quit
HEAlTH BEliEF modEl (HBm)
The health belief model (HBM) is also a value-expectancy theory. It was developed in the 1950s
by a group of psychologists at the U.S. Public Health service to help explain why people
would or would not use health services (Rosenstock, 1966). The HBM is based on Lewin’s
decision-making model (Lewin, 1935, 1936; Lewin et al., 1944). Since its creation, the HBM
has been used to help explain a variety of health behaviors (Becker, 1974; Janz & Becker,
1984; Jones, Smith, & Llewellyn, 2014).
The HBM hypothesizes that health-related action depends on the simultaneous occur-
rence of three classes of factors:
1. The existence of sufficient motivation (or health concern) to make health issues salient
or relevant.
2. The belief that one is susceptible (vulnerable) to a serious health problem or to the
sequelae of that illness or condition. This is often termed perceived threat.
3. The belief that following a particular health recommendation would be beneficial
in reducing the perceived threat, and at a subjectively acceptable cost. Cost refers
to the perceived barriers that must be overcome in order to follow the health
recommendation; it includes, but is not restricted to, financial outlays (Rosenstock
et al., 1988, p. 177). In fact, the lack of self-efficacy is also seen as a perceived barrier
to taking a recommended health action (Strecher & Rosenstock, 1997).
In recent years, self-efficacy has become a more meaningful concept in the perceived
barriers construct of the HBM. When the HBM was first conceived, self-efficacy was not
explicitly a part of it. “The original model was developed in the context of circumscribed
preventive health actions (accepting a screening test or an immunization) that were not per-
ceived to involve complex behaviors” (Champion & Skinner, 2008, p. 49). However, when
program planners want to use the HBM to plan health promotion interventions for priority
populations in need of lifestyle behaviors requiring long-term changes, self-efficacy must be
included in the model. Therefore, “[f]or behavior change to succeed, people must (as the orig-
inal HBM theorizes) feel threatened by their current behavioral patterns (perceived suscepti-
bility and severity) and believe that change of a specific kind will result in a valued outcome
at acceptable cost. They must also feel themselves competent (self-efficacious) to overcome
perceived barriers to taking action” (Champion & Skinner, 2008, p. 50) (see Figure 7.3).

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 163
Here is an example of the HBM applied to exercise. Someone watching television sees
an advertisement about exercise. This is a cue to action that starts her thinking about her
own need to exercise. There may be some variables (demographic, sociopsychological, and
structural) that cause her to think about it a bit more. She remembers her college health
course that included information about heart disease and the importance of staying active.
She knows she has a higher than normal risk for heart disease because of family history, poor
diet, and slightly elevated blood pressure. Therefore, she comes to the conclusion that she is
susceptible to heart disease (perceived susceptibility). She also knows that if she develops
heart disease, it can be very serious (perceived seriousness/severity). Based on these fac-
tors, the individual thinks that there is reason to be concerned about heart disease (perceived
threat). She knows that exercise can help delay the onset of heart disease and can increase the
chances of surviving a heart attack if one should occur (perceived benefits). But exercise
takes time from an already busy day, and it is not easy to exercise in the variety of settings in
which she typically finds herself, especially during bad weather (perceived barriers). Her con-
fidence in being able to overcome the barriers and exercise regularly will also be important
(self-efficacy). She must now weigh the threat of the disease against the difference between
benefits and barriers. This decision will then result in a likelihood of exercising or not exer-
cising (likelihood of taking recommended preventive health action).
pRoTECTion moTiVATion THEoRy (pmT)
The third value-expectancy theory presented in this section is the protection motivation theory
(PMT). It was originally created by Rogers (1975) and “proposed to provide explanations of
the effects of fear appeals on health attitudes and behavior” (Floyd, Prentice-Dunn, & Rogers,
2000, p. 409). The PMT was later revised and extended (Rogers, R., 1983) to a more general
theory of persuasive communication that included reward and self-efficacy components.
The PMT has some similarities to the HBM. Both contain a cost-benefit analysis in which the
individual weighs the costs of taking a precautionary action against the expected benefits of
taking action, and both share an emphasis on cognitive processes mediating attitudinal and
behavioral change (Floyd et al., 2000; Prentice-Dunn & Rogers, 1986).
As explained by the PMT, inputs come from environmental sources of information such
as verbal persuasion and observational learning, and from intrapersonal sources such as
Perceived
benefits less
perceived
barriers
Perceived
threat
Behavior
Perceived
seriousness
Perceived
self-efficacy
Perceived
susceptibility
Cues to
action
Age
Sex/gender
Race/ethnicity
Personality
Socioeconomics
Knowledge
Personal
experiences
⦁▲ Figure 7.3 Health belief Model

164 Part 1 Planning a Health Promotion Program
one’s personality and feedback from personal experiences associated with the targeted mal-
adaptive and adaptive responses (Floyd et al., 2000). Based on these inputs people make a
cognitive assessment of whether there is a threat to their health. Information about a threat
to one’s health arouses two cognitive mediating processes: threat appraisal and coping ap-
praisal (Floyd et al., 2000; McClendon & Prentice-Dunn, 2001).
The threat appraisal process is addressed first because a threat to one’s health must be
perceived or identified before there can be an assessment of the coping options (Floyd et al.,
2000). Threat appraisal assesses maladaptive behaviors (e.g., physical inactivity, smoking,
overeating, binge drinking). The assessment includes (1) a review of intrinsic (e.g., physical
and psychological pleasure such as feeling “good”) and extrinsic (e.g., peer approval such as
receiving attention) rewards; and (2) a review of the perceived severity of and the perceived
vulnerability to the threat. “Rewards increase the probability of selecting the maladaptive
response (not to protect self or others), whereas threat will decrease the probability of select-
ing the maladaptive response” (Floyd et al., 2000, p. 410). “Thus the rewards minus the sum
of severity and vulnerability indicate the amount of threat experienced by the individual”
(McClendon & Prentice-Dunn, 2001, p. 322).
Coping appraisal assesses adaptive behaviors (e.g., health enhancing behaviors). This type
of assessment includes (1) a review of response efficacy (e.g., belief that the coping action
will avert the threat) and self-efficacy (i.e., belief that the person is capable of completing
the coping action); and (2) a review of the response costs (e.g., “inconvenience, expense,
unpleasantness, difficulty, complexity, side effects, disruption of daily life, and overcoming
habit strength” [Rogers, 1984, p. 104]). “Response efficacy and self-efficacy will increase the
probability of selecting the adaptive response, whereas response costs will decrease the prob-
ability of selecting the adaptive response” (Floyd et al., 2000, p. 411). In sum, the amount of
coping appraisal experienced is indicated by the sum of response efficacy and self-efficacy
minus the response costs” (McClendon & Prentice-Dunn, 2001, p. 322).
When the results of the threat appraisal and coping appraisal processes are combined it is
the protective motivation that an individual possesses. Stated a bit differently, “The output
of these appraisal-mediating processes is the decision (or intention) to initiate, continue,
or inhibit the applicable adaptive responses (or coping modes)” (Floyd et al., 2000, p. 411).
When using the PMT to design an intervention protection motivation has been measured us-
ing behavioral intentions (Floyd et al., 2000).
Prentice-Dunn and Rogers (1986, p. 156) offered the following summary of the PMT:
PMT assumes that protection motivation is maximized when: (i) the threat to health is severe;
(ii) the individual feels vulnerable; (iii) the adaptive response is believed to be an effective means
for averting the threat; (iv) the person is confident in his or her abilities to complete successfully
the adaptive response; (v) the rewards associated with the mal-adaptive behavior are small; and
(vi) the costs associated with the adaptive response are small. Such factors produce protection
motivation and, subsequently, the enactment of the adaptive, or coping, response.
Since its development, the PMT has been successfully used to create program interven-
tions for a number of different health behaviors (Floyd et al., 2000). Some of the more
recent applications of the theory have included: adolescent drug use intention (Wu et al.,
2014), exercise among various groups (Bui, Mullan, & McCaffery, 2013; Gaston &
Prapavessis, 2012), living wills (Allen, Phillips, Whitehead, Crowther, & Prentice-Dunn,
2009), pro-environmental behavior (Bockarova & Steg, 2014), social networks (Salleh et al.,

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 165
2012), sun protection behavior/skin cancer (Prentice-Dunn, McMath, & Cramer, 2009), and
weight loss and bariatric surgery (Boeka, Prentice-Dunn, & Lokken, 2010).
ElABoRATion likEliHood modEl oF pERSuASion (Elm)
The Elaboration Likelihood Model of Persuasion, or the Elaboration Likelihood Model (ELM) for
short, was initially developed to help explain inconsistencies in the results from research
dealing with the study of attitudes (Petty, Barden, & Wheeler, 2009). Specifically, the model
was designed to help explain how persuasion messages (communication) aimed at changing
attitudes were received and processed by people. Though not created specifically for health
communication, since its development the ELM has been used to help interpret and predict
the impact of health messages (Petty & Briñol, 2012) (see Figure 7.4).
The utility of the ELM is that it does four essential things. First, the ELM proposes that
modifying attitudes or other judgments can be formed as a result of a high degree of thought
(i.e., central process route) or a low degree of thought (i.e., peripheral and processing route)
(Petty et al., 2009). “That is, the elaboration continuum’ ranges from low to high” (Petty &
Briñol, 2012, p. 226). The distinction among the places on the continuum is the amount of
elaboration. Elaboration refers to the amount of cognitive processing (i.e., thought) that a
person puts into receiving messages.
Second, the ELM postulates that there are numerous specific processes of change that
operate along the elaboration continuum (Petty & Briñol, 2011). The continuum stretches
from one end anchored with processes requiring no thinking, like classical conditioning (see
discussion on stimulus response theory earlier in the chapter), to processes requiring some
effortful thinking such as inferences based on one’s experiences, to processes requiring care-
ful consideration (see value-expectancy theories presented earlier in the chapter) (Petty et al.,
2009). The peripheral route processes involve minimal thought and rely on superficial cues
or mental shortcuts (called heuristics) about issue-relevant information as primary means for
attitude change (Petty et al., 2009). For example, people may form an attitude after hearing
a persuasive message simply because the person delivering the message is someone that they
admire. On the other hand, central route processes involve thoughtful consideration (or
effortful cognitive elaboration) of issue-relevant information and one’s own cognitive re-
sponses as the primary bases for attitude change (Petty et al., 2009). “Two conditions are nec-
essary for effortful processing to occur—the recipient of the message must be both motivated
and able to think carefully” (Petty et al., 2009, p. 188). An example of central route processing
would be a motorcyclist’s formation of an attitude about wearing a helmet based on thought-
ful consideration of a message about the pros and cons of helmet use along with recalling
knowledge gained in a motorcycle safety class and possibly the results of a motorcycle crash
in which his or her cousin was involved.
It should be clear that the distinction between the peripheral and central routes is the amount
of consideration given to the issue-relevant information and how the information is processed,
not the type of information itself (Petty, Wheeler, & Bizer, 1999). “Of course, much of the time,
persuasion is determined by a mixture of these processes” (Petty & Briñol, 2012, p. 226).
Third, when comparing the consequences of the two routes there are times when the re-
sult is similar. However, the two routes usually lead to attitudes with different consequences.
“High effort central route processes are more likely to lead to attitudes that are persistent over
time, resistant to counterattack, and influential in guiding thought and behavior than are
peripheral process” (Petty et al., 2009, pp. 207–208).

166 Part 1 Planning a Health Promotion Program
PERSUASIVE COMMUNICATION
MOTIVATED TO PROCESS?
(personal relevance,
need for cognition, etc.)
ABILITY TO PROCESS?
(distraction, repetition,
knowledge, etc.)
WHAT IS THE NATURE
OF THE PROCESSING?
(argument quality,
initial attitude, etc.)
ARE THE THOUGHTS
RELIED UPON?
(ease of generation,
thought rehersal, etc.)
Changed attitude is relatively
enduring, resistant to
counterpersuasion, and
predictive of behavior.
CENTRAL
POSITIVE
ATTITUDE
CHANGE
CENTRAL
NEGATIVE
ATTITUDE
CHANGE
RETAIN
INITIAL ATTITUDE
IS A PERIPHERAL
PROCESS OPERATING?
(identification with
source, use of heuristics,
balance theory, etc.)
Attitude does not
change from
previous position.
MORE
FAVORABLE
THOUGHTS
THAN BEFORE?
YES
YES
(Favorable)
YES
(Unfavorable)
YES
NO
NO
YES
YES
NO
NO
YES
NO
MORE
UNFAVORABLE
THOUGHTS
THAN BEFORE?
PERIPHERAL ATTITUDE SHIFT
Changed attitude is relatively
temporary, susceptible to
counterpersuasion, and
unpredictive of behavior.
⦁▲ Figure 7.4 The elaboration likelihood Model of Persuasion (elM)
Source: “The Elaboration Likelihood Model of Persuasion” by R. E. Petty, J. Barden, and G. R. Alexander, from Emerging Theories in Health
Promotion Practice and Research: Strategies for Improving Public Health, 2e, Ed. J. R. DiClemente, R. A. Crosby, and M. C. Kegler. Copyright
© 2009 by Jossey-Bass. Reprinted with permission.

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 167
Fourth, and arguably the “most useful thing that the ELM does is to organize the many
specific processes by which variables can affect attitudes into a finite set that operate at dif-
ferent points along the elaboration continuum” (Petty & Briñol, 2012, p. 226). The variables
can have an influence on people’s motivation to think or ability to think, as well as the va-
lence of people’s thought or the confidence in the thoughts generated (Petty et al., 2009). For
example, variables that have an impact on how a message is processed are the source of the
message (e.g., friend, expert), the message itself (e.g., funny, serious), the context (e.g., de-
livered person-to-person, on the Internet), and various characteristics of the recipient (e.g.,
intelligence, age, attentiveness).
The ELM has been used to develop a variety of interventions for health promotion pro-
grams. The one area where the ELM has been most useful in health promotion has been
with message tailoring. Tailored messages are those that are “crafted for and delivered to each
individual based on individual needs, interests, and circumstances” (NCI, n.d., p. 251). In
other words, tailored messages are matched to the needs, interests, and circumstances of the
intended recipient. It has been found that the more tailored the persuasive communication,
the more relevant it is to the recipient, and the more likely the message will be processed
through the central route. And, if a message is processed through the central route the more
likely it will impact attitude and behavior change.
inFoRmATion-moTiVATion-BEHAVioRAl (imB) SkillS modEl
The information-motivation-behavioral (IMB) skills model (see Figure 7.5) was initially created
to address the critical need for a strong theoretical basis for HIV/AIDS prevention efforts
(Fisher & Fisher, 1992). Since its development, there is evidence to support its usefulness
with HIV/AIDS prevention (Fisher, Fisher, & Shuper, 2009) as well as other intervention
strategies (Chang, Choi, Kim, & Song, 2014) including the management of diabetes (Osborn
& Egede, 2010). According to the IMB model, the constructs of information, motivation, and
behavioral skills are the fundamental determinants of preventive behavior. The information
provided needs to be relevant, easily enacted based on the specific circumstances, and serve
as a guide to personal preventive behavior. “In addition to facts that are easy to translate into
behavior, the IMB model recognizes additional cognitive processes and content categories
HIV prevention
motivation
HIV prevention
behavior skills
HIV prevention
information
HIV prevention
behavior
⦁▲ Figure 7.5 The Information-Motivation-behavioral Skills Model of HIV Prevention
Source: “Changing AIDS-Risk Behavior.” J. D. and W. A. Fisher from Psychological Bulletin 111(3). Copyright © 1992 by the American Psychological
Association.

168 Part 1 Planning a Health Promotion Program
that significantly influence performance of preventive behavior” (Fisher et al., 2009, p. 27).
Such as the simple decision rules a person may hold, like “if my best friend is willing to ride a
motorcycle without a helmet, it must be okay.”
Even though people are well informed about a particular health issue, they may not be
motivated to act. According to the IMB model, prevention motivation includes both per-
sonal motivation to act (i.e., one’s attitude toward a specific behavior) and social motivation
to act (is there social support for the preventive behavior?) (Sharma, 2012). Both types of
motivation are necessary for action to occur.
In addition to people being well informed and motivated to act, the IMB model also as-
serts that people must possess behavioral skills to engage in the preventive behavior. The
behavioral skills component of the IMB model includes an individual’s objective ability and
his or her perceived self-efficacy to perform the preventive behavior.
In applying the IMB model, health education specialists cannot simply use their own
judgment to determine what information to provide, how best to motivate, and what be-
havioral skills to teach to a given population. The process should begin by eliciting informa-
tion from a subsample of the priority population to identify deficits in their health-relevant
information, motivation, and behavior skills. Next health education specialists need to
design and implement “conceptually-based, empirically-targeted, population-specific” (p. 29)
interventions, constructed on the bases of the elicited findings (Fisher et al., 2009). Then,
after the implementation of the intervention, health education specialists must evaluate the
intervention to determine if it had significant and sustained effects on the information, mo-
tivation, and behavioral skill determinants of the preventive behavior and on the preventive
behavior itself (Fisher et al., 2009).
THE TRAnSTHEoRETiCAl modEl (TTm)
The transtheoretical model (TTM), sometimes referred to as the Stages of Change Model, was
developed to help explain how individuals and populations progressed toward adopting and
maintaining health behavior change. The model uses stages of change to integrate processes
and principles of change from across major theories, hence the name ‘Transtheoretical’”
(Prochaska, Johnson, & Lee, 1998). The model has its roots in psychotherapy and was devel-
oped by Prochaska (1979) after he completed a comparative analysis of therapy systems and
a critical review of therapy outcome studies. From the analysis and review, Prochaska found
that some common processes were involved in change.
As this model has evolved, researchers have applied it to many different types of health
behavior change, including but not limited to alcohol and substance abuse, anxiety and
panic disorders, delinquency, eating disorders and obesity, exercise, high-fat diets, hand-
washing, HIV/AIDS prevention, immunizations/vaccinations, mammography screening,
medication adherence/compliance, unplanned pregnancy prevention, pregnancy and
smoking, sedentary lifestyles, weight control, sun exposure, and physicians practicing pre-
ventive medicine (Angus et al., 2013; Prochaska, Redding, & Evers, 2008; Spencer, Adams,
Malone, Roy, & Yost, 2006).
The core constructs of the TTM include the stages of change, the processes of change, deci-
sional balance (i.e., the pros and cons of changing), self-efficacy, and temptation (see Table 7.3).
In addition, this model is “based on critical assumptions about the nature of behavior change
and interventions that can best facilitate change” (Prochaska et al., 1998, p. 60). A discussion of
these constructs and assumptions follows.

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 169
Table 7.3 Transtheoretical Model Constructs
Source: SPM Handbook for Health Assessment Tools. Colleen A. Redding, Joseph S. Rossi, S. R. Rossi, W. F. Velicer, and J. O. Prochaska. Copyright © 1999 by the Society of
Prospective Medicine. Reprinted with permission from the authors.
Constructs Description
Stages of change
Precontemplation No intention to take action within the next 6 months
Contemplation Intends to take action within the next 6 months
Preparation Intends to take action within the next 30 days and has taken some
behavioral steps in this direction
Action Has changed overt behavior for less than 6 months
Maintenance Has changed overt behavior for more than 6 months
Decisional balance
Pros The benefits of changing
Cons The costs of changing
Self-efficacy
Confidence Confidence that one can engage in the healthy behavior across
different challenging situations
Temptation Temptation to engage in the unhealthy behavior across
different challenging situations
Processes of change
Consciousness raising Finding and learning new facts, ideas, and tips that support the healthy
behavior change
Dramatic relief Experiencing the negative emotions (fear, anxiety, worry) that go with
unhealthy behavioral risks
Self-reevaluation Realizing that the behavior change is an important part of one’s
identity as a person
Environmental reevaluation Realizing the negative impact of the unhealthy behavior, or the positive
impact of the healthy behavior, on one’s proximal social and/or
physical environment
Self-liberation Making a firm commitment to change
Helping relationships Seeking and using social support for the healthy behavior change
Counterconditioning Substitution of healthier alternative behaviors and/or cognitions for
the unhealthy behavior
Reinforcement management Increasing the rewards for the positive behavior change and/or
decreasing the rewards of the unhealthy behavior
Stimulus control Removing reminders or cues to engage in the unhealthy behavior and/
or adding cues to reminders to engage in the healthy behavior
Social liberation Realizing that social norms are changing in the direction of supporting
the healthy behavior change
Behavioral change does not occur overnight. A person does not go to bed at night as a
nonexerciser and wake up the next morning as an exerciser. Behavior change occurs over
time. Thus, the stage construct, the core construct of the model, is comprised of categories
of change (i.e., stages) along a continuum of motivational readiness to change a problem
behavior (URI, 2015). On this continuum “people move from precontemplation, not intend-
ing to change, to contemplation, intending to change within 6 months, to preparation, actively

170 Part 1 Planning a Health Promotion Program
planning change, to action, overtly making changes, and into maintenance, taking steps
to sustain change and resist temptation to relapse” (Prochaska, Redding, Harlow, Rossi, &
Velicer, 1994). The precontemplation stage is defined as a time in which “people do not
intend to take action in the near term, usually measured as the next six months. The outcome
interval may vary, depending on behavior. People may be in this stage because they are un-
informed or under-informed about the consequences of their behavior. Or they may have
tried to change a number of times and become demoralized about their abilities to change”
(Prochaska et al., 2008, p. 100). People in this stage “tend to avoid reading, talking, or thinking
about their high-risk behaviors” (Prochaska et al., 1998). The second stage, contemplation
is the stage in which “people intend to change their behaviors in the next six months”
(Prochaska et al., 2008, p. 100). It occurs when people are aware that a problem exists and
are seriously thinking about a behavior change but have not yet made a commitment to take
action. They are more open to feedback and information about the problem behavior than
those in the precontemplation stage (Redding et al., 1999). For example, most smokers know
that smoking is bad for them and consider quitting, but are not quite ready to do so. The third
stage is called preparation and combines intention and behavioral criteria. In this stage,
“people intend to take action soon, usually measured as the next month. Typically, they have
already taken some significant step toward the behavior in the past year. They have a plan of
action, such as joining a health education class, consulting a counselor, talking to their physi-
cian, buying a self-help book, or relying on a self-change approach” (Prochaska et al., 2008,
p. 100). “These are the people we should recruit for such action-oriented programs as smoking
cessation, weight loss, or exercise” (Prochaska et al., 1998, p. 61).
People are in the fourth stage, the action stage, when they have made overt changes
in their behavior, experiences, or environment in order to overcome their problems within
the past six months. This stage of change reflects a consistent behavior pattern, is usually
the most visible, and receives the greatest external recognition (Prochaska, DiClemente,
& Norcross, 1992). Since the behavior change is very new in this stage and the chance of
relapse is high, considerable attention still must be given to relapse prevention (Redding
et al., 1999). Also, “not all modifications of behavior count as action in this model. People
must attain a criterion that scientists and professionals agree is sufficient to reduce risks of
disease” (Prochaska et al., 2008, p. 102). For example, in smoking, reduction in the number
of cigarettes smoked does not count, only total abstinence (Prochaska et al., 1998). If those
making changes continue with their new pattern of behavior, they will move into the fifth
stage, maintenance.
Working to prevent relapse is the focus of the maintenance stage. People in this stage
have made specific, overt modifications in then lifestyles for at least six months and are
increasingly more confident that they can continue their changes (Prochaska et al., 2008;
Prochaska et al., 1998; Redding et al., 1999). The person’s change has become more of a habit
and the chance of relapse is lower, but it still requires some attention (Redding et al., 1999).
The final stage is termination. This stage is defined as the time when individuals who
have changed have zero temptation to return to their old behavior and they have 100%
self-efficacy—that is, a lifetime of maintenance. No matter what their mood, they will not
return to their old behavior (Prochaska et al., 2008). This is a stage that few people reach with
certain behaviors (e.g., drinking for alcoholics). Since this may not be a practical goal for the
majority of people, it has been given less attention in the research (Prochaska et al., 2008).
Figure 7.6 provides a summary of the stages of change.

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 171
The second major construct of the TTM is the processes of change (see Table 7.3 for an
explanation of the 10 processes). “These are the covert and overt activities that people use to
progress through the stages” (Prochaska et al., 2008, p. 101). Studies over the years have indi-
cated that some of the processes are more useful at specific stages of change. The experimen-
tal set of processes (consciousness raising, dramatic relief, self-reevaluation, environmental
reevaluation, and social liberation) are most often emphasized in earlier stages (precontem-
plation, contemplation, and preparation) to increase intention and motivation, whereas
the behavioral set of processes (helping relationships, counterconditioning, reinforcement
management, stimulus control, and self-liberation) are most often utilized in the later stages
(preparation, action, maintenance) as observable behavior change efforts get underway and
need to be maintained (Redding et al., 1999) (see Table 7.4).
The construct of decisional balance refers to the pros and cons of the behavioral
change. That is, individuals’ decisions to move from one stage to the next are based on the
relative importance (pro), or the lack thereof (con), of the behavior change for the individu-
als. “Characteristically, the pros of healthy behavior are low in the early stages and increase
across the stages of change, and the cons of the healthy behavior are high in the early stages
and decrease across the stages of change” (Redding et al., 1999, p. 90).
The fourth construct of the TTM is self-efficacy. The developers of this model see self-ef-
ficacy as it was defined by Bandura (1977), as people’s confidence in their ability to perform a
certain behavior or task. The final construct of the TTM is temptation. Temptation “reflects
the converse of self-efficacy—the intensity of urges to engage in a specific behavior when in
Precontemplation
Contemplation
Relapse Preparation
Maintenance Action
Termination
⦁▲ Figure 7.6 The Stages of Change
Source: Models for Provider-Patient Interaction: Applications to Health Behavior Change. M. G.
Goldstein from The Handbook of Health Behavior Change by Shumaker, Sally Reproduced with
permission of SPRINGER PUBLISHING COMPANY, INCORPORATED via Copyright Clearance Center.

172 Part 1 Planning a Health Promotion Program
difficult situations. Typically, three factors reflect the most common types of temptations:
negative affect or emotional distress, positive social situations, and craving” (Prochaska
et al., 2008, p. 102). As one might guess, temptation decreases as one moves through the
stages; however, even in the maintenance stage temptation is still present.
As noted at the beginning of this discussion, the TTM not only includes the five core con-
structs but it is also based on five critical assumptions (Prochaska et al., 2008):
1. No single theory can account for all the complexities of behavior change. A more
comprehensive model will most likely emerge from an integration across major
theories.
2. Behavior change is a process that unfolds over time through a sequence of stages.
3. Stages are both stable and open to change just as chronic behavioral risk factors are
stable and open to change.
4. The majority of at-risk populations are not prepared for action and will not be served by
traditional action-oriented behavior change programs.
5. Specific processes and principles of change should be emphasized at specific stages to
maximize efficacy (p. 103).
Since its development, the TTM has been useful in several different ways. The first is
that it makes program planners aware that not everyone is ready for change “right now,”
even though there is a program that can help them modify their behavior. People proceed
through behavior change at different paces. Second, if individuals are not ready for action
right now, then other programs can be developed to help them become ready for action.
Box 7.3 provides an example how to “stage” a person with a series of TTM type questions.
With such information, planners can match a person’s stage to a specific intervention,
which in turn can increase the chances that the intervention will have an effect.
Table 7.4 Progressing Through the Stages of the Transtheoretical Model
Stage Transitions
Precontemplation
to Contemplation
Contemplation
to Preparation
Preparation
to Action
Action to
Maintenance
P
ro
ce
ss
e
s
Consciousness raising x
Dramatic relief x
Environmental
reevaluation
x
Self-reevaluation x
Self-liberation x
Counterconditioning x
Helping relationships x
Reinforcement
management
x
Stimulus control x
Source: Based on “The Transtheoretical Model and Stages of Change.” J. O. Prochaska, C. A. Redding, K. E. Evers, in Health Behavior and Health Education: Theory, Research, and
Practice. K. Glanz, B. K. Rimer, and K. Viswanath (eds.). Copyright © 2008 by Jossey-Bass.

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 173
pRECAuTion AdopTion pRoCESS modEl (pApm)
The precaution adoption process model (PAPM) is more recent than the TTM (Weinstein, 1988;
Weinstein & Sandman, 1992) and is based on decision theory (Simons-Morton et al., 2012).
Its goal “is to explain how a person comes to the decision to take action, and how he or she
translates that decision into action” (Weinstein et al., 2008, p. 126). Though the TTM and
PAPM are both stage models and appear similar, “it is mainly the names that have been
given to the stages that are similar. The number of stages is not the same in the two theories,
and those with similar names are defined quite differently” (Weinstein & Sandman, 2002a,
p.  125). The PAPM is most applicable for use with the adoption of a new precaution (e.g.,
getting an immunization), or the abandonment of a risky behavior (e.g., not using a safety
belt or not wearing a motorcycle helmet) that requires a deliberate action. It can also be used
to explain why and how people make deliberate changes in habitual patterns. It is not appli-
cable for actions that require the gradual development of habitual patterns of behavior such
as exercise and diet (Weinstein et al., 2008). It is also different from the TTM in that its stages
are defined without reference to arbitrary time periods (Sutton, n.d.).
The PAPM includes seven stages along the full path from ignorance about a specific
behavior to taking action to engaging in the behavior.
At some initial point in time, people are unaware of the health issue (Stage 1) [Unaware].
When they first learn something about the issue, they are no longer unaware, but they are not
yet engaged by it either (Stage 2) [Unengaged]. People who reach the decision-making stage
(Stage 3) [Deciding about acting] have become engaged by the issue and are considering their
response. This decision-making process can result in one of three outcomes: they may suspend
judgment, remaining in Stage 3 for the moment; they may decide to take no action, moving
to Stage 4 [Decide not to act] and halting the precaution adoption process, at least for the time
being; or they may decide to adopt the precaution, moving to Stage 5 [Decide to act]. For those
who decide to adopt the precaution, the next step is to initiate the behavior (Stage 6) [Acting].
A seventh stage, if relevant, indicates that the behavior has been maintained over time (Stage 7)
7.3
Box An Example of using Questions Based on the Transtheoretical model
to “Stage” a person
1. Do you eat at least five servings of fruits and vegetables each day?
Yes—Move to question #2
No—Skip to question #3
2. Have you been doing so for more than six months?
Yes—Maintenance stage
No—Action stage
3. Do you intend to in the next 30 days?
Yes—Preparation stage
No—Move to question #4
4. Do you intend to in the next six months?
Yes—Contemplation stage
No—Precontemplation stage
A
pp
lic
at
io
n

174 Part 1 Planning a Health Promotion Program
[Maintenance]. (Weinstein et al., 2008, p. 126; note: names of the stages were inserted by
McKenzie, Neiger, & Thackeray.)
Figure 7.7 provides an example of the application of the PAPM to deciding whether or
not to get the shingles vaccine. You will note in this example that Stage 7 is not applicable
because only a single dose of the shingles vaccine is needed. However, if the flu vaccine was
used as the example Stage 7 would read “Get the flu vaccine once a year, usually starting in
September.” As with the TTM, the usefulness of this model is its ability to identify various
stages of the behavior change process (see Box 7.4). Once it is known what stage the program
participants are in, then the program planners can develop a stage-specific intervention to
move the participants toward action. Table 7.5 presents the important issues that need to be
addressed to move participants from one stage to the next.
Stage 6: Got the
shingles vaccine
Stage 7: Not applicable
Stage 5: Decided to get the
shingles vaccine
Stage 3: Deciding about getting
the shingles vaccine
Stage 4: Decided not to get the
shingles vaccine
Stage 2: Never thought about
the shingles vaccine
Stage 1: Unaware there is a
shingles vaccine
⦁▲ Figure 7.7 application of the Precaution adoption Process Model to shingles vaccine

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 175
7.4
Box An Example of using a Question Based on the precaution Adoption
process model to “Stage” a person
What are your intentions for receiving the new vaccine for shingles?
⦁⦁ I have already gotten it. (Stage 6)
⦁⦁ I have decided to get it. (Stage 5)
⦁⦁ I have thought about it and decided not to get it. (Stage 4)
⦁⦁ I am not sure. I am still trying to decide whether to get it or not. (Stage 3)
⦁⦁ I heard there was a vaccine, but I really haven’t thought much about it. (Stage 2)
⦁⦁ I was not aware there was a vaccine for shingles. (Stage 1)
A
pp
lic
at
io
n
Table 7.5 Progressing Through the Stages of the Precaution Adoption Process Model
Source: Based on Health Behavior and Health Education: Theory, Research, and Practice, by Karen Glanz, Barbara K. Rimer, and K. Viswanath. Copyright © 2008a
by John Wiley & Sons, Inc.
Stage Transitions
Stage 1:
(unaware of
issue) to
Stage 2:
(unengaged
by issue)
Stage 2:
(unengaged by
issue) to
Stage 3:
(Deciding to act)
Stage 3:
(Deciding to act)
to
Stage 4:
(Decided not to
act) or to Stage 5:
(Decided to act)
Stage 5:
(Decided to
act) to
Stage 6:
(Acting)
Im
p
o
rt
a
n
t
In
fo
rm
a
ti
o
n
f
o
r
St
a
g
e
-S
p
e
ci
fi
c
In
te
rv
e
n
ti
o
n
s
Information about hazard
and precaution
x x
Communication with
significant other about
hazard and precaution
x
Previous experience with
hazard
x
Beliefs about hazard
likelihood, severity and
personal susceptibility
x
Perceived social norms
and behaviors and
recommendations of others
x
Personal fear and worry x
Time, effort, and resources
(including assistance) to act
x
“How to” information and
cues to action
x

176 Part 1 Planning a Health Promotion Program
interpersonal level Theories
Health behavior theories that focus on the interpersonal level assume individuals exist within,
and are influenced by, a social environment (i.e., the people with whom they interact). That is
to say, that an individual’s attitudes and behaviors will be influenced by the actions, opinions,
thoughts, attitudes, behavior, advice, and support of others. Further, an individual has a re-
ciprocal effect on those people who make up their social environment (Rimer & Glanz, 2005).
The individuals who have the greatest influence on others include spouse/partner, other
family members, friends, peers (i.e., fellow students and coworkers), fellow members of social
groups, health care providers, religious leaders, and others (Rimer & Glanz, 2005).
Although social relationships can have an impact on many different human behaviors,
research has shown that they can be a powerful influence on health and health behaviors
(Heaney & Israel, 2008). Therefore a number of theories have been created to explain concepts
such as social learning (learning that occurs in a social context), social power (ability to influence
others or resist activities of others), social integration (structure and quality of relationships), social
networks (“web of social relationships and the structural characteristics of that web”) (IOM, 2001,
p. 7), social support (“aid and assistance exchanged through social relationships and interpersonal
transactions” [Heaney & Israel, 2008, p. 191]), social capital (“relationships between community
members including trust, reciprocity, and civic engagement” [Minkler, Wallerstein, & Wilson,
2008, p. 294]), and interpersonal communication. In the sections that follow, we present a detailed
description of a well-established interpersonal theory—the social cognitive theory, and we
present brief overviews of two newer theories—the social network theory and the social capital
theory. These latter two theories may be theories in name only. Earlier in this chapter we made a
distinction between theories and models. You may remember we said that there are some theo-
ries that have the term “model” in their title because that is the way they were initially identified
and now that there is empirical evidence to call them theories the “model title” has remained
because that is what we have gotten used to calling them. We believe that the social network and
the social capital theories may have been prematurely called theories and are probably more in
the model stage. But again as Goodson (2010) stated, “. . . it seems to matter little to us whether
we deal with theories or with models; it seems to matter even less what labels we attach to them”
(p. 228). Therefore, the important point of presenting the social network and social capital theo-
ries (or models) is to make you aware of the important concepts contained in each.
SoCiAl CogniTiVE THEoRy (SCT)
The social learning theories (SLT) of Rotter (1954) and Bandura (1977)—or, as Bandura
(1986) relabeled them, the social cognitive theory (SCT)—combine SR theory and cognitive
theories. Stimulus response theorists emphasize the role of reinforcement in shaping behav-
ior and believe that no “thinking” or “reasoning” is needed to explain behavior. However,
Bandura (2001) stated, “If actions were performed only on behalf of anticipated external
rewards and punishments, people would behave like weather vanes, constantly shifting di-
rections to conform to whatever influence happened to impinge upon them at the moment”
(p. 7). Cognitive theorists believe that reinforcement is an integral part of learning, but em-
phasize the role of subjective hypotheses or expectations held by the individual (Rosenstock
et al., 1988). In other words, reinforcement contributes to learning, but reinforcement along
with an individual’s expectations of the consequences of behavior determine the behavior.

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 177
“Behavior, in this perspective, is a function of the subjective value of an outcome and the
subjective probability (or ‘expectation’) that a particular action will achieve that outcome.
Such formulations are generally termed ‘value-expectancy’ theories” (Rosenstock et al.,
1988, p. 176). In brief, SCT explains human functioning in terms of triadic reciprocal causa-
tion (Bandura, 1986). “In this model of reciprocal causality, internal personal factors in the
form of cognitive, affective, and biological events, behavioral patterns, and environmental
influences all operate as interacting determinants that influence one another bidirection-
ally” (Bandura, 2001, pp. 14–15). The constructs of the SCT that have been most often used
in designing health promotion interventions will be presented here.
As already noted, reinforcement is an important component of SCT. According to SCT,
reinforcement can be accomplished in one of three ways: directly, vicariously, or through self-
reinforcement (Baranowski, Perry, & Parcel, 2002). An example of direct reinforcement is
a group facilitator who provides verbal feedback to participants for a job well done. Vicarious
reinforcement is having the participants observe someone else being reinforced for behav-
ing in an appropriate manner. This has been referred to as observational learning (Baranowski
et al., 2002) or social modeling. In a system of reinforcement by self- reinforcement, the par-
ticipants would keep records of their own behavior, and when the behavior was performed in
an appropriate manner, they would reinforce or reward themselves.
If individuals are to perform specific behaviors, they must know first what the behaviors are
and then how to perform them. This is referred to as behavioral capability. For example,
if people are to engage in cardiovascular (i.e., “cardio”) exercise, first they must know that car-
diovascular exercise exists, and second they need to know how to do it properly. Many people
begin exercise programs, only to quit within the first six months (Dishman, Sallis, & Orenstein,
1985), and some of those people quit because they do not know how to exercise properly. They
know they should exercise, so they decide to run a few miles, have sore muscles the next day,
and quit. Skill mastery is very important. The construct of expectations refers to the ability
of human beings to think, and thus to anticipate certain things to happen in certain situa-
tions. For example, if people are enrolled in a weight loss program and follow the directions of
the group facilitator, they will expect to lose weight. Expectancies, not to be confused with
expectations, are the values that individuals place on an expected outcome. “Expectancies
influence behavior according to the hedonic principle: if all other things are equal, a person
will choose to perform an activity that maximizes a positive outcome or minimizes a negative
outcome” (Baranowski et al., 2002, p. 173). Someone who enjoys the feeling of not smoking
more than that of smoking is more likely to try to do the things necessary to stop. The construct
of self-regulation or self-control states that individuals may gain control of their own be-
havior through monitoring and adjusting it (Clark et al., 1992). In writing about this construct,
Bandura (1991) believed that self-regulation systems could have a big influence on behavior
change. Later (Bandura, 1997) he expanded his thoughts about the construct and identified six
methods for achieving self-regulation. They include (1) self-monitoring (i.e., self-observation)
of one’s behavior, (2) setting both incremental and long-term goals, (3) obtaining feedback on
the quality of a behavior and how it can be improved, (4) rewarding self (or self-reinforcement)
for meeting goals, (5) self-instructing both before and as the behavior is being performed, and
(6) gaining social-support for the behavior. These six methods have been used extensively in
health promotion programs. For example, when helping individuals to change their behavior
(i.e., a goal of losing weight, quitting smoking, or exercising more), it is a common practice to

178 Part 1 Planning a Health Promotion Program
have them monitor their behavior over a period of time, say through 24-hour diet or smoking
records or exercise diaries, analyze their behavior based on data recorded, and then to have
them reward (reinforce) themselves based on meeting their goals.
One construct of SCT that has received special attention in health promotion programs is
self-efficacy (Strecher et al., 1986), which refers to the internal state that individuals experi-
ence as “competence” to perform certain desired tasks or behavior, “including confidence in
overcoming the barriers to performing that behavior” (Baranowski et al., 2002, p. 173). “Unless
people believe they can produce desired results and forestall detrimental ones by their actions,
they have little incentive to act or to persevere in the face of difficulties” (Bandura, 2001, p. 10).
Self-efficacy is situation specific; that is, individuals may be self-efficacious when it comes to
regular exercise but not so when faced with reducing the amount of fat in their diet. People’s
competency feelings have been referred to as efficacy expectations. Thus, people who
think they can exercise on a regular basis no matter what the circumstances have efficacy ex-
pectations. Even though people have efficacy expectations, they still may not want to engage
in a behavior because they may not think the outcomes of that behavior would be beneficial to
them. Stated another way, they may not feel that the reward (reinforcement) of performing the
behavior is great enough for them. These beliefs are called outcome expectations. For ex-
ample, in order for individuals to quit smoking for health reasons (behavior), they must believe
both that they are capable of quitting (efficacy expectation) and that cessation will benefit
their health (outcome expectation) (I. M. Rosenstock, personal communication, April 1986).
Individuals become self-efficacious in four main ways:
1. Through performance attainments (personal mastery of a task)
2. Through vicarious experience (observing the performance of others)
3. As a result of verbal persuasion (receiving suggestions from others)
4. Through emotional arousal (interpreting one’s emotional state)
Not only can individuals be self-efficacious, so can groups of people. The term given
to groups or organizations being efficacious is collective efficacy. Collective efficacy has
been defined as the people’s shared belief in their collective ability to act to produce specific
changes. Like self-efficacy, collective efficacy is situation specific. It is a construct that has ap-
plication when people seek to alter social systems (e.g., neighborhood watches and commu-
nity organizing (see Chapter 9), but also has application in health promotion with regards to
health policy (McAlister et al., 2008). Bandura (1982, p. 143) noted that “[p]erceived collec-
tive efficacy will influence what people choose to do as a group, how much effort they put
into it, and their staying power when group efforts fail to produce results.”
The construct of emotional–coping response states that for people to learn, they must
be able to deal with the sources of anxiety that may surround a behavior. For example, fear is
an emotion that can be involved in learning; according to this construct, participants would
have to deal with the fear before they could learn the behavior.
The construct of reciprocal determinism states, unlike SR theory, that there is an
interaction among the person, the behavior, and the environment, and that the person can
shape the environment as well as the environment shape the person. All these relationships
are dynamic. Glanz and Rimer (1995) provide a good example of this construct:
A man with high cholesterol might have a hard time following his prescribed low-fat diet
because his company cafeteria doesn’t offer low-fat food choices that he likes. He can try to

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 179
change the environment by talking with the cafeteria manager or the company medical or
health department staff, and asking that healthy food choices be added to the menu. Or, if
employees start to dine elsewhere in order to eat low-fat lunches, the cafeteria may change its
menu to maintain its lunch business (p. 15).
Finally, there is one other construct that grew out of the social learning theory of Rotter
(1954) that needs to be mentioned because of its association with health behavior. “Rotter
posited that a person’s history of positive or negative reinforcement across a variety of situa-
tions shapes a belief as to whether or not a person’s own actions lead to those reinforcements”
(Wallston, 1994, p. 187). Rotter referred to this construct as locus of control. He felt that
people with internal locus of control perceived that reinforcement was under their control,
whereas those with external locus of control perceived reinforcement to be under the control
of some external force. In the 1970s, Wallston and his colleagues at Vanderbilt University
began testing the usefulness of this construct in predicting health behavior (Wallston, 1994).
They explored the concept of whether individuals with internal locus of control were more
likely to participate in health-enhancing behavior than those with external locus of control.
They began their work by examining locus of control as a two-dimensional construct (inter-
nal versus external), then moved to a multidimensional construct (i.e., Multidimensional
Health Locus of Control [MHLC]) when they split the external dimension into “powerful
others” and “chance” (Wallston, Wallston, & DeVellis, 1978). Since developing the MHLC
scale, a health/medical condition specific scale (Wallston, Stein, & Smith, 1994) and a re-
ligion and health scale (Wallston, 2007) for locus of control have been created. (Note: All
scales are in the public domain and available from Wallston, 2007).
After a number of years of work by many different researchers, Wallston has come to the
conclusion that locus of control accounts for only a small amount of the variability in health
behavior (Wallston, 1992). The internal locus of control belief about one’s own health status
is a necessary but not sufficient determinate of health-enhancing behavior (Wallston, 1994).
Since the rise of the construct of self-efficacy, Wallston (1994) feels that self-efficacy is a bet-
ter predictor of health-promoting behavior than locus of control. This is not to say that locus
of control is not a useful construct in developing health promotion programs. Knowing the
locus of control orientation of those in the priority population can provide planners with
valuable information when considering social support as part of a planned intervention.
Table 7.6 provides a summary of the constructs of the SCT and an example of how each con-
struct might be operationalized.
SoCiAl nETwoRk THEoRy (SnT)
The term social network (“web of social relationships that surround people and the struc-
tural characteristics of that web” [IOM, 2001, p. 7]) arose in the 1950s from the work of a
sociologist who studied Norwegian villages. Barnes (1954) created the term to describe social
relationships and characteristics of the villagers that could not be described through tradi-
tional social units such as families (Edberg, 2015; Heaney & Israel, 2008). Since that time, the
concept has continued to be used and studied by sociologists and professionals in various
other disciplines including health education/health promotion. One primary reason for the
growth in its use in recent years is that researchers have become dissatisfied with many of the
other theories presented in this chapter. “For example, theories that show attitudes toward a
behavior are associated with the behavior often do not help us to understand how to change
those attitudes” (Valente, 2010, p. 7). To support the work of health education specialists

180 Part 1 Planning a Health Promotion Program
Table 7.6 Often-used Constructs of the Social Cognitive Theory and Examples of Their
Application
Source: Principles and Foundations of Health Promotion and Education. Randall R. Cottrell, James T. Girvan, James F. McKenzie, and Denise M. Seabert. Copyright © 2015 by
Pearson Education. Reprinted with permission.
Construct Definition Example
Behavioral
capability
Knowledge and skills necessary to
perform a behavior.
If people are going to exercise
aerobically, they need to know what it
is and how to do it.
Expectations Beliefs about the likely outcomes
of certain behaviors.
If people enroll in a weight-loss
program, they expect to lose weight.
Expectancies Values people place on expected
outcomes.
How important is it to people that they
become physically fit?
Locus of control Perception of the center of control
over reinforcement.
Those who feel they have control over
reinforcement are said to have internal
locus of control. Those who perceive
reinforcement under the control of an
external force are said to have external
locus of control.
Reciprocal
determinism
“Environmental factors influence
individuals and groups, but individuals
and groups can also influence their
environments and regulate their own
behavior” (McAlister, Perry, & Parcel,
2008, p. 171).
Lack of use of vending machines could
be a result of the choices within the
machine. Notes about the selections
from the nonusing consumers to the
machine’s owners could change the
selections and change the behavior of
the nonusing consumers to that of users.
Reinforcement
(directly, vicariously,
self-management)
Responses to behaviors that increase
the chances of recurrence.
Giving verbal encouragement to those
who have acted in a healthy manner.
Self-control, or
self-regulation
Gaining control over one’s own
behavior through monitoring and
adjusting it.
If clients want to change their eating
habits, have them monitor their current
habits for seven days.
Self-efficacy People’s confidence in their ability
to perform a certain desired task or
function
If people are going to engage in a
regular exercise program, they must
feel they can do it.
Collective efficacy Beliefs about the ability of the group
to perform concerted actions that bring
desired outcomes (McAlister et al.,
2008, p. 171).
If a group of people is going to work to
change a community’s culture toward
healthy behavior, they must feel that
they can do it.
Emotional-coping
response
For people to learn, they must be able
to deal with the sources of anxiety that
surround a behavior.
Fear is an emotion that can be involved
in learning, and people would have to
deal with it before they could learn a
behavior.
there is now evidence from social epidemiological observational studies that have clearly
documented the beneficial effects of supportive networks on health status (Heaney & Israel,
2008; Valente, 2010). But is there enough evidence to suggest there is such a thing as a social
network theory (SNT)? Heaney and Israel (2008) feel that the social network, and the closely
related concept of social support, “do not connote theories per se. Rather, they are concepts
that describe the structure, processes, and functions of social relationships” (p. 193). They
feel that intervention studies are “needed to identify the most potent causal agents and criti-
cal time periods for social network enhancement” (p. 197). For example, it is not known how

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 181
much social networking is enough to enhance health or how much is too much. It is also not
known what are the characteristics of “good networks” that result in positive health behav-
ior (e.g., regular exercise) versus “bad networks” that lead to negative health behavior (e.g.,
smoking). But what is known is that people who are part of social networks are as a whole
healthier than those who are not involved in networks.
One person who has written about SNT is Edberg (2015). He has described different types of
social networks (e.g., ego-centered networks and full relational networks) and indicated that the
key components to SNT are the relationships between and among individuals and how the na-
ture of those relationships influences beliefs and behaviors. He further states that those who use
the SNT need to consider the items on the following list when assessing the role of a network on
the health behavior of individuals who are part of the network (Edberg, 2015):
⦁⦁ Centrality versus marginality of individuals in the network—how much involvement
does the person have in the network?
⦁⦁ Reciprocity of relationships—are relationships one-way or two-way?
⦁⦁ Complexity or intensity of relationships in the network—are the relationships between
two people or are they multiplexed?
⦁⦁ Homogeneity or diversity of people in the network—do all members of the network have
similar characteristics or are they different?
⦁⦁ Subgroups, cliques, and linkages—are there concentrations of interactions among some
members and do they interact or are they isolated from others?
⦁⦁ Communication patterns in the network—how does information pass between the
members in the network?
In summary, we know that social networks can impact health, but the specifics of who is
most impacted and how best to set up and use social networks are unknown. Nevertheless,
because of the impact of social networks, health education specialists planning interventions
need to consider if social networks should be a part of the strategy they use to bring about
change. And finally, with the power of the Internet and social networking, the impact of so-
cial networks in the work of health education specialists will to continue to grow.
SoCiAl CApiTAl THEoRy
The often-quoted definition of social capital is “the relationships and structures within a
community, such as civic participation, networks, norms of reciprocity, and trust, that promote
cooperation of mutual benefit” (Putnam, 1995, p. 66). More recently, it has been defined as
“the degree of social connectedness” (Simons-Morton et al., 2012, p. 410). “Social capital is a
collective asset, a feature of communities rather than the property of individuals. As such, indi-
viduals both contribute to it and use it, but they cannot own it” (Warren, Thompson, & Saegert,
2001, p. 1). The term got its start in political science and has been used in the health education/
promotion field since the mid-1990s. The influence of social capital is well documented (Crosby
et al., 2009). There are epidemiological studies that show that greater social capital is linked to
several different positive outcomes (i.e., reduced mortality, some access to health care). There
are also correlational studies that show that lack of social capital is related to poorer health out-
comes (e.g., Kawachi, Subramanian, & Kim, 2008). But as with social networks, a cause-effect
relationship has not been established between social capital and better health. Social capital is
an important descriptor of community wellness, but it is not a strategy and requires community
organizing and capacity building in order to be strengthened (Minkler & Wallerstein, 2012).

182 Part 1 Planning a Health Promotion Program
Figure 7.8 provides a graphic representation of the social capital. This particular figure
includes the key concepts of Putman’s (1995) definition of social capital and three different
types of network resources—bonding, bridging, and linking social capital. These three types
are differentiated based on the strength of the relationships between/among those people in
the social network (Hayden, 2014). Originally, bonding social capital (sometimes referred to
as exclusive social capital) was defined as “the type that brings closer together people who
already know each other” (Gittell & Vidal, 1998, p.15), but since then it has been expanded
to encompass people who are similar or people who are members of the same group. Bonding
social capital would come from those who are members in a service organization (e.g., Lions,
Elks, American Legion) or religious community, for example. Bridging social capital (some-
times referred to as inclusive social capital), was originally defined as “the type that brings
together people or groups who previously did not know each other” (Gittell & Vidal, 1998,
p. 15), though now bridging social capital is seen more as the resources that people obtain
from their interaction with people from outside their group, oftentimes from people with
different demographic characteristics. An example would be people from different parts of a
community working to create a community park.
The most recently recognized, and weakest, network resource is linking social capital
(Hayden, 2014). In this type of network social capital comes from relationships between/
among individuals with institutions and individuals who have relative power over them
(Szreter & Woolcock, 2004). An example would be when a boss and an employee work to-
gether on a project.
Again, as with social networks it is important that health education specialists be aware of
the concept of social capital when planning interventions. It is not an intervention in itself,
but it is a concept that needs to be considered and monitored.
Community level Theories
As noted earlier in this chapter, the community level theories include any theory that would
apply to the last five levels of the ecological perspective—institutional, community, public
policy, environmental, and culture. Community level theories “explore how social systems
Networks Resources
(Bonding, Bridging, Linking)
Trust & Reciprocity
Norms & Expectations
Social Capital
E
n
vi
ro
n
m
e
n
t
⦁▲ Figure 7.8 Social Capital
Source: Based on Introduction to Health Behavior Theory, by J. Hayden. Copyright © 2014 by Jones & Bartlett Learning.

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 183
function and change and how to mobilize community members and organizations. They
offer strategies that work in a variety of settings such as health care institutions, schools,
worksites, community groups, and government agencies” (Rimer & Glanz, 2005, p. 22).
Like the other levels already discussed in this chapter, a number of different community-
level theories are available for health planners. Several community level theories involve
community organizing and developing (see Chapter 9). The following section presents a
discussion of two community level theories–– diffusion theory and the community readi-
ness model.
diFFuSSion THEoRy
Diffusion theory (Rogers, 1962) provided an explanation for the spread of innovations
(something new, such as a product, service, or program) in populations; stated another way,
it provides an explanation for the pattern of adoption of the innovations. Like other pro-
cesses discussed in this chapter, adoption is situation specific and it results from people going
through a series of stages. Rogers (2003) outlined the following five stages: (1) knowledge (ac-
quisition of about the innovation), (2) persuasion (i.e., attitude concerning the innovation);
(3) decision (about adopting or not adopting); (4) implementation (beginning to use the in-
novation); and (5) confirmation (commitment to use, continue to use, or discontinue use of
the innovation). If one thinks of a health promotion program as an innovation, the theory
describes a pattern the priority population will follow in adopting the program.
The pattern of adoption can be represented by the normal bell-shaped curve (Rogers,
2003) (see Table 7.7). Those individuals who fall in the portion of the curve to the left of mi-
nus 2 standard deviations from the mean (this would be between 2% and 3% of the priority
population) would probably become involved in the program just because they had heard
about it and wanted to be first. These people are called innovators. They are venturesome,
independent, and daring. They want to be the first to do things, although others in the social
system may not respect them.
The second group of people to adopt something new includes those represented on the
curve between minus 2 and minus 1 standard deviations. This group, which composes about
14% of the priority population, is called early adopters. These people are very interested
in the innovation, but they are not the first to sign up. They wait until the innovators are
already involved to make sure the innovation is useful. Early adopters are respected by others
in the social system and looked upon as opinion leaders.
The next two groups are the early majority and the late majority. They fall between
minus 1 standard deviation and the mean and between the mean and plus 1 standard
Table 7.7 Diffusion of Innovations
Group % of Population Place on a Bell-shaped Curve
Innovators ~2-3 Less than minus 2 standard deviations
Early Adopters ~14 Between minus 2 and minus 1 standard deviations
Early Majority ~34 Between minus 1 standard deviation and the mean
Late Majority ~34 Between the mean and plus 1 standard deviation
Laggards ~16 Greater than plus 1 standard deviation

184 Part 1 Planning a Health Promotion Program
deviation on the curve, respectively. Each of these groups comprises about 34% of the pri-
ority population. Those in the early majority may be interested in the health promotion
program, but they will need external motivation to become involved. Those in the early
majority will deliberate for some time before making a decision. It will take more work to get
the late majority involved, because they are skeptical and will not adopt an innovation until
most people in the social system have done so. Planners may be able to get them involved
through a peer mentoring program, or through constant exposure about the innovation.
The last group, the laggards (16%), is represented by the part of the curve greater than
plus 1 standard deviation. They are not very interested in innovation and would be the last
to become involved in new health promotion programs, if at all. They are very traditional
and are suspicious of innovations. Laggards tend to have limited communication networks,
so they really do not know much about new things.
Because diffusion occurs over time, the cumulative prevalence of adopters at successive
points can be represented by a S-shaped curve. At first, only a few people adopt (innovators).
However, over time, the curve begins to climb as additional individuals decide to adopt the
innovation (early adopters, early majority, and late majority). The curve then levels off as
adoption of the innovation ceases, leaving a few who have not adopted (laggards) (Goldman,
1998; Rogers, 2003).
One of the more useful application of the diffusion theory is when marketing a health
promotion program because “the distinguishing characteristics of the people who fall into
each category of adopters from ‘innovators’ to ‘early adopters’ to middle majority categories
to ‘late adopters’ [laggards] tend to be consistent across a wide range of innovations” (Green,
1989). Therefore, different marketing techniques can be used depending on the type of
people the planners are trying to reach with a program. For example, program planners want
rapid diffusion of innovations. They know that although innovators will adopt the program
or product first, the key subgroups of the priority population are the early adopters and early
majority. It is especially important to identify the early adopters (opinion leaders) as soon as
possible in the implementation process since, according to diffusion theory, the sooner they
adopt the innovation the sooner the rest of the population will follow. The challenge is how
to identify and reach the early adopters.
The diffusion of innovations theory has been applied to many different types of health
promotion programs. One of the more interesting uses of diffusion theory has been to
“conceptualize the transference of health promotion programs from one locale to another”
(Steckler, Goodman et al., 1992). Steckler, Goodman, and colleagues (1992) developed a
series of six questionnaires to measure the extent to which health promotion programs are
successfully disseminated. Planners should refer to this work if they are interested in using
and measuring diffusion.
CommuniTy REAdinESS modEl (CRm)
Community readiness “is the degree to which a community is willing and prepared
to take action on an issue” (Tri-Ethnic Center for Prevention Research at Colorado State
University, 2014, p. 4). Like with individuals, communities are in different levels of readi-
ness for change. The community readiness model (CRM) is a stage theory for communities.
The concept of community readiness got its start back in the early 1990s, growing out of
the need to understand the problems associated with developing and maintaining com-
munity programs. (See Edwards, Jumper-Thurman, Plested, Oetting, & Swanson, 2000, for a

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 185
description of the origin of the CRM.) What was evident from the beginning is that few com-
munities were alike. They may have had similar problems, but the dynamics in each com-
munity did not mean that the starting point for dealing with the problem could be the same.
“Communities are fluid—always changing, adapting, growing” (Edwards et al., 2000, p.
291), and like individuals, communities are in various stages of readiness for change. Yet, the
stages of change for communities are not the same as for individuals. “The stages of readiness
in a community have to deal with group processes and group organization, characteristics
that are not relevant to personal readiness” (Edwards et al., 2000, p. 296–297). Though the
model was developed initially to deal with alcohol and drug abuse, it has been useful in help-
ing with a variety of health and nutrition topics (e.g., AIDS awareness, elimination of heart
disease, depression awareness, reduction of sexually transmitted diseases), environmentally
centered programs (e.g., air quality and recycling), and social programs (e.g., intimate part-
ner violence programs) (Edwards et al., 2000).
The CRM defines nine stages:
1. No Awareness. The problem is not generally recognized by the people in the community
or the leaders of the community.
2. Denial. There is little or no recognition in the community that there is a problem; if so,
the feeling is nothing can be done about it.
3. Vague Awareness. Feeling among some in the community that there is a problem and
something should be done, but no motivation or leadership to do so.
4. Preplanning. The clear recognition by some that there is a problem and something
should be done. There are leaders for action, but no focused or detailed planning.
5. Preparation. There is planning going on but it is not based on collected data. There is
leadership, resources are being sought, and there is modest support for efforts.
6. Initiation. Information is available to justify and begin efforts. Staff is in, or has just
completed, training. Leaders are enthusiastic and there is usually little resistance and
involvement from the community members.
7. Stabilization. Program is running, staffed, and supported by community and decision
makers. Program is perceived as stable with no need for change. May include routine
tracking, but no in-depth evaluation.
8. Confirmation/Expansion. Standard efforts are in place and supported by the community
and decision makers. Program has been evaluated and modified, and efforts are in place
to seek resources for new efforts. Data are collected on an ongoing basis to link risk
factors and problems.
9. Professionalism. Much is known about prevalence, risk factors, and cause of
problems. Highly trained staff runs effective programs, aimed at general population
and appropriate subgroups. Programs have been evaluated and modified.
Community is supportive but should hold programs accountable (Edwards et al.,
2000).
A community’s readiness for addressing an issue can be assessed through a process in
which interviews are conducted and scored with key informants. The interviews are based on
five key dimensions of community readiness (i.e., community knowledge of efforts, leader-
ship, community climate, community knowledge of the issue, and resources). Once the stage
of readiness is known, like the other stage theories, there are suggested processes for moving

186 Part 1 Planning a Health Promotion Program
a community from one stage to the next. Table 7.8 presents the nine stages and the goal
for each stage. A handbook for using this model has been created and is available from the
Tri-Ethnic Center for Prevention Research at Colorado State University (2014).
Cognitive-Behavioral Model of the Relapse Process
For most people, relapse is a part of change. Relapse “refers to the breakdown or failure
in a person’s attempt to change or modify a particular habit pattern, such as stopping ‘bad
habits’ or developing new, optimal health behaviors” (Marlatt & George, 1998, p. 33).
Marlatt and George (1998) differentiate between relapse (an indication of total failure) and
a lapse (a single slip or mistake). The first drink or cigarette following a period of abstinence
would be considered a lapse. It has been said that getting people to change behavior is hard,
but having them maintain the behavior is much harder. This is nicely illustrated by the
old saying, “Giving up smoking is easy; I’ve done it a hundred times.” At one time, it was
enough for program planners just to get people to change their behavior; now they need to
do more. Because of the difficulty of maintaining a new behavior, program planners need
to give special attention to helping those in the priority population avoid slipping back to
their previous behaviors.
Although much of the early research dealing with this concept of slipping back was con-
ducted using addictive behaviors, such as substance abuse and gambling, the concept applies
to all behavior change, including preventive health behaviors. Marlatt (1982) indicates that
a high percentage of individuals who enter programs for health behavior change relapse to
their former behaviors within one year. More specifically, researchers have warned program
planners of recidivism problems with participants in exercise and diet (Gaesser, Angadi, &
Sawyer, 2011), oral health care treatment (McCaul et al., 1990), weight loss (Grattan, &
Connolly-Schoonen, 2012), and smoking cessation (Leventhal & Cleary, 1980) programs.
Therefore, planners need to make sure that program interventions include the skills necessary
for dealing with those difficult times during behavior change.
Table 7.8 Community Readiness Stages and Goals
Source: “Community readiness: Research to practice.” Ruth W. Edwards, Pamela Jumper-Thurman, Barbara A. Plested, Eugene R. Oetting, Louis Swanson, in Journal
of Community Psychology 28(3). Copyright © 2000 by John Wiley & Sons, Inc.
Stage Goal
1. No awareness Raise awareness of the issue
2. Denial Raise awareness that the problem or issue exists in the community
3. Vague awareness Raise awareness that the community can do something
4. Preplanning Raise awareness with the concrete ideas to combat condition
5. Preparation Gather existing information to help plan strategies
6. Initiation Provide community-specific information
7. Stabilization Stabilize efforts/programs
8. Confirmation/expansion Expand and enhance service
9. Professionalism Maintain momentum and continue growth

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 187
Marlatt (1982) refers to the process of trying to prevent slipping back as relapse prevention.
Relapse prevention, which is based on the social cognitive theory, combines behavioral skill-
training procedures, cognitive therapy, and lifestyle rebalancing (Marlatt & George, 1998).
Relapse prevention (RP) is “a self-control program designed to help individuals to antici-
pate and cope with the problem of relapse in the habit-changing process” (Marlatt & George,
1998, p. 33). Relapse is triggered by high-risk situations. “A high-risk situation is defined broadly
as any situation (including emotional reactions to the situation) that poses a threat to the in-
dividual’s sense of control and increases the risk of potential relapse” (Marlatt & George, 1998,
p. 38). Cummings, Gordon, and Marlatt (1980), in a study of clients with a variety of prob-
lem behaviors (e.g., drinking, smoking, heroin addiction, gambling, and overeating), found
high-risk situations tend to fall into two major categories: intrapersonal and interpersonal
determinants. They found that 56% of the relapse situations were caused by intrapersonal
determinants, such as negative emotional states (35%), negative physical states (3%), positive
emotional states (4%), testing personal control (5%), and urges and temptations (9%). The
44% of the situations represented by interpersonal determinants included interpersonal con-
flicts (16%), social pressure (20%), and positive emotional states (8%). These determinants can
be referred to as the covert antecedents of relapse. That is to say, these high-risk situations do not
just happen; instead, they are created by what Marlatt (1982) calls lifestyle imbalances.
People who have the coping skills to deal with a high-risk situation have a much greater
chance of preventing relapse than those who do not. Marlatt has developed both global
and specific self-control strategies for relapse intervention. Specific intervention proce-
dures are designed to help participants anticipate and cope with the relapse episode itself,
whereas the global intervention procedures are designed to modify the early antecedents of
relapse, including restructuring of the participant’s general style of life. A complete applica-
tion of the relapse prevention model would include both specific and global interventions
(Marlatt, 1982).
Limitations of Theory
The major foci of this chapter have been to present an overview and the major constructs
of the theories that are commonly used to design interventions for health promotion pro-
grams. Although all the theories presented have been found to be useful in certain situations
and settings, no one theory has been shown to be useful in all situations and settings. In
fact, each of the theories presented has its limitations. For example, the SR theory focuses on
consequences (i.e., reinforcement or punishment) that result from behaviors acting on the
environment. These consequences either increase or decrease the probability of the behav-
ior being repeated but they do not take into consideration that thinking and reasoning also
impact behavior. The value-expectancy theories presented in this chapter (i.e.,TPB, HBM,
PMT) focus on cognitive variables but fail to suggest that change takes place over time in
stages. Yet the stage theories have been criticized because a number of psychologists feel that
behavior is much more complex and that behavior change cannot be neatly placed within a
stage. Several different author groups have reviewed the various theories and identified their
weaknesses. Three sources (Angus et al., 2013; Boston University School of Public Health,
2013; Munro, Lewin, Swart, & Volmink, 2007) present limitations of many of the theories
presented in this chapter. If you are interested in limitations of other theories not noted in

188 Part 1 Planning a Health Promotion Program
these sources or are interested in other view points about limitations of a theory simply type
the words “limitations of” and add the name of the theory into a Internet search engine and
a number of sources will appear.
Summary
Many theories are available to program planners, and it is important to remember that no
one theory is best. This chapter presented an overview of the theories that are most often
used in health promotion programs. These theories are important for planners because they
provide information about why people are, or are not, engaging in health-enhancing behav-
iors; what factors to consider when creating interventions; and what factors to look for when
evaluating a program. Theories can be categorized in a number of ways. This chapter presents
two categories. The first categorizes theories by the level of influence at which it is most effec-
tive; the second classifies theories as either the continuum or stage theories. Finally, a brief
explanation is provided about the limitations of theory.
Review Questions
1. Define theory, using your own words.
2. How is a theory different from a model?
3. How do concepts, constructs, and variables relate to theories?
4. Why is it important to use theories when planning and evaluating health promotion
programs?
5. How can the socio-ecological approach be used to select a theory for use?
6. What makes stage theories different from continuum theories?
7. What is the underlying concept for each of the following theories?
a. Stimulus response theory
b. Social cognitive theory
c. Theory of planned behavior
d. Health belief model
e. Protection motivation theory
f. Elaboration likelihood model of persuasion
g. Information-motivation-behavioral skills model
h. Transtheoretical model
i. Precaution adoption process model
j. Social network theory
k. Social capital theory
l. Diffusion of innovations
m. Community readiness model
8. What is the major difference between the transtheoretical model and the precaution
adoption process model?

Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions 189
9. How is the community readiness model different from the other stage models?
10. How can program planners help to prepare those in the priority population for relapse
prevention?
Activities
1. Assume that you have identified a prioritized need for a given priority population. In a
two-page paper:
a. State who the priority population is and what the need is.
b. Select a theory to use as a guide in developing an intervention to address the problem.
c. Explain why you chose the theory that you did.
d. Defend why you think this is the best theory to use.
e. Show how the problem “fits into” the theory.
2. In a two-page paper, identify a theory that you plan to use in developing the intervention
for the program you are planning. Explain why you chose the theory, and why you think
it is a good fit for the problem you are addressing.
3. Write a paragraph on each of the following:
a. Using the stimulus response theory, explain why a person might smoke.
b. Using the social cognitive theory (SCT), explain how you could help people change
their diets.
c. Explain how the SCT construct of behavioral capability applies to managing stress.
d. Explain the differences between, and the relationship of, the SCT constructs of expec-
tations and expectancies.
e. Explain what would have to take place for individuals to be self-efficacious with regard
to taking their insulin.
f. Use the information-motivation-behavioral skills model to explain how to encourage
a person to eat a healthy diet.
g. Use the theory of planned behavior to explain how a smoker stops smoking.
h. Use protection motivation theory to explain how you could create a public service
announcement to encourage people to exercise.
i. Apply the health belief model to getting a person to get a flu shot.
j. Apply the transtheoretical model to get a person to change any health behavior.
k. Using the precaution adoption process model, explain how a person decides to get
screened for blood cholesterol.
l. Explain how a social network could be used to encourage people to adopt a healthy
behavior.
m. Explain how you might increase the social capital of a community.
n. Explain who and when those in a priority population may join a new exercise program.
o. Explain how the community readiness model could be used by planners who are
interested in getting a citywide smoking ordinance passed.
4. Your supervisor at the local health department has asked you to create a new program to
encourage people in your county to get the influenza vaccine. After conducting a needs
assessment it was found that the priority population for the program would be senior

190 Part 1 Planning a Health Promotion Program
citizens who to seem lack enabling factors for getting vaccinated. Which theory/model
do you feel would be the best to use as the foundation for the intervention you will
create? Write a brief rationale defending your choice.
5. You have been asked to create a brief education program to prepare outpatients for a
screening colonoscopy for the gastroenterology department at the hospital where you
work. The request was made because feedback from a significant number of patients who
received the screening last year indicated that they wished they would have known what
to expect in advance. Which theory/model do you feel would be the best to use to plan
the education program around? Write a brief rationale defending your choice.
6. After tallying the results of an employee satisfaction survey, the director of the human
resources (HR) department in the company where you work wants to begin an incentive
program to encourage more people to participate in the employee health promotion
program. The HR director would like you to create the incentive-based intervention for
the program. Which theory/model do you feel would be the best to use to create the
incentive-based intervention? Write a brief rationale defending your choice.
Weblinks
1. http://web.uri.edu/cprc/about-ttm/
Cancer Prevention Resource Center (CPRC), University of Rhode Island
CPRC is the home of the Transtheoretical Model. At this Website, you can obtain
information about the model, as well as measures that can be used to “stage” a person.
2. http://www.cdc.gov/Violenceprevention/overview/social-ecologicalmodel.html
National Center for Injury Prevention and Control, Division of Violence Prevention,
Centers for Disease Control and Prevention
This Website provides an application of the socio-ecological approach to violence prevention.
3. http://sbccimplementationkits.org/demandrmnch/ikitresources
/theory-at-a-glance-a-guide-for-health-promotion-practice-second-edition/
Health Communication Capacity Collaborative National Cancer Institute (NCI)
At this Website you will be able to download a copy of the National Cancer Institute’s
publication Theory at a Glance: A Guide for Health Promotion Practice. This volume presents a
single, concise summary of health behavior theories that is both easy to read and practical.
4. http://people.umass.edu/aizen/tpb.html
Theory of Planned Behavior
This is part of the Website of Dr. Icek Ajzen, creator of the theory of planned behavior.
The site provides great detail about the theory, as well as sample questionnaires to show
how data can be collected using this theory.
5. http://cancercontrol.cancer.gov/brp/constructs/index.html
Cancer Control and Population Sciences, National Cancer Institute (NCI)
This page at the NCI’s Cancer Control and Population Sciences Website presents
definitions, background information, references, published examples, and information
about the best measures of a number of theoretical constructs used in health promotion
practice and research.

http://web.uri.edu/cprc/about-ttm/

http://www.cdc.gov/Violenceprevention/overview/social-ecologicalmodel.html

http://sbccimplementationkits.org/demandrmnch/ikitresources

http://people.umass.edu/aizen/tpb.html

http://cancercontrol.cancer.gov/brp/constructs/index.html

191
Once the goals and objectives have been developed, planners need to decide on the
most appropriate means of reaching or attaining those goals and objectives. The planners must
adopt, adapt, or design an activity or set of activities that would permit the most effective (leads
8
Chapter Interventions
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁⦁ Define the word intervention and apply it to a
health promotion setting.
⦁⦁ Provide a rationale for selecting an intervention
strategy.
⦁⦁ Explain the advantages of using a combination
of several intervention strategies rather than a
single intervention strategy.
⦁⦁ List and explain the different categories of
intervention strategies.
⦁⦁ Briefly explain motivational interviewing.
⦁⦁ Explain the terms curriculum, scope, sequence,
units of study, lessons, lesson plans, health
advocacy, health literacy, and health numeracy.
⦁⦁ Briefly explain the modified framework for
instructional design.
⦁⦁ Explain how behavioral economics might shape
incentives.
⦁⦁ Explain the difference between adopting and
adapting an evidence-based intervention.
⦁⦁ Describe how to adapt an evidence-based
intervention.
⦁⦁ Create a new intervention for a health
promotion program.
Key Terms
behavioral economics
best experience
best practices
best processes
built environment
communication
channel
community advocacy
community building
community
organization
contest
contingencies
contract
cultural audit
culturally sensitive
curriculum
disincentives
dose
GINA
health advocacy
health communication
health literacy
health numeracy
incentive
intervention
lessons
lesson plan
literacy
motivational
interviewing
multiplicity
numeracy
penetration rate
scope
segmenting
sequence
social media
strategy
tailoring
unit plans

192 Part 1 Planning a Health Promotion Program
to desired outcome) and efficient (uses resources in a responsible manner) achievement of the
outcomes stated in the goals and objectives. These planned activities make up the intervention, or
what some refer to as treatment. When applied to the planning of health promotion programs,
an intervention can be defined as the planned actions that are designed to prevent disease or
injury or promote health in the priority population. For example, let’s say that you want the
employees of Company S to increase their use of safety belts while riding in company-owned
vehicles. You can measure their safety belt use before doing anything else, by observing them
driving out of the motor pool. This would be a pre-program measure. Then you can intervene in
a variety of ways. For example, you could provide an incentive by stating that all employees seen
wearing their safety belts would receive a $10 bonus in their next paycheck. Or you could put in
each employee’s pay envelope a pamphlet on the importance of wearing safety belts. You could
institute a company policy requiring all employees to wear safety belts while driving company-
owned vehicles. Each of these activities for getting employees to increase their use of safety belts
would be considered part of an intervention. After the intervention, you would complete a post-
program measurement of safety belt use to determine the success of the program. In the case of
the example just given, health education specialists could use an incentive by itself and call it an
intervention, or they could use an incentive, pamphlets, and a company policy all at the same
time to increase safety belt use and refer to the combination as an intervention.
The above discussion about the number of activities that make up an intervention in part
speaks to the size of an intervention. Two terms that relate to the size of an intervention are
multiplicity and dose. Multiplicity refers to the number of components or activities that make
up the intervention. We have known for a number of years (Erfurt et al., 1990; Kline & Huff,
1999; Shea & Basch, 1990) that interventions that include several activities are more likely to
have an effect on the priority population than are those that consist of a single activity. What
has become more apparent in recent years is that these intervention activities are more likely to
be effective if they are aimed at multiple levels of influence that affect individuals’ and popula-
tions’ behaviors and health status (Glanz & Bishop, 2010). In other words, they have a greater
chance of being successful if they use a socio-ecological approach. Some refer to this as a systems
approach. Few people change their behavior based on a single exposure; instead, multiple ex-
posures are generally needed to change most behaviors. It stands to reason that “hitting” the
priority population at multiple levels or through multiple means should increase the chances of
making an impact. Although research has shown that using several activities is better than one,
it has not identified an exact number of activities or a specific combination of activities that will
ensure the most effective results (Kline & Huff, 1999). The right combination of activities will
depend on the needs of those in the priority population and the specific planning situation.
When speaking about the dose of an intervention, we are referring to the number of pro-
gram units delivered. For example, say that it was decided that the intervention for a skin cancer
program would consist of multiple activities (multiplicity) and those activities would include an
educational class for the public, distribution of text messages to those at high risk, and radio
and television public service announcements (PSAs). The dose questions related to these activi-
ties would be: How many times would the class be offered? How many text messages would be
distributed? And, how many times would the PSAs run? Again, like multiplicity, we know that
the greater the dose of an intervention, the greater the chance for change. (Chapter 14 includes
additional information about multiplicity and dose as they relate to process evaluation.)
Box 8.1 identifies the responsibilities and competencies for health education specialists
that pertain to the material presented in this chapter.

Chapter 8 Interventions 193
Types of Intervention Strategies
As mentioned earlier, there are many different types of activities that planners can use as
part of an intervention. Most activities can be placed in larger categories called strategies. By
strategy, we mean “a general plan of action for affecting a health problem” (CDC, 2003, glos-
sary). Here, we present several categories of intervention strategies based on a modification of
the Centers for Disease Control and Prevention’s (2003) terminology for intervention strate-
gies. These categories cover the more common strategies used by planners, but in actuality
the variety of strategies is limited only by the planners’ imagination. Irrespective of the types
of strategies used, health education specialists should seek to use strategies that are evidence-
based. Note that the categories presented here are not always mutually exclusive—that is,
some of the examples that we use to help explain the strategies could be used in more than
one category. Even with this limitation, the strategies have been categorized into the follow-
ing seven groups:
1. Health communication strategies
2. Health education strategies
8.1
Responsibilities and Competencies for Health Education Specialists
The content of this chapter focuses on the creation or adaptation of the intervention
that will be used in the program. The intervention is really the heart of a program. It is
the component of the program that will cause the change in the priority population. The
responsibilities and competencies related to the tasks of creating an intervention include:
RESponSiBility i: Assess Needs, Resources, and Capacity for Health Education/
Promotion
Competency 1.6: Examine factors that enhance or impede the
process of health education/promotion
RESponSiBility ii: Plan Health Education/Promotion
Competency 2.3: Select or design strategies/interventions
Competency 2.4: Develop a plan for the delivery of health education/
promotion
RESponSiBility Vi: Serve as a Health Education/Promotion Resource Person
Competency 6.2: Train others to use health education/promotion
skills
RESponSiBility Vii: Communicate, Promote, and Advocate for Health, Health Education/
Promotion, and the Profession
Competency 7.1: Identify, develop, and deliver messages using a
variety of communication strategies, methods, and techniques.
Competency 7.2: Engage in advocacy for health education/promotion
Competency 7.3: Influence policy and/or systems change to promote
health education
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing,
Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education
Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE).
Box

194 Part 1 Planning a Health Promotion Program
3. Health policy/enforcement strategies
4. Environmental change strategies
5. Health-related community service strategies
6. Community mobilization strategies
7. Other strategies
Health Communication Strategies
Health communication has been defined as “the study and use of communication
strategies to inform and influence individual and community decisions that affect health”
(USDHHS, 2015a, para. 1). It can also be defined by the form it takes in health promotion
programs (e.g., mass media, media advocacy, risk communication, public relations, enter-
tainment education, print material, electronic communication). Of the various interven-
tion strategies used in health promotion, we present health communication strategies first
for several reasons. First, almost all health promotion interventions include some form of
communication ranging from simple, such as speaking and listening, to the more complex
communication campaigns delivered through various forms of media. Second, communica-
tion strategies are useful in reaching many of the goals and objectives of health promotion
programs. They have been shown to create awareness of an issue, change attitudes toward a
health behavior, encourage and motivate individuals to follow recommended health behav-
iors, reinforce attitude and behavior change, increase demand and support for services, and
build social norms (Ammary-Risch, Zambon, & Brown, 2010; NCI, n.d.). Third, communica-
tion strategies probably have the highest penetration rate (number in the priority popu-
lation exposed or reached) of any of the intervention strategies. And fourth, they are much
more cost effective and less threatening than most other types of strategies. But be aware that
health communication also has its limitations. For example, health communication alone is
rarely sufficient to change behavior and reduce the risk of disease.
Although communication has always been an important strategy in health promotion
programs, the means by which communication takes place has changed. In the traditional
communication model, a sender relays a message through a channel to receivers (i.e.,
consumers)—a vertical or top-down process. In such a model, the sender is the gatekeeper
of the information, while the consumers play a less active, almost passive, role in receiving
the message (Thackeray & Neiger, 2009). An example is when a health department posts
information on its Website for public consumption. However, with the enhanced capabili-
ties of the Internet and the development of other emerging communication technologies,
the means of delivering health communications have been greatly expanded and blurred
the strict roles of the sender and receiver. With the new technology has come a new commu-
nication model: the multidirectional communication (MDC) model (Thackeray & Neiger,
2009) (see Figure 8.1). In the MDC model, communication occurs through a combination
of: (1) sender top-down (vertical) messages, (2) consumer created bottom-up messages, (3)
consumer shared horizontal (side-to-side) messages, and (4) consumers seeking information.
Thus in the MDC model consumers not only receive information but also actively seek, de-
velop, and share information (Thackeray & Neiger, 2009).
An underlying concept of the MDC model is that the sophistication with which health
information is communicated has changed dramatically in recent years due in large part to

Chapter 8 Interventions 195
new technology. To compete for the attention and participation of consumers, those who
plan health promotion programs must either develop a working knowledge of these com-
munication technologies or have the foresight to access those who can provide the necessary
expertise. A key characteristic of effective health communication campaigns is that they are
people- (or audience-) centered (Schiavo, 2014). This requires that planners understand con-
sumer tendencies, needs, and preferences before designing campaigns and messages.
There are literally hundreds of communication activities that could be used with a health
communication strategy. Communication channels is one way to subdivide these activities.
A communication channel is the route through which a message is disseminated to the
priority population. “Understanding communication channels is imperative to conducting
strategic, effective and user-centric health interventions, campaigns and outreach” (CDC,
2014b, para. 1). Selecting appropriate channels for a priority population is often related to,
or in some cases limited by, the setting where the communication will be delivered (Kreps,
Barnes, Neiger, & Thackeray, 2009). “For example, if the home is identified as the prime
Tradition
al
m
ed
ia
c
ha
n
n
e
ls
New media channels
Horizontal side-to-side
information sharing
Informationseeking
Bottom-
up
user-
generated
messages
Vertical
expert-
generated
messages
Consumer
⦁▲ Figure 8.1 A Multidirectional Communication Model
Source: Thackeray, R., & Neiger, B. L. (2009). A multidirectional communication model: Implications for social marketing practice. Health
Promotion Practice, 10(2), 171–175. © 2009 Sage Publications.

196 Part 1 Planning a Health Promotion Program
setting, appropriate channels could include one-on-one home visits, technology via the tele-
phone, or mass media via television or radio” (Kreps et al., 2009, p. 91). The four traditional
communication channels include intrapersonal (one-on-one communication), interper-
sonal (small group communication), organization and community, and mass media. These
channels are hierarchical in nature with regards to the number of people they reach. The
intrapersonal channel typically reaches the fewest number of people, while the mass media
channel reaches the largest number of people.
Because of the Internet and the other emerging technologies we are adding social media as
a fifth communication channel. Social media, or interactive media, is an overarching term
for any type of media that uses the Internet and other technologies to enhance social inter-
action for sharing and discussing information. Unlike the other four communication chan-
nels, social media does not have a set place in the hierarchy because it “cuts across” several
different levels. That is, depending on the type and purpose of social media, it can be used to
generate social interaction at any of the levels of the traditional communication channel hi-
erarchy. After we address each of the four traditional communication channels found in the
hierarchy, we will present information on social media.
Over the years, the intrapersonal channel has most often been used, but by no means exclu-
sively, in health care settings when the health care provider and patient interact. This is a fa-
miliar channel for most people and one they trust. It is typically an effective communication
channel, but it is also typically the most time and resource intensive channel for the number
of people reached. This is especially true when the health communication messages have
some level of personal relevance. Means of creating personal relevance in a message include
personalizing (i.e., placing the recipient’s name on/in the communication), targeting (i.e., pro-
viding standardized information to a segmented group like Asian American adolescent girls),
or tailoring it for the recipient. Tailoring has been defined as “any combination of informa-
tion or change strategies intended to reach one specific person, based upon characteristics
that are unique to that person, related to the outcome of interest, and have been derived
from an individual assessment” (Kreuter & Skinner, 2000, p. 1). Tailoring takes more effort
and resources than personalizing or targeting communication because it requires obtaining in-
dividual information on each member of the priority population (Kreuter, Farrell, Olevitch,
& Brennan, 1999; Schmid, Rivers, Latimer, & Salovey, 2008; Suggs & McIntyre, 2009).
Tailoring is best for helping to change complex behaviors, targeting is best when behavior is
relatively simple (e.g., a one time behavior like getting a vaccination) (Schmid et al., 2008),
while personalizing a message helps to get an individual’s attention.
In more recent years, the tailoring of intrapersonal communication has been greatly en-
hanced by the use of technology. Tailoring of messages has been used with electronic mail
messages (Kreuter et al., 1999) and with information delivered through Websites (Suggs &
McIntyre, 2009). Another example involves the use of telephones. Although most people no
longer think of the telephone, when it is used to talk with another person, as “technology,” it
too is used for health promotion interventions via the intrapersonal channel. Planners have
used it for “gathering information, disseminating information, providing health education
and counseling, promoting health education programs, offering cues to action and social
support” (Soet & Basch, 1997, p.  760) on a variety of health topics ranging from asthma
management (e.g., Raju, Soni, Aziz, Tiemstra, & Hasnain, 2012), to diabetes and hyperten-
sion (e.g., Goode et al., 2011), to weight management (e.g., Terry, Seaverson, Grossmeier, &
Anderson, 2011). Health education delivered by telephone “can be classified into two broad

Chapter 8 Interventions 197
categories: individual initiated, whereby the individual must actively seek contact and as-
sistance from a health information hotline; and outreach, whereby the individual is called”
(Soet & Basch, 1997, p. 760). Individual-initiated health information hotlines or help lines
usually provide information, and sometimes education and counseling, whereas outreach
activities range from brief, one-time preappointment reminders to long-term interactive pro-
fessional health counseling (Soet & Basch, 1997) or coaching. Soet and Basch (1997) present
a generic process for developing a telephone intervention activity that includes: (a) design-
ing the intervention protocol, (b) selecting and training those delivering the intervention,
and (c) developing the documentation and data collection protocol.
Within the intrapersonal channel, one health communication activity in particular that
has received much attention is health coaching. Health coaching is the process by which a
trained health coach, using the results from some type of personal health assessment (e.g.,
health risk appraisal), assists a client/consumer in identifying health-enhancing goals and uses
behavioral psychology principles to help motivate the client to work toward the goals. This
confidential communication relationship often takes place via a series of telephone conversa-
tions but can be conducted in face-to-face sessions. There are a number of commercial com-
panies that offer health coaching services. Such services have been used as part of employee
health promotion programs for a number of years (e.g., Chapman, Lesch, & Baun, 2007;
Harris, Hannon, Beresford, Linnan, & McLellan, 2014) to help enhance employee health and
reduce health care costs, and more recently in clinical settings to assist patients with health
behavior change and management of chronic diseases (e.g., Willard-Grace et al., 2015).
A technique that is often used in health coaching is motivational interviewing. Motivational
interviewing (MI) “is a collaborative, person-centered form of guiding to elicit and
strengthen motivation for change (Miller & Rollnick, 2009, p. 137). Miller (1983) first used
MI with individuals who had drinking problems. Since that time it has been used to help indi-
viduals with a wide variety of health problems in which a behavior change was needed (Rubak,
Sandbaek, Lauritzen, & Christensen, 2005). At the heart of MI is helping a person explore and
resolve the ambivalence associated with behavior change. “The operational assumption in MI
is that ambivalent attitudes or lack of resolve is the primary obstacle to behavioral change, so
that the examination and resolution of ambivalence becomes its key goal” (SAMHSA, 2015,
para. 1). MI is not a process where a trained professional “gives advice” or “tells a person what
to do,” but rather is a process in which the trained professional helps guide an individual to
identify internal motivation for change. Box 8.2 presents the four principles of MI.
Examples of the interpersonal channel are support groups and small classes. This channel
has many of the same characteristics of the intrapersonal channel, but reaches larger num-
bers of people with fewer resources.
Many people receive a lot of information through organization and community channels.
Often health promotion programs have priority populations that are part of or entirely
comprise already existing groups (e.g., workers of a particular company, social groups, or
members of a religious organization), or who may participate in a community activity. As such,
organizational and community channels provide excellent ways to reach priority populations.
Thus church bulletins, company or agency newsletters, organizations or community bulletin
boards, and community activities are often used as a part of communication activities.
Probably the most visible communication channel to most people is the mass media chan-
nel. Mass media interventions can seek to influence people either directly or indirectly. When
done directly the intervention identifies a problem of concern and targets the people who can

198 Part 1 Planning a Health Promotion Program
8.2
Box principles of Motivational interviewing
The four principles of MI are presented below. Each is followed by bulleted points that
provide more detail about the principle and an example application of the principle. Note:
The participant is the person who could benefit from a behavior change and the trained
professional is the one providing the motivational interviewing.
Principle 1: Express Empathy – Expressing empathy towards a participant shows
acceptance and increases the chance of the trained professional and the
participant developing a rapport.
⦁⦁ Acceptance enhances self-esteem and facilitates change.
⦁⦁ Skillful reflective listening is fundamental.
⦁⦁ Ambivalence is normal.
— Example statement from the trained professional: “I understand that is has been
difficult for you to quit smoking. Many people with whom I work find this to be difficult.
It is still important for us to try to identify ways for you to work on this. What do you
think you can do to stop smoking?”
Principle 2: Develop Discrepancy – Developing discrepancy enables a participant to see
that his/her present situation does not necessarily fit into his/her values and
what he/she would like in the future.
⦁⦁ The participant rather than the trained professional should present the
arguments for change.
⦁⦁ Change is motivated by a perceived discrepancy between present
behavior and important personal goals and values.
— Example statement from the trained professional: “You have told me that you would
like to feel better. I think you know quitting will improve your health. Why do you think
it has been hard for you to quit once and for all?”
Principle 3: Roll with Resistance – Rolling with resistance prevents a breakdown in
communication between a participant and a trained professional and allows
the participant to explore his/her views.
⦁⦁ Avoid arguing for change.
⦁⦁ Do not directly oppose resistance.
⦁⦁ New perspectives are offered but not imposed.
⦁⦁ The participant is a primary resource in finding answers and solutions.
⦁⦁ Resistance is a signal for the trained professional to respond differently.
— Example statement from the trained professional: I know you have tried to quit “cold turkey”
in the past, would you like to know how some others have been successful at quitting?,
Principle 4: Support Self-Efficacy
⦁⦁ Self-efficacy is a crucial component to facilitating change. If a participant
believes that he/she has the ability to change, the likelihood of change
occurring is greatly increased.
⦁⦁ A participant’s belief in the possibility of change is an important motivator.
⦁⦁ The participant, not the trained professional, is responsible for choosing
and carrying out change.
⦁⦁ The trained professional’s own belief in the participant’s ability to change
becomes a self-fulfilling prophecy.
— Example statement from the trained professional: “I know that it must seem like an
impossible task to stop smoking, but now that we have discussed some options that
have helped others stop, which ones do you think might work for you?
Source: Adapted from United States Department of Agriculture (n.d.).
Fo
cu
s
O
n

Chapter 8 Interventions 199
change it while, when it is done indirectly, the interventions seek to influence people by creat-
ing beneficial changes in the places or environments (e.g., homes, schools, worksites, roads,
grocery stores, cities) in which people live and work (Abroms & Maibach, 2008). For example,
to increase the number of children who are immunized properly a direct mass media interven-
tion would target the parents/guardians of the children. A mass media intervention to counter
the advertising of unhealthy foods and drinks in a specific neighborhood would be an exam-
ple of indirect mass media intervention. The mass media channel includes both print and elec-
tronic (e.g., distribution via the Internet) formats, such as billboards; direct mail; daily papers
with national or local circulation; local weekly newspapers; local, public, and network televi-
sion, including cable television; public and commercial radio stations; and magazines with
either a broad readership or a narrow focus. There are many ways to convey a message using
the mass media. These include news coverage, public affairs coverage, talk shows, public ser-
vice roundtables, entertainment, public service announcements (PSAs), paid advertisements,
editorials, letters to the editor, comic strips, and columnists’ commentaries (Arkin, 1990).
With the growth of and the developments in technology, the social media channel has
significantly changed the way people communicate both formally and informally. Social
media, sometimes referred to as interactive media or Web 2.0, has several characteristics that
set it apart from the other communication channels already discussed. The unique character-
istics of social media include 1) it is user or consumer generated, organized, and distributed;
(2) information can be revised or updated almost immediately; (3) it is typically low cost in
terms of creation and maintenance; (4) it can reach broader, more diverse audiences, and (5)
it is generally entertaining to use. There are many different forms of social media that allow
for content management (collaborative writing, e.g., wikis), content sharing (e.g., podcasts,
Webinars, widgets, eCards), social bookmarking (i.e., tagging, saving, searching, and rating
Websites, e.g., Digg), social gaming, social journaling (e.g., blogs), social networking (e.g.,
Facebook, MySpace, LinkedIn, Twitter, text messaging), social news (i.e., tagging, voting
for, and commenting on news articles, e.g., Newsvine), social video and photo sharing (e.g.,
YouTube, Flickr), and syndication (e.g., real simple syndication [RSS] feeds).
Though the use of social media in health promotion interventions may be limited only
by planners’ creativity, we feel that its greatest potential lies in three uses: (1) the Internet as
a platform to deliver behavior change interventions (e.g., weight loss programs; see Bennett
& Glasgow, 2009); (2) the Internet to promote health promotion programs (e.g., viral mar-
keting; see Thackeray, Neiger, Hanson, & McKenzie, 2008); and (3) the Internet and mobile
devices for community mobilization or advocacy (e.g., organizing youth to get involved in
civic affairs; see Thackeray & Hunter, 2010). However, as with other channels of communica-
tion, when using social media planners need to think strategically about what they are trying
to accomplish and then decide how to use technology to accomplish the program’s goals.
In other words, planners need to focus on the relationship between themselves and those in
the priority population, and the ways people connect with each other, because social media
is really all about developing relationships. Thackeray and Bennion (2009) have adapted the
strategic thinking acronym POST, found in a book by Li and Bernoff (2008), to assist program
planners in creating health promotion interventions that include social media (see table 8.1).
The CDC has created two publications that provide information about and best practices
for the use of social media. They include: CDC’s Guide to Writing Social Media (CDC, 2012a)
and The Health Communicator’s Social Media Toolkit (CDC, 2011b). (Note: See the references
for location of these publications.)

200 Part 1 Planning a Health Promotion Program
Regardless of the communication channel used in creating a communication intervention,
planners need to consider the literacy level of those in the priority population. Literacy “is
the ability to use printed and written information to function in society, to achieve one’s goals,
and to develop one’s knowledge and potential” (White & Dillow, 2005, p. 4). “Literacy can be
thought of as currency in this society. Just as adults with little money have difficulty meeting
their basic needs, those with limited literacy skills are likely to find it more challenging to pursue
their goals—whether these involve job advancement, consumer decision making, citizenship,
or other aspects of their lives” (Kirsch, Jungeblut, Jenkins, & Kolstad, 1993, p. xix). The last na-
tional assessment of adult literacy in the United States was conducted in 2003. That study, called
the National Assessment of Adult Literacy (NAAL), assessed a representative sample of over
19,000 adults age 16 and older on prose (the knowledge and skills to perform prose tasks such as
reading and comprehending a news story), document (the knowledge and skills to perform docu-
ment tasks such as completing a job application), and quantitative literacy, sometimes referred
to as numeracy (the knowledge and skills to perform quantitative tasks such as balancing a
checkbook or calculating a tip) (USDE, n.d.). Results of the 2003 NAAL were reported using four
literacy levels: below basic (indicates no more than the most simple and concrete literacy skills,
e.g., searching a short, simple text to find out when to show up for an appointment), basic (skills
necessary to perform simple and everyday literacy activities, e.g., finding specific information
in a pamphlet), intermediate (skills necessary to perform moderately challenging literacy activi-
ties, e.g., consulting reference materials to determine which foods contain a particular vitamin),
and proficient (skills necessary to perform more complex and challenging literacy activities, e.g.,
comparing viewpoints in two editorials). Figure 8.2 provides a comparison of the percentage of
adults in each literacy level for the two most recent national literacy assessments.
The 2003 NAAL included the first-ever national health literacy assessment of adults in the
United States. The health literacy scale used in the assessment and the tasks that the adults
were asked to perform were guided by the following definition of health literacy: “the
capacity to obtain, process, and understand basic health information and services to make
appropriate health decisions” (USDHHS, 2015b, para 1).
Like the general literacy assessment, health literacy results from the NAAL were reported
using the same four literacy categories: below basic, basic, intermediate, and proficient. The re-
sults showed that 14% had below basic health literacy, 22% had basic health literacy, 53% had
intermediate health literacy, and 12% had proficient health literacy (Kutner, Greenberg, Jin, &
Paulsen, 2006). Stated a bit differently, this study showed that “nearly 9 out of 10 adults have
TAble 8.1 Using POST to Think Strategically About Social Media
PoST Li & Bernoff (2008) Thackeray & Bennion (2009)
People What are they ready for? What technology do they use? Why?
objectives Why do you want to pursue the
groundswell?
What do you want to happen (i.e., a
change in attitudes, knowledge, and/or
behavior)?
Strategy How do you want relationships to change
(e.g., customers to carry your messages;
customers to become engaged)?
How will you use the marketing mix (i.e.,
product, price, place, promotion)?
Technology What technology to use? What technology will you use, given what
you are trying to accomplish?

Chapter 8 Interventions 201
difficulty using the everyday health information that is routinely available in our health care
facilities, retail outlets, media, and communities” (USDHHS, 2010, p. 1). Though the problem
of limited health literacy affects people of all ages, races, incomes, and education levels, it dis-
proportionately affects lower socioeconomic and minority groups (Kutner et al., 2006).
Though the NAAL assessment of health literacy included a quantitative component,
in recent years health numeracy has emerged as a separate and important issue (Golbeck,
Ahlers-Schmidt, Paschal, & Dismuke, 2005). As with health literacy, health numeracy is not
at the levels it should be and may have a significant impact on health status (Estrada, Martin-
Hryniewicz, Peek, Collins, & Byrd, 2004). Health numeracy has been defined as “the degree
to which individuals have the capacity to access, process, interpret, communicate, and act on
numerical, quantitative, graphical, biostatistical, and probabilistic health information needed
to make effective health decisions” (Golbeck et al., 2005, p. 375). This definition recognizes
that there are degrees of health numeracy that fall along a continuum, and “that health nu-
meracy is not simply about understanding (processing and interpreting), but also functioning
(communicating and acting) on numeric concepts in terms of health” (Golbeck et al., 2005,
p. 375). Further, Golbeck and her colleagues (2005) suggested that health numeracy consists
of four skills: basic (e.g., counting the number of pills), computational (e.g., determining the
number of calories consumed using a nutritional label), analytical (e.g., determining if test
results are in the normal range), and statistical (e.g., determine risk with probability).
Because of the lack of health literacy and health numeracy in the United States, health
education specialists need to work to ensure that the health communication interventions
are appropriate for their priority population and consistent with the National Action Plan
to Improve Health Literacy (USDHHS, 2010). The CDC has created a publication–Simply Put:
⦁▲ Figure 8.2 Percentage of Adults in each literacy level: 1992 and 2003
Source: White & Dillow (2005). White, S., & Dillow, S. (2005). Key concepts and features of the 2003 National Assessment of Adult Literacy
(NCES 2006-471). Washington, DC: National Center for Education Statistics, U.S. Department of Education.
70 60 50 40 30 20 10 0 10 20 30 40 50 60 70 80 90 100
14 28 42
44
49
58∗
29
22
22
14
14
12∗
22∗
26 32
33 33∗
30
Literacy scale
and year
Prose
1992
2003
Document
1992
2003
Quantitative
1992
2003
Percent below basic Percent basic above
Below basic Basic Intermediate Proficient
15
15
13∗
13∗
13
13
*Significantly different from 1992
Note: Detail may not sum to totals because of rounding. Adults are defined as people 16 years of age and older living in households or
prisons. Adults who could not be interviewed due to language spoken or cognitive or mental disabilities (3 percent in 2003 and 4 percent in
1992) are excluded from this figure.

202 Part 1 Planning a Health Promotion Program
A guide for creating easy-to-understand materials (CDC, 2009a) (Note: See the references for
location of this publication.)– that provides many useful ideas for creating health commu-
nication materials.
As noted in the Simply Put (CDC, 2009a) document, making sure written materials are
presented at the appropriate reading level for the priority population is an important con-
cept. Americans, on average, read at the 7th grade reading level (Mishoe, 2008). Therefore,
when writing for the general public you should try to write at the 6th grade reading level.
Reading levels can be checked using a readability test such as, the Fog-Gunning Index,
Flesch-Kincaid Grade Level Readability Formula, the Fry Readability Formula, or the
SMOG (stands for Simple Measure of Gobbledegook). Today many computer word-pro-
cessing programs include a tool that can be used to check the reading level. In case yours
does not, Box 8.3 presents the steps in the process of testing readability using the SMOG.
the SMoG Readability Formula
To calculate the SMOG reading grade level, begin with the entire written work that is
being assessed, and follow these four steps:
1. Count off 10 consecutive sentences near the beginning, in the middle, and near the
end of the text.
2. From this sample of 30 sentences, circle all of the words containing 3 or more syllables
(polysyllabic), including repetitions of the same word, and total the number of words
circled.
3. Estimate the square root of the total number of polysyllabic words counted. This is
done by finding the nearest perfect square, and taking its square root.
4. Finally, add a constant of 3 to the square root. This number gives the SMOG grade,
or the reading grade level that a person must have reached if he or she is to fully
understand the text being assessed.
A few additional guidelines will help to clarify these directions:
⦁⦁ A sentence is defined as a string of words punctuated with a period (.), an exclamation
point (!), or a question mark (?).
⦁⦁ Hyphenated words are considered as one word.
⦁⦁ Numbers that are written out should also be considered, and if in numeric form in the
text, they should be pronounced to determine if they are polysyllabic.
⦁⦁ Proper nouns, if polysyllabic, should be counted, too.
⦁⦁ Abbreviations should be read as unabbreviated to determine if they are polysyllabic.
Not all pamphlets, fact sheets, or other printed materials contain 30 sentences. To test
a text that has fewer than 30 sentences:
1. Count all of the polysyllabic words in the text.
2. Count the number of sentences.
3. Find the average number of polysyllabic words per sentence as follows:
Average =
Total # polysyllabic words
Total # of sentences
4. Multiply that average by the number of sentences short of 30.
A
pp
lic
at
io
n
8.3
Box
Source: The SMOG Readability Formula from “SMOG grading—a new reading formula” by H.G. McLaughlin, The Journal of Reading 12, 639-646.
Copyright © 1969 by John Wiley & Sons. Reprinted with permission.

Chapter 8 Interventions 203
Health Education Strategies
Earlier (Chapter 1) health education was defined as “any planned combination of learning
experiences designed to predispose, enable, and reinforce voluntary behavior decisions con-
ducive to health in individuals, groups, or communities” (Green & Kreuter, 2005, p. G-4).
You may be asking, “How is this definition different from the definition presented in the
earlier section for health communication strategies?” There are some health communication
strategies, because of the way they are designed, that could be classified as health education
strategies. And, there are some health education strategies that could meet the definition of
health communication strategies. There is no clear dividing line between these two catego-
ries of intervention strategies. That is, they are not mutually exclusive categories. In fact, it
is for this reason that some authors have included health education strategies as part of the
health communication strategies category or vice versa. Yet, we have decided to separate
the two types of strategies. In general, we see health communication strategies as those that
inform people (e.g., a brochure on skin cancer or a mass media campaign on preventing
HIV), while health education strategies are those that are planned learning experiences that
provide knowledge and skills to the learners in a more formal educational setting. We see
SMoG Conversion table*
total polysyllabic
Word Counts
Approximate Grade level
(±1.5 Grades)
0–2 4
3–6 5
7–12 6
13–20 7
21–30 8
31–42 9
43–56 10
57–72 11
73–90 12
91–110 13
111–132 14
133–156 15
157–182 16
183–210 17
211–240 18
*Developed by Harold C. McGraw, Office of Educational Research, Baltimore County
Schools, Towson, Maryland.
5. Add that figure to the total number of polysyllabic words.
6. Find the square root and add the constant of 3.
Perhaps the quickest way to administer the SMOG grading test is by using the SMOG
conversion table. Simply count the number of polysyllabic words in your chain of 30
sentences and look up the appropriate grade level on the chart.
8.3
Box
continued

204 Part 1 Planning a Health Promotion Program
health education strategies as those usually associated with settings such as classes, semi-
nars, workshops, and courses, both face-to-face and online. Some examples include prenatal
classes for expectant parents, a workshop for parents on how to better communicate with
their teenager, or a first aid and CPR course for potential babysitters.
Prior to presenting information about creating health education interventions it is
important to have some background in how people learn. Many theories/models have been
put forth to help explain how people learn. While many of the theories/models include com-
ponents that are unique to the theory/model, there is also much overlap in the content. Space
does not allow for the review of those theories/models here. However, we are fortunate that
other authors (Bryan, Kreuter, & Brownson, 2009; Minelli & Breckon, 2009) have reviewed
those theories/models. Those reviewers have identified many of the common components
and created lists of learning principles. Their lists can help guide planners as they create health
education interventions. We present their lists here. Minelli and Breckon (2009) refer to their
list as the 10 general principles of learning. For them, learning is facilitated: (1) if several of
the senses (e.g., seeing, hearing, speaking) are used; (2) if the learner is actively involved in the
process, rather than a passive participant; (3) if the learner is not distracted by discomfort or
extraneous events; (4) if the learner is ready to learn; (5) if that which is to be learned is rele-
vant to the learner and that relevance is perceived by the learner; (6) if repetition is used; (7) if
the learning encountered is pleasant, if progress occurs that is recognizable by the learner, and
if that learning is recognized and encouraged; (8) if the material to be learned starts with what
is known and proceeds to the unknown, while concurrently moving from simple to complex
concepts; (9) if application of concepts to several settings occurs, which generalizes the mate-
rial; and (10) if it is paced appropriately for the learner.
The principles offered by Bryan and colleagues (2009) are specific to adult learners. The
principles represent a synthesis of recurring themes that the authors found when reviewing
existing theories/models related to adult education. Their adult learning principles include:
1. “Adults need to know why they are learning.
2. Adults are motivated to learn by the need to solve problems.
3. Adults’ previous experience must be respected and built upon.
4. Adults need learning approaches that match their background and diversity.
5. Adults need to be actively involved in the learning process.” (p. 559)
With this brief overview of learning principles, let’s look at the makeup of a health edu-
cation intervention. Though health communication strategies may be the most frequently
used health promotion intervention strategy, health education strategies are the ones that
provide the opportunity for the priority population to gain in-depth knowledge about
a particular health topic. Well-designed health education strategies take an understand-
ing of the educational process and take a great deal of effort to create. In order to better
understand this process, several terms must be defined. The first is the word curriculum.
Curriculum refers to “a planned set of lessons or courses designed to lead to competence
in an area of study” (Gilbert, Sawyer, & McNeill, 2015, p. 437). Examples include the
health education curriculum of a school district or the curriculum for a hospital’s diabe-
tes education program. To further define a curriculum it is important to understand the
terms scope and sequence. Scope refers to the breadth and depth of the material covered in
a curriculum, whereas sequence defines the order in which the material is presented. To

Chapter 8 Interventions 205
Resources & References Content
Introduction:
Conclusion:
Evaluation:
Body:
1.
2.
3.
Teaching Method
Unit: Lesson No.:
Priority Population: Length of Lesson:
Title of Program: Title of Lesson: Page of
⦁▲ Figure 8.3 example lesson Plan Format
further clarify these definitions, scope has been referred to as the horizontal organization
of the substance of the curriculum (Goodlad & Su, 1992), while the sequence is the vertical
relationship among the curricular areas (Ornstein & Hunkins, 1998). It is not unusual for
the scope of a health education curriculum to be presented as unit plans. A unit plan is de-
fined as “an orderly, self-contained collection of activities educationally designed to meet
a set of objectives. Other terms for this are curriculum plans, modules, and strands” (Gilbert
et al., 2015, p. 202). Thus, a school health curriculum may have units on exercise, nutri-
tion, chronic diseases, communicable diseases, and so forth, while the diabetes education
curriculum might include units on self-management, working with a health care profes-
sional, and avoiding emergencies. And finally, units of study are further subdivided into
lessons—the amount of material that can be presented during a single educational en-
counter, say for example the amount of material that can be presented in a one-hour class.
The written outline of a lesson is referred to as a lesson plan and typically includes three
components—introduction, body, and conclusion. The introduction provides an over-
view of what will be covered, the body presents the health content, and the conclusion
reviews what was presented. There is an old saying that summarizes these three parts that
states tell them what you are going to tell them [introduction], tell them it [body], and tell them
what you told them [conclusion]. (See Figure 8.3 for an example lesson plan format.)
The heart of any lesson is the body or the content portion of the lesson. Gagne (1985)
has created a framework, called the Nine Events of Instruction, for designing educational ex-
periences that provides a nice outline for creating the body of a lesson. More recently, Kinzie
(2005) modified Gagne’s framework for application to health promotion applications. The
modified framework includes five stages instead of the original nine created by Gagne: (1)
gain attention (convey health threats and benefits); (2) present stimulus material (target or
tailor the message to audience knowledge and values, demonstrate observable effectiveness,
make behaviors easy to understand and do); (3) provide guidance (use trustworthy models to
demonstrate); (4) elicit performance and provide feedback (to enhance trailability, and develop

206 Part 1 Planning a Health Promotion Program
TAble 8.2 Application Instructional Design Framework for a Lesson on Breast Cancer
Stage Content Covered Method of Presentation
Gain attention • Help participants identify
personal risk to breast cancer
• Use breast cancer risk appraisal
or breast cancer pretest
• Share benefits of doing
breast self-examinations
(BSE), regular breast exams by
physicians, and mammograms
• Present a case study of women
finding a lump in the breast
early
Present stimulus material
Target/tailor message
to knowledge and values
• Using information from
risk appraisal or pretest,
target/tailor breast cancer
information
• Lecture/discussion
Demonstrate
observable
effectiveness
• Explain importance of early
diagnosis
• Use peer educators to
role-play interaction with
physician
Make desired
behaviors easy
to understand
• Present steps in BSE and
making appointment
with physician and for
mammogram
• Use video showing correct
steps for BSE or peer
educators to demonstrate on
models
Provide guidance • Have others share experiences
on how exams are conducted
• Use guest speakers who
perform regular BSE and
radiographers who do
mammograms
Elicit performance and
provide feedback
• Repeat steps in BSE and let
participants practice BSE
• Use breast models for practice
and provide critique
Enhance
retention and transfer
• Encourage participants to
share information learned
with others and ways to
remember to act
• Lecture/discussion
• Brainstorm reminder ideas
• Distribute BSE shower cards
that explain importance
of regular action for
participants to place in their
bathrooms
proficiency and self-efficacy); and (5) enhance retention and transfer (provide social support
and deliver behavioral cues) (Kinzie, 2005). table 8.2 provides an example of how these five
stages can be applied to a health topic.
There are many different ways of presenting health education such as lecture, discussion,
group work, audiovisual materials, computerized instruction, laboratory exercises, and writ-
ten materials (books and periodicals). Box 8.4 provides a more complete listing of educational
activities, and Gilbert et al. (2015) have provided a detailed discussion of these activities.
Health policy/Enforcement Strategies
Health polices/enforcement strategies include executive orders, laws, ordinances, judicial
decisions, policies, regulations, rules, and position statements. Though each of the differ-
ent types of policy/enforcement strategies has its own definition, common to all of them is
a decision made by an authoritative person, agency/organization, or body and that is pre-
sented in a statement or guidelines intended to direct or influence the actions or behaviors

Chapter 8 Interventions 207
8.4
Commonly Used Educational Activities
A. Audiovisual materials and equipment
1. Audiotapes, records, and CDs
2. Bulletin, chalk, cloth, flannel, magnetic, and peg boards
3. Charts, pictures, and posters
4. Films and filmstrips
5. Instructional television
6. Opaque projector or Elmo
7. Slides and slide projectors
8. Transparencies, PowerPoint® slides, and overhead projector
9. Video (DVDs and tapes)
B. Technology-assisted instruction
1. World Wide Web
2. Desktop publishing
3. Photo and video voice
4. Presentation programs
5. Individualized learning programs
6. Video conferencing (e.g., Skype)
7. Social media
C. Printed educational materials
1. Displays and bulletin boards
2. Instructor-made handouts and worksheets
3. Pamphlets
4. Study guides (commercial and instructor-made)
5. Text and reference books
6. Workbooks
D. Teaching strategies and techniques for the classroom
1. Brainstorming
2. Case studies
3. Cooperative learning
4. Debates
5. Demonstrations and experiments
6. Discovery or guided discovery
7. Discussion
8. Group discussion
9. Guest speakers
10. Lecture
11. Lecture/discussion
12. Newspaper and magazine articles
13. Panel discussions
14. Peer group teaching/coaching
15. Personal improvement projects
16. Poems, songs, and stories
17. Problem solving
Fo
cu
s
O
n
Box

208 Part 1 Planning a Health Promotion Program
8.4
Box
18. Puppets
19. Questioning
20. Role playing and plays
21. Simulation, games, and puzzles
22. Tutoring
23. Values clarification activities
24. Word games
E. Teaching strategies and techniques for outside of the classroom
1. Community resources
2. Field trips
3. Health fairs
4. Health museums
5. Health education centers
continued
of others. Another way to think about them is as strategies that are mandated or regulated.
Such strategies revolve around establishing some type of standard or requirement, some-
times associated with incentives or disincentives, to encourage or discourage actions by
groups of individuals or society as a whole (Riegelman, 2014). This type of intervention
strategy can regulate the behavior of individuals (e.g., use of safety belts and motorcycle
helmets), organizations (e.g., paying taxes for certain activities), institutions (e.g., school
board adopting a position statement that a district will only provide well-balanced meals
in the cafeteria), or communities (e.g., housing codes for rental properties) (Brennan
Ramirez et al., 2008). This type of intervention strategy can also be used to “affect the built
environment, such as zoning related to new grocery stores or fast food restaurants, mainte-
nance of sidewalks and streetscapes, or architectural design features such as neighborhood
signage addressing the history and culture of the community” (Brennan Ramirez et al.,
2008, p. 70).
Health policy/enforcement strategies may be controversial. Some have criticized this type
of strategy because it mandates a particular response from those governed by it. It takes away
individual freedoms and sometimes plays on a person’s pride, “pocketbook,” and psyche.
Stated a bit differently, “it runs counter to a fundamental emphasis on property rights, eco-
nomic individualism, and competition in American political culture. The exceptionalism
of the United States lies in its antistatist beliefs: Americans are less concerned with what
government will do to benefit individuals than what government might do to control them”
(Oliver, 2006, p. 196). This type of strategy must be based on sound evidence and must be
sold on the basis of “common good.” That is, the justification for this type of societal action
is to protect the public’s health. Health policy/enforcement strategies exist for the protection
of the community and of individual rights. For example, in order to establish herd immunity
most in a population need to be immunized, thus the reasoning behind immunizing chil-
dren prior to entering school.

Chapter 8 Interventions 209
Some would say that health policy/enforcement strategies do not allow for the “voluntary
behavior conducive to health” suggested by Green and Kreuter (2005, p. G-4) in their defini-
tion of health education. But, at the same time, this kind of activity can get people to change
their behavior when other strategies have failed. Brownson, Chriqui, and Stamatakis (2009)
have pointed out that if we review the 10 great public health achievements of the 20th century
(CDC, 1999b), we will find that each of them was influenced by policy. For example, before the
passage of safety belt laws, a national study showed that about 11% of drivers and front-seat
passengers of automobiles were observed using a safety belt (Goodwin et al., 2013). Now that
safety belt laws are in effect, national safety belt use is 86%; in states where the law permits law
enforcement officers to stop and cite a safety belt violator independent of any other traffic be-
havior (i.e., primary enforcement belt use law), usage rates average 90% (Goodwin et al., 2013).
Policymaking is complex and each setting in which policy is created has its own char-
acteristics. For example, a state legislature where a law for smokefree public places is being
debated would have many different characteristics from a boardroom of a private company
where a no smoking policy is being created. Regardless of the setting, Block (2008) has identi-
fied six phases of policymaking—agenda setting, policy formulation, policy adoption, policy
implementation, policy assessment, and policy modification—that we feel can be adapted
and applied to the creation of any of the health policy/enforcement strategies for a health
promotion program. The first phase, agenda setting, deals with determining what the health
problem is, analyzing whether the cause of the problem can best be solved with a policy/
enforcement strategy, and identifying evidence to show that such a strategy will work. Phase
2, policy formulation, is the phase in which the policy or mandated action is actually devel-
oped. The actual wording of the policy is not easy work. It is difficult to move from a concept
or idea to wording that effectively carries out the intent of the concept or idea and creates
the most good for the most people. The simplest language possible should be the goal. If the
policy being created is a legal document (e.g., law, ordinance), it is not unusual for various
interest groups to try to influence those writing the document so that the resulting work
best represents their interests. In other words, there are likely to be both pro and con feelings
toward the policy and thus this phase can be very political. The third phase, policy adoption or
approval, takes place when the authoritative individual or group “approves” the formulated
policy. Again, depending on the policy being considered, politics can impact the outcome.
Once the policy has been approved it must be implemented. This is the fourth phase of
the process. In this phase, the necessary human and financial resources must be assembled
to make the policy work. As a part of this phase, it is important that those who are imple-
menting the new policy use good judgment and show respect for others when doing so.
Depending on the policy and its complexity there may be a need for education programs to
ensure that the priority population understands the policy. Consideration may also need to
be given to the enforcement of the policy. The fifth phase of the process, policy assessment,
entails making sure that the policy is being carried out as written and that it is indeed work-
ing to solve the problem it was intended to solve. Based on the results of the policy assess-
ment, the authoritative individual or group must consider the sixth and final phase—policy
modification. In this phase some judgment and possible action must be made to determine
whether the policy should be maintained, modified, or eliminated (Dunn, 1994). Box 8.5
provides a list of questions that need to be considered when determining whether or not
policy should be the or part of the health promotion intervention.

210 Part 1 Planning a Health Promotion Program
Environmental Change Strategies
Another group of strategies that has been used in meeting the goals and objectives of health
promotion programs is environmental change strategies. Such strategies have been most use-
ful in providing “opportunities, support, and cues to help people develop healthier behav-
iors” (Brownson, Haire-Joshu, & Luke, 2006, p. 342). As such, they help remove barriers in
the environment. “Environmental barriers in a community can make modifying unhealthy
behaviors challenging. Poor environmental quality; inadequate access to affordable, nutri-
tious food; and safety issues often make healthy living impractical” (Flores, Davis, & Culross,
2007, para. 4). In other words, environmental change strategies are about creating health-
enhancing environments (Hunnicutt & Leffelman, 2006). In the 1986 Ottawa Charter for
Health Promotion, it was stated that the healthier choice should be the easier choice (WHO,
2009). Friedan (2010) stated it a bit differently when he said that the content of the envi-
ronment should be changed to make healthy options the default choice so that individuals
would have to expend significant effort not to benefit from them. Removing environmental
barriers often helps to make the healthier choice the easier choice.
Environmental change strategies are characterized by changes “around” individuals and
are not limited to the physical environment. Other environments include the economic envi-
ronment (e.g., financial costs, affordability), service environment (e.g., accessibility to health
care or patient education), social environment (e.g., social support, peer pressure), cultural
environment (e.g., traditions of ethnic group), psychological environment (e.g., emotional
learning environment), and political environment (e.g., support for healthy environments).
Environmental change strategies have a close relationship to health policy/enforcement
strategies because there are times when a policy change may be needed to make a change in
the environment, for example a city or county ordinance that creates smokefree workplaces.
Other examples of such strategies include equipping automobiles with safety belts, air bags,
and child safety seats; placing speed bumps in parking lots by playgrounds to slow traffic
where children are present; or installing fire and safety doors in apartment buildings to make
8.5
Questions to Consider When Creating policy
⦁⦁ Is policy the best way to deal with the problem? Is it necessary?
⦁⦁ Is there evidence to show that the proposed policy has the potential to be effective?
⦁⦁ Is the proposed policy based on ethical principles that balance rights, interests, and
values?
⦁⦁ Is the proposed policy stated clearly?
⦁⦁ Will the proposed policy include implementation and enforcement language?
⦁⦁ Is the policy culturally appropriate for the priority population?
⦁⦁ Has a representative group from the priority population been engaged and involved in
the policy making process?
⦁⦁ Is there support for the proposed policy?
⦁⦁ Is there a need for the public to discuss/debate the proposed policy?
⦁⦁ What are the potential barriers to getting the policy enacted, implemented, sustained,
and evaluated? Opposition? Resources? Political climate?
⦁⦁ Would it be useful to phase-in the policy overtime?
Fo
cu
s
O
n
Box

Chapter 8 Interventions 211
them safer for the residents. Often environmental change strategies do not necessarily require
action on the part of the priority population (CDC, 2003) as noted in the examples above. Yet,
some of these strategies provide a “forced choice” situation, as when the selection of foods
and beverages in vending machines or cafeterias are changed to include only healthful foods.
If people want to eat foods from these places, they are forced to eat certain types of foods.
Other activities in this category may provide those in the priority population with health
messages and environmental cues for certain types of behavior. Examples would be post-
ing of no-smoking signs, eliminating ashtrays, providing lockers and showers, using role
modeling by others, playing soft music in a work area, organizing a shuttle service or some
other type of transportation system to get seniors to congregate for meals or to a health care
provider, and providing point-of-purchase education, such as a sign on a vending machine
or food labeling on the food options in the cafeteria.
One “environment” that has received increased attention in recent years is the built en-
vironment. The term built environment “generally refers to an interdisciplinary area of
focus that describes the design, construction, management, and land use of human-made
surroundings as an interrelated whole, as well as their relationship to human activities
over time” (Coupland, Rikhy, Hill, & McNeil, 2011, p. 6). It includes, but is not limited to:
transportation systems (e.g., mass transit); urban design features (e.g., bike paths, sidewalks,
adequate lighting); parks and recreational facilities; land use (e.g., community gardens, loca-
tion of schools, trail development); building with health enhancing features (e.g., green roofs,
stairs); road systems; and housing free from environmental hazards (Coupland et al., 2011;
Davidson, 2015; IOM, 2005). The built environment can be structured to give people more or
fewer opportunities to behave in health enhancing ways. Earlier (see Chapter 4) we discussed
the use of health impact assessments (HIAs) as a special type of needs assessment process “to
determine the potential effects of a proposed policy, plan, program, or project on the health
of a population and the distribution of those effects within the population” (NRC, 2011, p. 5).
Although the major focus of an HIA is to make sure change is not made that could harm the
health of a population, the results of a HIA could also lead to the modifications or additions to
the built environment that provide more opportunities for enhancing health.
Finally, like so many of the other intervention strategies, environmental change strate-
gies often are more effective when combined with intervention strategies from the other
categories. An example of such multiplicity is combining the mandating of safety belts in
automobiles, which is important alone, with strict enforcement of safety belt laws (a health
policy/enforcement strategy), which makes for a much more effective intervention.
Health-Related Community Service Strategies
Health-related community service strategies include services, tests, treatments, or care to
improve the health of those in the priority population (CDC, 2003). Examples of this type
of intervention strategy include, but are not limited to, completing a health risk assessment
(HRA) form (see Chapter 4 for a discussion of HRAs); offering low-cost flu shots or child im-
munizations; providing clinical screenings (sometimes called biometric screenings) for diabe-
tes, blood pressure, or cholesterol; and providing professional health checkups and exami-
nations. Because a health-related community service strategy requires action on the part of
those in the priority population, an important component of this type of strategy is to reduce
the barriers to obtaining the service. Thus planners must be mindful of the affordability and

212 Part 1 Planning a Health Promotion Program
accessibility of such services. Also, planners must weigh the consequences of including this
type of strategy in an intervention. For example, if abnormal readings are found during a
screening, those conducting the screening have an ethical obligation to follow up and make
sure appropriate referrals for care are made. Chapman (2003) has provided a nice review of
many of the concerns associated with biometric screening.
Health-related community service strategies are often carried out by partnering organiza-
tions and are offered in a variety of settings including grocery stores, pharmacies, shopping
malls, health fairs, worksites, personal residencies, mobile units (e.g., vans equipped with
mammography units), and easily accessible health care facilities. Such strategies usually have
high credibility with priority populations because of their link with health care providers.
Community Mobilization Strategies
“Community mobilization strategies involve helping communities identify and take ac-
tion on shared concerns using participatory decision making, and include such methods as
empowerment” (Barnes, Neiger, & Thackeray, 2003, p. 60). There is increasing evidence to
support population-wide, community-level interventions to change health behaviors when
community mobilizing strategies are combined with other strategies (Karwalajtys et al.,
2013). In this book we present two subcategories of community mobilization strategies: (1)
community organization and community building, and (2) community advocacy.
CoMMUnity oRGAnizAtion AnD CoMMUnity BUilDinG
Other than defining the terms community organization and community building, little will be pre-
sented here about these terms because more information is presented elsewhere (Chapter 9).
Community organization has been defined as “the process by which community groups
are helped to identify common problems or change targets, mobilize resources, and develop
and implement strategies to reach their collective goals” (Minkler & Wallerstein, 2012, p. 37).
Community building is “an orientation to practice focused on community, rather than a
strategic framework or approach, and on building capacities, not fixing problems” (Minkler,
2012, p. 10).
CoMMUnity ADVoCACy
Community advocacy is a process in which the people of the community become in-
volved in the institutions and decisions that will have an impact on their lives. It has the
potential for creating more support, keeping people informed, influencing decisions, activat-
ing nonparticipants, improving service, and making people, plans, and programs more re-
sponsive (Checkoway, 1989). Some individuals often confuse or use the words advocacy and
lobbying interchangeably. There is a distinction. Lobbying is when individuals/organizations
attempt to influence a specific piece of pending legislation by contacting elected officials or
their representatives, while advocacy is trying to affect generalized change (e.g., healthier
school lunches) by expressing opinions for or against causes or positions. Community advo-
cacy can have a big impact on social change issues, including those dealing with health. The
community advocacy that deals with health issues is called health advocacy. This type of
advocacy has been defined as “the processes by which the actions of individuals or groups at-
tempt to bring about social, environmental, and/or organizational change on behalf of a par-
ticular health goal, program, interest, or population” (Joint Committee on Health Education
and Promotion Terminology, 2012, p. 17). Galer-Unti, Tappe, and Lachenmayr (2004) have

Chapter 8 Interventions 213
identified seven different ways of advocating for health and health education: (1) influenc-
ing voting behavior, (2) electioneering, (3) direct lobbying, (4) integrating grassroots lob-
bying into direct lobbying efforts, (5) using the Internet, (6) media advocacy—newspaper
letters to the editor and opinion-editorial (op-ed) articles, and (7) media advocacy—acting
as a resource person. They have further organized these seven advocacy strategies in a three-
tiered approach to show the varying levels of involvement in the advocacy process. These
levels and examples of each are presented in table 8.3.
As noted in our earlier discussion of health communication strategies, the Internet and
emerging technologies can be effective means to enhance advocacy efforts. Thackeray and
Hunter (2010) have suggested that cell phones and social networking sites (SNS) on the
Internet can be used for: (1) recruiting people to join the cause, (2) organizing collective ac-
tion, (3) raising awareness and shaping attitudes, (4) raising funds to support the cause, and
(5) communicating with decision makers. While both cell phones and SNS can be used for
these advocacy-related purposes there are advantages and disadvantages to using one over
the other in various situations. table 8.4 outlines the comparative qualities of each.
TAble 8.3 Advocacy Strategies: Good, Better, Best
Source: Galer-Unti, R. A., Tappe, M. K., Lachenmayr, S. (2004). Advocacy 101: Getting Started in Health Education Advocacy. Health Promotion Practice Vol 5(3) pp. 280-288.
Copyright © 2004 by Society for Public Health Education. Reprinted by permission of SAGE Publications, Inc.
Strategy Good Better Best
Voting behavior Register and vote Encourage others to
register and vote
Register others to vote
Electioneering Contribute to the
campaign of a
candidate friendly to
public health and
health education
Campaign for a
candidate friendly to
public health and
health education
Run for office or seek a
political appointment
Direct lobbying Contact a policy maker Meet with your
policy makers
Develop ongoing
relationships with your
policy makers and their
staff
Integrate grassroots
lobbying into direct
lobbying activities
Start a petition drive
to advocate a specific
policy in your local
community
Get on the agenda
for a meeting of a
policy-making body
and provide
testimony
organize a community
coalition to enact changes
that influence health
Use the Internet Use the Internet to
access information
related to health
issues
Build a Webpage that
calls attention to a
specific health issue,
policy, or legislative
proposal
Teach others to use
the Internet for
advocacy activities
Media advocacy:
Newspaper letters to
the editor and op-ed
articles
Write a letter to the
editor
Write an op-ed piece Teach others to write
letters and op-ed
pieces for media
advocacy
Media advocacy:
Acting as a resource
person
Respond to requests by
members of the media
for health-related
information
Issue a news release Develop and
maintain ongoing
relationships
with the media
personnel

214 Part 1 Planning a Health Promotion Program
TAble 8.4 Comparative Qualities of Social Networking Sites and Cell Phones in Advocacy
Source: “Empowering Youth: Use of Technology in Advocacy to Affect Social Change.” R. Thackeray and M. Hunter, from the Journal of Computer–Mediated Communication,
Volume 15, pp. 575–591. Copyright © 2010 by John Wiley & Sons, Inc. Reprinted with permission.
Technology Advantages for Advocacy Disadvantages for Advocacy
Social Networking Sites Message sent on SNS can be
stored indefinitely
Not all advocates may be able to
attend in-person events because
of geographic distances inherent
in an online community
Easy to invite friends and fans to
join the advocacy cause
older decision makers may not give
as much credence to this form of
communication
Can organize events and post
specifics about location, time,
and purpose
Requires Internet access
Reach a large number of people
quickly
one central location for advocates
to find information about the
advocacy cause
Can post videos or photos
Unlimited space to post
information
Can update posts from a
Web-enabled cell phone or
mobile device
Can check posts from a
Web-enabled cell phone or
mobile device
Cell Phones Reach a large number of people
quickly in real-time
A text or video message may be
quickly erased
Text or video message will be
received immediately
Decision makers may not be able
to answer the phone when in a
meeting
Can use phones to take photos Have to limit messages to 160
characters
Decision maker can read a text
message while in a meeting
Advocates’ cell phone calling plans
may be limited by the number of
text messages they can send
Can be used to send quick, brief
reminders of events
Not all advocates may own a cell
phone
No need for Internet access Cell phone numbers may be
changed and contact with
advocates is lost.
Can talk to the other individual in
person.
Can forward text or video messages
to friends and other advocates

Chapter 8 Interventions 215
For planners interested in improving their knowledge and skills related to community
advocacy activities, the Society for Public Health Education (SOPHE) and the American
Public Health Association (APHA) have created useful guides. SOPHE’s document is titled
Guide to Effectively Educating State and Local Policymakers (available at: http://www.sophe.
org/CDP/Ed_Policymakers_Guide.cfm), while APHA’s is titled APHA Legislative Advocacy
Handbook: A Guide for Effective Public Health Advocacy (available at: http://www.iowapha.org/
resources/Documents/APHA Legislative Advocacy Handbook1 ).
other Strategies
The other strategies category includes a variety of intervention activities that do not fit
neatly into one of the six categories discussed above.
BEHAVioR MoDiFiCAtion ACtiVitiES
Behavior modification activities, often used in intrapersonal-level interventions, include
techniques intended to help those in the priority population experience a change in be-
havior. Behavior modification is usually thought of as a systematic procedure for changing a
specific behavior. The process is based on the stimulus response and social cognitive theories.
As applied to health behavior, emphasis is placed on a specific behavior that one might want
either to increase (such as exercise or stress management techniques) or to decrease (such as
smoking or consumption of fats). Particular attention is then given to changing the events
that are antecedent or subsequent to the behavior that is to be modified.
In changing a health behavior, the behavior modification activity often begins by having
those trying to make a change keep records (diaries, logs, or journals) for a specific period
of time (24 to 48 hours, one week, or one month) concerning the behavior (such as eating,
smoking, or exercise) they want to alter. Using the information recorded, one can plan an ac-
tivity to modify that behavior. For example, facilitators of smoking cessation programs often
will ask participants to keep a record of all the cigarettes they smoke from one class session
to the next (see Figure 8.4 for an example of such a record). After keeping the record, partici-
pants are asked to analyze it to see what kind of smoking habit they have. They may be asked
questions such as: “What three cigarettes seem to be the most important of the day to you?”
“In what three places or activities do you find yourself smoking the most?” “With whom do
you find yourself smoking most often?” “Is there a primary reason or mood for your smok-
ing?” “When during the day do you find yourself smoking the most and the least?” Once
the participant has answered these questions, appropriate interventions can be designed to
deal with the problem behavior. For example, if participants say they smoke only when they
are by themselves, then activities would be planned so that they do not spend a lot of time
alone. If other participants seem to do most of their smoking while drinking coffee, an activ-
ity would be developed to provide some type of substitute. If participants seem to smoke the
most while sitting at the table after meals, activities could be planned to get them away from
the table and doing something that would occupy their hands.
Another way of leading into a behavior modification activity is through a health status
evaluation, or what is often referred to as a health screening. Such screenings could happen
at home (e.g., BSE, TSE, hemocult), at a community health fair (e.g., blood pressure, cho-
lesterol), or in the office of a health care professional (e.g., breast examination). Like record
keeping via diaries, logs, or journals, health screenings can “grab the attention” (develop
awareness) of those in the priority population to begin the behavior modification process.

http://www.sopheorg/CDP/Ed_Policymakers_Guide.cfm

http://www.iowapha.org/resources/Documents/APHA Legislative Advocacy Handbook1

http://www.sopheorg/CDP/Ed_Policymakers_Guide.cfm

http://www.iowapha.org/resources/Documents/APHA Legislative Advocacy Handbook1

216 Part 1 Planning a Health Promotion Program
Name ____________________
Date _____________________
Number of
Cigarettes Need Place With Mood
During the Day Time of Day Rating* of Activity Whom or Reason
1. ___________ 1 2 3 ___________ ___________ _____________
2. ___________ 1 2 3 ___________ ___________ _____________
3. ___________ 1 2 3 ___________ ___________ _____________
4. ___________ 1 2 3 ___________ ___________ _____________
5. ___________ 1 2 3 ___________ ___________ _____________
6. ___________ 1 2 3 ___________ ___________ _____________
7. ___________ 1 2 3 ___________ ___________ _____________
8. ___________ 1 2 3 ___________ ___________ _____________
9. ___________ 1 2 3 ___________ ___________ _____________
10. ___________ 1 2 3 ___________ ___________ _____________
11. ___________ 1 2 3 ___________ ___________ _____________
12. ___________ 1 2 3 ___________ ___________ _____________
13. ___________ 1 2 3 ___________ ___________ _____________
14. ___________ 1 2 3 ___________ ___________ _____________
15. ___________ 1 2 3 ___________ ___________ _____________
16. ___________ 1 2 3 ___________ ___________ _____________
17. ___________ 1 2 3 ___________ ___________ _____________
18. ___________ 1 2 3 ___________ ___________ _____________
19. ___________ 1 2 3 ___________ ___________ _____________
20. ___________ 1 2 3 ___________ ___________ _____________
21. ___________ 1 2 3 ___________ ___________ _____________
22. ___________ 1 2 3 ___________ ___________ _____________
23. ___________ 1 2 3 ___________ ___________ _____________
24. ___________ 1 2 3 ___________ ___________ _____________
25. ___________ 1 2 3 ___________ ___________ _____________
26. ___________ 1 2 3 ___________ ___________ _____________
27. ___________ 1 2 3 ___________ ___________ _____________
28. ___________ 1 2 3 ___________ ___________ _____________
29. ___________ 1 2 3 ___________ ___________ _____________
30. ___________ 1 2 3 ___________ ___________ _____________
*Need rating: How important is the cigarette to you at this time?
1 = Most important; I would miss it very much
2 = Average
3 = Least important; I would not miss it
⦁▲ Figure 8.4 Twenty-Four-Hour Cigarette Count

Chapter 8 Interventions 217
oRGAnizAtionAl CUltURE ACtiVitiES
Closely aligned with environmental change strategies are activities that affect organizational
culture. Culture is usually associated with norms and traditions that are generated by and
linked to a “community” of people and reflects the group’s values, beliefs, and practices.
Organizations, which are made up of people, also can have their own culture. The culture of
an organization can be thought of as its personality. The culture expresses what is and what
is not considered important to the organization. “Cultural norms are not statistical averages,
but instead are related to social standards of appropriate behavior. Cultural norms are accepted
and expected practice” (Golaszewski et al., 2008, p. 7). The nature of the culture depends on
the type of organization—corporation, school, or nonprofit group and the importance that the
organization’s leadership places on it. Thus, the leadership of an organization could advance
a culture that supports health, or stated a bit differently, could advance a culture that includes
health-related values, beliefs, and practices (Terry, 2012). For example, if organizational deci-
sion makers believe exercise is important, they may provide employees with an extra 20 min-
utes at lunchtime for exercise. Similarly, it is surprising to see how many young executives will
use a corporation’s exercise facility because the chief executive officer does. Other examples of
organizational culture activities that support health might include changing the types of foods
found in vending machines, closing the “junk food” machines during lunch periods at school,
offering discounts on the health foods found in the company cafeteria, and getting retailers to
change the way they have done things in the past, such as moving their tobacco products from
in front of a counter to behind a counter, so that an employee has to get them for the customer.
For organizational culture activities to be effective in supporting a culture of health there
must be a consistency about the importance of health throughout the organization. It must
be system-wide and delivered through multiple channels (Terry, 2014). For example, if a
culture of health is to be achieved, if an organizational culture activity is associated with em-
ployee benefits (e.g., regular free health screenings), it would be counter productive to stock
the organization’s vending machines with unhealthy snack choices.
Like other health promotion strategies, the use of organizational culture activities should
begin with an assessment. The term that has been given to assessments associated with or-
ganizational culture is a culture (or cultural) audit. A cultural audit is an evaluation of the
assumptions, values, normative philosophies, and cultural characteristics of an organization
in order to determine whether they support or hinder that organization’s central mission
(BusinessDictionary.com, 2015b). When applied to health, the audit would help determine
whether the culture hinders or supports health. There are companies that will perform
health culture audits for organizations (Note: search the Internet with key words “health cul-
ture audit” for sources). In addition, the Wellness Council of America (WELCOA) has created
a free WELCOA Quick-Inventory (Hunnicutt, 2009) as a means to help assess the environ-
ment of a workplace.
Once the status of the organizational culture has been determined there are several steps
that can be taken to work toward a health supporting culture. Golaszewski and his colleagues
(2008) have identified the following influences on an organization’s health supporting
culture: (1) shaping cultural health values (e.g., raise the visibility of benefits of healthy
lifestyles, raise the visibility of leadership promoting healthy lifestyles, encourage employee
forums where they can discuss health, showcase the organization’s involvement in health
promotion); (2) shaping cultural health norms (e.g., identify key norms for health promo-
tion in the organization, conduct interviews of those in the priority population to determine

218 Part 1 Planning a Health Promotion Program
support or lack thereof for a healthy culture, evaluate idea versus actual norm levels); (3)
use cultural touch points (e.g., mechanisms that support a healthy culture like committing
resources to health, leaders’ modeling healthy lifestyles, rewards and recognitions for health,
include health promoting ideas in organizational recruitment, orientation, training, com-
munication, relationships, and rites, symbols, and rituals); (4) encourage peer support (e.g.,
mobilize existing support systems, develop mutual support systems); and (5) building a sup-
portive cultural climate for health (e.g., foster a sense of community, foster a shared vision,
foster a positive outlook, and foster cultural climate with health promotion).
inCEntiVES AnD DiSinCEntiVES
The use of incentives (sometimes referred to as “carrots”) and disincentives (sometimes re-
ferred to as “sticks”) to influence health behaviors is a common type of activity, especially in
worksite settings. However, it has also been applied to community and public health settings
(Ashraf, 2013). An incentive is “an anticipated positive or desirable reward designed to
influence the performance of an individual or group” (Chapman, 2005, p. 6). An incentive
can increase the perceived value of an activity (Patton et al., 1986), motivate people to get
involved, encourage health service use behavior (Chapman, 2005), encourage compliance
with professional health advice (Chapman, 2005), remind program participants of their
commitment to and goals for behavior change (Wilbur, 1983), promote short-term behavior
change (French, Jeffery, & Oliphant, 1994; Robison, 1998), and maintain behavior change
over time (Ashraf, 2013; Pescatello et al., 2001; Poole, Kumpfer, & Pett, 2001). Incentives can
work because they make good health decisions easier and poor ones more difficult (Ashraf,
2013). The key to motivating people with incentives, either intrinsic or extrinsic, is knowing
what will incite them to action. Thus for this type of activity to work, the planners need to
match the incentives with the needs, wants, or desires of the priority population. However,
this is not easy, for what is an incentive for one person may be a deterrent for another, and
vice versa. If planners are not in touch with what program participants want, there is a
chance of losing participant interest in the program (Hunnicutt, 2001). Therefore, incentives
work best when they are tailored to the individual characteristics of the participants. For
example, a financial incentive will typically generate less response from wealthy participants
than lower income participants (Haveman, 2010).
Because incentives are used to assist individuals in making decisions about their health,
it is important to better understand what influences decision making. We only need to look
around us to see that individuals do not always make good health choices. Consider indi-
viduals who continue to smoke even though they know it is bad for their health. To help un-
derstand the reasoning behind such decisions, the concept of behavioral economics can help.
Behavioral economics has been called “the hybrid offspring of economics and psychology”
(Lambert, 2006, p. 53). Neoclassical economics or traditional economics assumes individuals
make decisions based on rational thinking by weighting the gains (pros) and losses (cons) as-
sociated with the decision. Behavioral economics is a method of analysis that applies psy-
chological insights into decision making. Thus, behavioral economists believe that decisions
are not based solely on rational thinking but that they are highly dependent on the context
in which the decision is made (Samson, 2014; Zimmerman, 2009). Here are some behavioral
economic insights that help explain decision making. Individuals: (1) are more concerned
about avoiding losses than acquiring gains, (2) are comfortable with status quo and do not
want to change, (3) are aware of social norms and want to conform, (4) experience decision

Chapter 8 Interventions 219
fatigue (i.e., choice overload) and put off difficult choices, (5) use heuristics (i.e., shortcuts or
quick answers) because of decision fatigue, (6) have trouble evaluating probabilities associ-
ated with health decisions, and (7) overvalue the present outcomes of decision and discount
the future outcomes (i.e., present bias) (Arhraf, 2013; Riedel & Calao, 2014). (See Box 8.6 for
an application of behavioral economics.)
For program planners, the task becomes one of matching the needs of the program par-
ticipant or potential program participant with available incentives. A couple of different
approaches can be used to accomplish this. The first is to include questions about incen-
tives as part of any needs assessment conducted in program planning keeping in mind the
insights from behavioral economics. For example, a needs survey or focus group might in-
clude a question on incentives, such as “What incentives would entice you to participate in
the exercise program?” or “What would it take to get you to participate in this program?” or
“What would it take to keep you involved in a health promotion program?” or “Would you
continue to participate in an exercise program if you knew you were going to be given a nice
T-shirt after logging 100 miles running or walking, or participating for 50 days in a yoga class
or swimming program?” The responses to these questions should provide some indication of
the type of incentives that would be most appropriate for this priority population.
A second approach would be to conduct an “experiment” with different incentives. This
could be accomplished via a pilot study with a small group from the priority population
using different incentives. In such a pilot study, half of the participants would receive one
incentive, while the other half would receive another. The outcomes at which the incentives
were aimed would then be compared to determine which incentive was more useful. A third
approach would be use the most promising incentive based on previous experience or the
experience reported by others (see discussion on best experiences later in the chapter). This
third approach might be used when program resources are limited.
Based on the idea that incentives should meet the individual needs of those in the prior-
ity population, the possibility of different types of incentives is almost endless. Incentives
are usually grouped into two major categories: material (i.e., financial) and nonmaterial.
Behavioral Economics
To address some of the insights from behavioral economics program planners have used
several different techniques to assist people to making good health decision. One of these
techniques is message framing. Planners who frame their health promotion programs
by emphasizing the “program benefits” versus “program obligations” have had better
results in getting people to make good health decisions. For example, a smoking cessation
program framed as “You are not alone in your battle to quit, come see what a smokefree
life can mean for you,” has a much better chance of resulting in a good health decision
than one framed as “This smoking cessation program is science-based and has shown
good results for those who stick with it.” Another technique used to help people make
good health decisions and sustain change overtime has been commitment devices. An
example of a commitment device related to a weight loss program would have enrollees
put up a bond, say $500, at the beginning of the program and would not be returned until
their goal weight was reached. In addition, the bond could also be donated to a charity
if the goal weight was not reached in a reasonable period of time. Such a program takes
advantage of people’s tendency to prefer avoiding losses to acquiring gains.
H
ig
hl
ig
ht
s
8.6
Box

220 Part 1 Planning a Health Promotion Program
Some examples of material incentives include providing any material item (e.g., food,
clothing) of worth to those in the priority population, or actual money in the form of extra
pay, bonuses, or rebates (Ashraf, 2013; Chapman 2005; Haveman, 2010; Pescatello et al.,
2001; Poole, Kumpfer, & Pett, 2001); paying membership fees to health-related facilities
(Chapman, 2005); giving gift certificates; or reducing health insurance premiums or deduct-
ibles. Examples of nonmaterial incentives include altruistic feeling like after giving blood
(Ashraf, 2013; Serxner, 2013), giving special attention or recognition (e.g., name mentioned
in a newsletter) (Chapman, 2005; Haveman, 2010), social support, or providing additional
vacation days or “well” days (Chapman, 2005; Haveman, 2010).
Terry and Anderson (2011) noted that incentives should be safe, effective, participant-
centered, timely, and equitable. In addition, Haveman (2010) has offered six principles that
can assist program planners in creating effective incentives. His principles were intended for
use with incentives associated with the delivery of health care, but we have adapted them to
health promotion. Principle one is identifying the desired outcome or, stated a different way,
what is the problem that needs to be addressed. This may seem obvious but is often overlooked.
For example, if the desired outcome is to have program participants stop smoking, the incen-
tives should be tied to quitting or the steps to quitting. The second principle is identifying the
behavior change that will lead to the desired outcome. In the smoking cessation example, par-
ticipants need to come up with a strategy to quit smoking, actually stop, and stay off cigarettes
for a specified period of time. Principle three is determining the potential effectiveness of the
incentive in achieving the behavior change. This is not easy because responsiveness to incen-
tives varies greatly. “Understanding this response involves determining the extent to which the
behavior targeted is amenable to change through the incentive” (Haveman, 2010, p. 2). The
“size” of the incentive should be appropriate to the effort required. If the perceived benefit of
the action is exceeded by its perceived cost, the incentive will be ineffective (Haveman, 2010).
(See Box 8.7 for a list of factors that determine the effectiveness incentives.) The fourth principle
is to link the incentive directly to the desired outcome or behavior. In the smoking cessation ex-
ample, any incentive should be linked to either the final outcome—no smoking for one year af-
ter the quit date—or to the actions leading up to it, for example, setting a quit date, deciding on
a strategy to quit, actually quitting, not smoking for six months, and not smoking for one year.
If the second option is used, an incentive could be attached to each step. Further if this second
option is used the incentives could be graduated so that incentives are worth more than the
one given at the previous step. Principle five is identifying any possible adverse effects of the
incentive. In the smoking cessation example, nonsmokers may say that they have no chance
to receive a smoking cessation incentive. So how could those creating the incentive deal with
this situation? The sixth, and final, principle is to evaluate and report changes in the behavior
or outcome in response to the incentive. If a case is going to be made for using incentives as part
of health promotion programs in the future, planners will need to document their work and
show that the incentives, at least in part, were responsible for the outcomes or desired behavior.
Just as incentives can be used to get people involved in behavior change, disincentives can
be used to discourage a certain behavior. More formally, disincentives have been defined
as “an anticipated negative or undesirable consequence designed to influence the perfor-
mance of an individual or group” (Chapman, 2005, p. 6). For example, “[s]ustained increases
in excise taxes, constraining advertising and marketing, constricting use in public places,
and penalizing the sale and distribution to minors have all worked to help drive down the
use of tobacco” (McGinnis et al., 2002, pp. 88–89).

Chapter 8 Interventions 221
One final note that we need to mention before leaving this topic is the impact that federal
legislation has had on incentives and disincentives. As we noted at the beginning of this sec-
tion, though incentives and disincentives have been used in health promotion programs in
a variety of settings, they have been used with great favor in worksite settings. Up until 1996,
there were few limitations on how incentive and disincentives were structured (Chapman,
2005) and because of this some employers were creatively tying incentives and disincentives
associated with health to individual and group health insurance plans. However, Congress
was concerned that employers were being unfair to some employees in order to reduce their
health care costs. Accordingly, Congress has now enacted three pieces of legislation that
have impacted the way incentives and disincentives can be used. They include the Health
Insurance Portability & Accountability Act of 1996 (more commonly referred to as HIPAA),
the Genetic Information Nondiscrimination Act of 2008 (officially known as Public Law 110-
233 and referred to as GINA), and the Affordable Care Act (ACA) (ACA actually refers to two
separate pieces of legislation—the Patient Protection and Affordable Care Act [P.L. 111-148]
and the Health Care and Education Reconciliation Act of 2010 [P.L. 111-152].
HIPAA created provisions in it that make it illegal for employers to discriminate against
their employees because of a “health status related factor” with the outcome of affecting
coverage or cost to the employee under a group or individual health plan (Chapman, 2005).
That is, those who offer and administer health insurance plans cannot deny health care
claim expenses, charge some employees more for their health insurance premiums, or place
a surcharge on their premiums because of health status related conditions like high blood
Factors that Determine the Effectiveness of incentives
MAjoR FACtoRS MinoR FACtoRS
⦁⦁ Dollar value of the reward(s)
⦁⦁ Convertibility into item of personal value
⦁⦁ Amount of effort needed to qualify
⦁⦁ Clarity of messaging
⦁⦁ Timing and repetition of messaging
⦁⦁ Extent of distrust in employers’ motives
⦁⦁ Supporting messages from management
⦁⦁ Ease of enrollment
⦁⦁ Perceived complexity of requirements
⦁⦁ Fairness and defensibility of requirements
⦁⦁ Group or competitive nature
⦁⦁ Desirability of required behavior
⦁⦁ Readiness composition of population
⦁⦁ Combination of pay values
⦁⦁ Spousal eligibility
⦁⦁ Compatibility of incentives with culture
⦁⦁ Past wellness incentive performance
⦁⦁ Importance to supervisor
⦁⦁ Degree of fun experienced
⦁⦁ Language compatibility
⦁⦁ Convenience of record keeping
⦁⦁ Amount of change in benefits
⦁⦁ Availability of alternative standards
⦁⦁ Credibility of wellness staff
⦁⦁ Use of outside vendor
⦁⦁ Adequacy of FAQs
⦁⦁ Availability of FAQs
⦁⦁ Treatment of “gamers”
⦁⦁ Utility of program documents
⦁⦁ Tax implications
⦁⦁ Option to ask questions
⦁⦁ Time of the year
⦁⦁ Generational effects
⦁⦁ Reporting back to employees
8.7
Box
Fo
cu
s
O
n
Source: “The Changing role of incentives in health promotion and wellness.” L. S. Chapman, D. Whitehead, and M. C. Connors, from The Art of Health
Promotion. Copyright © 2008 by American Journal of Health Promotion. Reprinted with permission.

222 Part 1 Planning a Health Promotion Program
pressure, high blood cholesterol, or poor vision. For example, an employer cannot require
employees to pay higher premiums than their coworkers because they have high blood pres-
sure. However, the law does not preclude offering incentives—in the form of premium dis-
counts or rebates or modifying applicable co-payments or deductibles—to those who partici-
pate in health promotion programs. So an employer could reduce employees’ co-payment on
a visit to a doctor or on the cost of a prescription medication if the employees participated in
the company’s employee health promotion program.
GINA, which amends portions of HIPAA by treating genetic information as protected health
information (PHI), prohibits discrimination in health coverage and employment based on ge-
netic information. GINA went into effect for health care plans starting on or after December 7,
2009. Though the bulk of GINA is aimed at health care coverage provided by employers, it also
impacts health promotion/wellness programs. The area of health promotion programming
that it most affected is the use of health risk assessments (HRAs). HRAs cannot request genetic
information prior to enrollment in a health care “plan, and no rewards or penalties may be
offered in conjunction with an HRA that requests genetic information, even if the request is
made after the enrollment” (Grudzien, 2009, para. 6). As a result of these regulations, planners
“should review all wellness and disease management plans to determine how a HRA is used
and what information is requested; remove any financial incentives or penalties if genetic
information is collected in the HRA; and remove any genetic information from the HRA if
financial incentives or penalties want to be offered” (Grudzien, 2009, para. 6).
The ACA further refined rules associated with how incentives could be used in programs
that are a part of group health insurance plans. These new rules apply to health plans that
began on or after January 1, 2014. The ACA continued to support employee wellness pro-
grams but also included rules to ensure the programs would not discriminate based on health
status. It did so by making a distinction between participatory wellness programs and health-
contingent wellness programs. A participatory wellness program is one that does not provide an
incentive or does not tie an incentive to a health factor. Examples of participatory program
incentives include: fitness center membership reimbursements; paying employees who
complete a health risk assessment without requiring them to take further action, or waiving
an out-of-pocket cost for attending a smoking cessation program that is not contingent on
quitting.
A health-contingent wellness program is one that requires individuals to meet a specific
health-related standard to obtain an incentive. Examples include programs that provide an in-
centive to those who do not use, or decrease their use of tobacco, or programs that provide an
incentive to those who achieve a specified cholesterol or blood pressure level (USDOL, n.d.).
Because health-contingent wellness programs have the potential to discriminate based on
health status, the ACA also includes the following:
1. Programs must give those covered by the health insurance plan an opportunity to
qualify for the incentive at least once per year.
2. Programs must be designed to have a reasonable chance of improving health or
preventing disease and not be overly burdensome for individuals.
3. Programs must be reasonably designed to be available to all similarly situated
individuals (i.e., those with same problems or circumstances).
4. Programs must include a reasonable alternative standard or waiver to qualify for the
incentive for individuals whose medical conditions make it unreasonably difficult, or

Chapter 8 Interventions 223
for whom it is medically inadvisable, to meet the specified health-related standard. In
addition, individuals must be given notice of the opportunity to qualify for the same
incentive through other means.
5. The incentives for wellness program participants may not exceed 30% of the cost of
health insurance coverage.
SoCiAl ACtiVitiES
The importance of social support for behavior change and its relationship to health have
been known for a number of years (e.g., IOM, 2001). Many people find it much easier to
change a behavior if those around them provide support or are willing to be partners in the
behavior change process. Social support can be provided in a variety of ways. “There are at
least four types of social support: (1) emotional, (2) instrumental, (3) informational, and
(4) appraisal” (Valente, 2010, pp. 36-37). Emotional support is assistance from people close
to a person that focuses on the person’s feelings. Instrumental support deals with providing
material items and services to people. Informational support comes in the format of provid-
ing various forms of information such as advice, knowledge, and suggestions to people.
Appraisal support includes analysis and feedback that allows people to evaluate their situa-
tion (Valente, 2010). A discussion of several different types of social support activities that
can provide these different types of social support follows.
SUppoRt GRoUpS AnD BUDDy SyStEM
The importance of support groups as part of comprehensive interventions has been well
established. One need only look to the 12-step programs (e.g., Alcoholics Anonymous,
Overeaters Anonymous, and Gamblers Anonymous) and commercial programs (e.g., Weight
Watchers) to realize the importance of people coming together to share their experiences
and support one another’s efforts. A support group need not be large; it might be as small as
just two people. A buddy system is an example of a two-person group. A buddy system can
take one of two different forms. In the first, both individuals are trying to change a behavior.
In such a relationship, the two individuals support each other, whether this means helping
each other stay on a special diet or meeting each other at 6 A.M. for exercise. In the other
form, only one of the two is trying to change a behavior. The one not changing the behavior
may have already changed (e.g., has already quit smoking or is exercising regularly) and is
acting as a mentor to the one trying to change, or may not be trying to change but provides
support at regular intervals or as problems arise.
To enhance the motivation provided by support groups and buddy systems it is not un-
common for these activities to also use a contest (also referred to competitions or challenges)
or a contract. A contest can be described as a challenge between two individuals/groups in
which the object is to outperform the competitor. Examples of contests include the com-
petition between two individuals to see who can lose the most weight, who can walk/run
the most miles, or who can go the longest without a cigarette. Contests could also be based
on teams within the priority population (such as two different companies, two schools, or
departments within an organization), using similar criteria but now based on group total
figures (pounds, miles, or cigarettes). Contests have been useful in introducing and promot-
ing health promotion programs and achieving significant initial participation rates, but they
have not been as useful as an ongoing recruitment tool (Wilson, 1990).

224 Part 1 Planning a Health Promotion Program
A contract is an agreement between two or more parties that outlines the future be-
havior of those parties. Contracts are a common part of everyday living. People enter into
contracts when they sign a lease for an apartment or a residence hall agreement, take out an
insurance policy, borrow money, or buy something over a period of time. The same concept
can be applied to getting and keeping people motivated in health promotion programs.
Program participants would enter into a contract with another person (the program facilita-
tor, a significant other, or a fellow participant) and then work toward an objective or agree-
ment specified in the contract. The contract would also specify contingencies—that is,
what happens as a result of the contract’s term either being met or not being met.
For an exercise program, this system might work as follows: The program participant and
program facilitator would draw up a contract based on the participant’s present status in the
program (e.g., exercising for 30 minutes once a week) and on what would be a reasonable
goal for the near future (e.g., eight weeks). Thus the contract might state that the participant
will exercise for 30 minutes twice a week for the first week, 30 minutes three times a week
for the second week, and so forth, building up gradually to the final goal of exercising for
30 minutes most days of the week at the end of eight weeks. The outcome should focus on a
behavior that can be maintained at the end of the contract period. For a weight loss program,
the goal might be written as eliminating snacking in the evening, increasing fruits and veg-
etables in the diet to five servings per day, and walking for 30 minutes three times a week.
These are behaviors that can reasonably be maintained after the weight loss.
The parties to the contract then decide on what the contingencies will be. Thus the partici-
pant might offer to make a contribution to some local charity or state that she will continue
in the program for another eight weeks if she does not meet the contract goal. The facilitator
might promise the participant a program T-shirt if she fulfills the contract during the specified
eight-week period. Other ideas for contingencies might include granting a kickback on fees for
completing a certain percentage of the classes, or earning points toward products or services.
No matter what the contingencies are, it seems to help if the contract is completed in writing.
SoCiAl GAtHERinGS
Social gatherings can be an important type of social intervention. Bringing together people
who may be confronting similar problems for the purpose of purely social interaction not
related to the problem can indirectly help them deal with the problem. Examples of such
activities might be single parents having a cookout or a group of senior citizens attending a
play. Although these gatherings do not deal directly with these people’s common problems,
they do help fill voids in their lives and thus indirectly help with the problem.
SoCiAl nEtWoRkS
Social networks are another type of social intervention. A social network is the “web of social
relationships and the structural characteristics of that web” (IOM, 2001, p. 7). The nature of
the structural characteristics can be quite varied, consisting of almost anything that creates
a special feeling: need, concern, loyalty, frustration, power, affection, or obligation, to name
just a few. When people are “networking,” they are said to be looking for relationships that
would be useful in helping them with their concerns, such as problem solving, program de-
velopment, resource identification, and others. As part of a health promotion intervention,
social networking may take many different forms and can range from informal networking
where participants create relations on their own to more formal networking where program

Chapter 8 Interventions 225
participants are “assigned” others with whom to network. The actual networking itself may
take place face-to-face, via the telephone, or through some type of social media. An example
would be when program smoking cessation participants trade contact information (e.g.,
email address, telephone numbers, or “friend” another) for the purpose of connecting when
trying to resist a cigarette or trying to locate a needed resource to solve a problem.
It should also be noted that although most social support and buddy systems take place
between individuals, they can also be established at the institutional level. Like individu-
als, institutions can be paired up to help one another. For example, if two companies are
interested in establishing health promotion programs, they could work together on their
programs and share information and resources where appropriate. Or, if one company has
a well-established program in place, then that company could mentor another company in
setting up a program.
Creating Health Promotion Interventions
Once program planners have completed a needs assessment, written program goals and
objectives, and considered different types of intervention strategies, they are in a position to
begin identifying an appropriate intervention. Identifying an intervention is not as straight-
forward as taking a new medical procedure from one hospital to the next. Most health pro-
motion problems result from the interaction of complicated social dynamics that must be
accommodated (Runyan & Freire, 2007). There is no one best way of intervening to accom-
plish a specific program goal that can be generalized to all priority populations. Each priority
population has unique needs and wants that must be addressed, and each setting has its own
peculiarities. Nevertheless, well planned and successful health promotion programs have
common characteristics such as: (1) addressing one or more risk factors of the priority popu-
lation, (2) being theory-driven, (3) being based on the best possible evidence (see the discus-
sion of scientific evidence later in the chapter), (4) adhering to professional ethical standards,
(5) being culturally appropriate, (6) being consistent with professional criteria, guidelines, or
codes of practice (e.g., America College of Sports Medicine’s guidelines for exercise programs
(ACSM, 2014)), (7) using resources efficiently, and (8) including an evaluation component.
Such characteristics help standardize and ensure the quality of the program, give credibility
to a program, help with program accountability, provide a legal defense if a liability situation
might arise, and identify ethical concerns that need to be addressed as a part of planning,
implementing, and evaluating programs.
intervention planning
When deciding on how best to intervene to reach the program goals and objectives, program
planners have three possible avenues available to them. They could adopt an existing inter-
vention that is supported by evidence showing that the intervention was effective when used
elsewhere. They could adapt an existing intervention that is supported by evidence showing
it was effective elsewhere but the circumstances or setting in which it was used were differ-
ent that the proposed setting. Or, the planners could design a new intervention. Irrespective
of the avenue used to identify an intervention, interventions should be based on a sound
rationale backed by the best available evidence as opposed to chance; a strategy should not
be selected just because the planners think it “sounds good” or because they have a “feeling”

226 Part 1 Planning a Health Promotion Program
that it will work. Too often, intervention decisions are “based on perceived short-term op-
portunities, lacking systematic planning and review of the best evidence regarding effective
approaches” (Brownson, Fielding, & Maylahn, 2009, p. 175). As mentioned earlier, planners
should choose or create an intervention that will be both effective and efficient.
Adopting a Health promotion intervention
In order for program planners to adopt an intervention for use in their program there are sev-
eral questions they must be able to respond to with a “Yes” answer. The questions include: (1)
Is there sufficient evidence to show that the intervention has been successful in dealing with
the problem in question? (2) Is there sufficient evidence to show that the intervention has
been successful in dealing with the problem in question in a population with similar char-
acteristics (e.g., age, sex, culture, racial/ethnic make-up, social circumstances) to the popula-
tion in the new setting? (3) Is there evidence to show that the intervention was successful in
more than one setting? (4) Are there similar resources available in the new setting to ensure
the fidelity of the intervention? and (5) Is the new environment setting similar to the envi-
ronmental setting identified in the evidence? If “No” is the answer to any of these questions
then planners should consider either adapting the existing intervention or developing a
new intervention. If the answers to the questions are not clearly “Yes” or “No” Runyan and
Freire, (2007) have noted that planners might “benefit from discussion among several people
knowledgeable about the problem, the setting, and program planning” (p. 423).
Adapting a Health promotion intervention
If the evidence supporting the successful use of an intervention is different (e.g., social context
or other unique characteristics) than the one in which the planners are currently working, the
question becomes “Can the intervention that was successful in another setting (i.e., evidence-
based intervention [EBI]) be adapted to work in the new setting?” That is, can an intervention be
adapted to the circumstance in which the priority population lives? To help answer this question,
the CDC’s Division of HIV/AIDS, along with some external partners, developed draft guidance to
adapt EBIs (McKleroy et al., 2006). The approach of this framework emphasizes both the planners’
experience working with the priority population and the resources available for adaption and im-
plementation, while still maintaining fidelity to the core elements of the intervention, the theory
on which it was based, and internal logic of the original intervention (McKleroy et al., 2006).
The adaptation framework is a five-step approach that is presented graphically in a linear
format (see Figure 8.5). However, like other planning models presented in this book, the
steps are interconnected and thus overlap in terms of their timing and ordering. McKleroy et
al. (2006) have presented the following description of the five steps.
The first action step, assess, involves assessing the target population, the EBIs being considered
for implementation, and the agency’s capacity to implement the intervention. The second,
select, is determining whether to adopt the intervention without adaptation, implement the
intervention with adaptation, or choose another intervention and repeating the assess action
step before moving forward. The third action step, prepare, falls within the preparation phase
and involves actually adapting the intervention materials, pre-testing the adapted materials
with the target population, and increasing agency capacity and developing collaborative
partnerships when necessary to implement the intervention. The fourth action step, pilot, is
pilot testing the adapted intervention or its components if it is not feasible to pilot the entire

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227

228 Part 1 Planning a Health Promotion Program
intervention and developing an implementation plan. The fifth, implement, is conducting
the entire adapted intervention with minor revision as needed. Additionally, the guidance
includes feedback loops and checkpoints to ensure each action step is addressed adequately,
and to provide an opportunity to revisit earlier action steps should difficulties occur.
Process monitoring and evaluation, and routine supervision and quality assurance are also
important considerations for the guidance. Credible evidence collected during the adaptation
process should be evaluated to determine the success of the adaptation process as well as the
effectiveness of the adapted intervention (p. 64).
If you are interested in adapting an EBI, we strongly recommend that you review McKleroy
et al. (2006) for a more in-depth description and practical examples of the five-step framework.
Designing a new Health promotion intervention
If there is not sufficient evidence to support the adoption or adaptation of an intervention
to a new setting then planners are faced with creating a new intervention. Although no pre-
scription for an appropriate intervention has been developed, experience has indicated that
the results of some interventions are more predictable than others. In this section, we present
eight major questions that planners need to consider when creating new health promotion
interventions. Figure 8.6 summarizes these major considerations.
1. What needs to change? And, where is the change needed? Designing an appropriate
intervention begins by going back to the early steps in the program planning process
and examining the results of the needs assessment and reviewing the goals and
What needs to change? Where is change needed?
What level of prevention?
What level(s) of influence?
Single or multiple
strategies?
Appropriate fit for
priority population?
Planned intervention
Resources
available?
Any guide for intervention selection?
Best practices or Best experiences
if not then
Best processes
⦁▲ Figure 8.6 Items to Consider When Creating a Health Promotion Intervention

Chapter 8 Interventions 229
objectives of the proposed program. The needs assessment identified the behavioral,
environmental, and genetic determinants or risk factors of the health problem. (Note:
Remember that because genetic determinants either cannot be changed or often
interact with behavior and environment, the planners’ focus should be on behavioral
and environmental factors.) For example, after identifying the determinants of a health
problem, planners then determine the predisposing, enabling, and reinforcing factors
that need to be addressed in their proposed program. These factors should be reflected
in the program goals and objectives. If the single purpose of a program were to increase
the awareness of the priority population, the intervention would be very different from
what it would be if the purpose were to change behavior.
Knowing what must be changed is critical to creating an intervention, but
just as critical is understanding the context in which the change will take place.
Understanding the context has been referred to as the settings approach (Baric, 1993)
to health promotion. More specifically, a settings approach means addressing the
contexts (physical, organizational, and social) “within which people live, work, and
play and making these the object of inquiry and intervention as well as the needs and
capacities of the people found in the different settings” (Poland, Krupa, & McCall,
2009, p. 505). Therefore when creating an intervention, planners need to analyze the
setting—“who is there; how they think or operate; implicit social norms, hierarchies
of power; accountability mechanisms; local moral, political, and organizational
culture; physical and psychosocial environment; broader sociopolitical and economic
context, etc.” (Poland et al., 2009, p. 506)—to make sure the intervention is a good
“fit” for those in the priority population. For those interested in more of what to
consider when analyzing the setting, we recommend the questions posed by Poland
et al. (2009).
2. At what level of prevention will the program be aimed? Because of the needs and wants
of those in the priority population, planners need to consider at which level or levels
of prevention—primary, secondary, and tertiary—the program will be aimed. For
example, a program aimed at increasing the level of exercise is likely to be received
differently by asymptomatic nonexercisers (primary prevention) than by a patient
recovering from a heart attack (tertiary prevention).
3. At what level(s) of influence will the intervention be focused? Program planners must recognize
that those in the priority population “live in social, political, and economic systems
that shape behaviors and access to the resources they need to maintain good health”
(Pellmar et al., 2002, p. 210). As such, planners need to decide at what level or levels of
influence they can best obtain the goals and objectives of the program. For example, if
the goal of the program is to increase safety belt use, can that be best accomplished by
trying to intervene at an intrapersonal level with an individual education program, at the
institutional level with a company policy, at the public policy level with an enhanced
state safety belt law, or at multiple levels? Though it is possible that an intervention can
be aimed at a single level of influence, the evidence is mounting that there is a greater
chance of changing and maintaining health behaviors if interventions are aimed at
multiple levels of influence (Glanz & Bishop, 2010). Therefore, planners need to ask and
answer the question, “What levels of influence should be addressed to provide the best
chances of achieving the program goal and objectives?”
4. What types of intervention strategies are known to be effective (i.e., have been successfully used in
previous programs) in dealing with the program focus? In other words, what does the evidence
show about the effectiveness of various interventions to deal with the problem that the
program is to address? (Refer back to Chapter 2 for the definition of and available sources

230 Part 1 Planning a Health Promotion Program
of evidence.) Using evidence does not mean finding a specific intervention to deal with
the problem but rather going through a process of decision making that is based on the
evaluation of reliable data and previous work (Baker, Brownson, Dreisinger, McIntosh,
& Karamehic-Muratovic, 2009). To assist planners in identifying the best available
evidence, Green and Kreuter (2005) and Brownson and colleagues (2009) have put forth
typologies for classifying interventions based on the level of scientific evidence. Green
and Kreuter (2005) have suggested three sources of guidance for selecting intervention
strategies—best practices, best experiences, and best processes. Best practices refer to
“recommendations for an intervention, based on critical review of multiple research and
evaluation studies that substantiate the efficacy of the intervention in the populations
and circumstances in which the studies were done, if not its effectiveness in other
populations and situations where it might be implemented” (p. G-1).
When best practice recommendations are not available for use, planners need to
look for information on best experiences. Best experience intervention strategies are
those of prior or existing programs that have not gone through the critical research
and evaluation studies and thus fall short of best practice criteria but nonetheless show
promise in being effective. Best experiences can be found by networking with other
professionals and by reviewing the literature.
If neither best practices nor best experiences are available to planners, then the
third source of guidance for selecting an intervention strategy is using best processes.
Best processes intervention strategies are original interventions that the planners
create based upon their knowledge and skills of good planning processes including the
involvement of those in the priority population and appropriate theories and models
(see Chapter 7). (See table 8.5 for a matrix of aligning objectives, program outcomes,
methods, theory, intervention strategies, and activities.)
Whereas the Green and Kreuter (2005) typology for classifying interventions has
three levels, the typology put forth by Brownson and colleagues (2009) has four—
evidence-based, effective, promising, and emerging. The first level, evidence-based, includes
interventions that are peer reviewed via a systematic or narrative review (e.g., those
contained in the Guide to Community Preventive Services [CDC, 2015c]). This first level is
parallel to the best practices level of Green and Kreuter (2005). The interventions found
in the second level, effective, have been peer reviewed but are not part of a systematic or
narrative review (e.g., article that appears in the scientific literature). Those interventions
that are deemed effective via a program evaluation but without formal peer review make
up the third level, promising (e.g., state or federal government reports that have not gone
through peer review). Levels two and three, effective and promising respectively, are
parallel to the best experiences described by Green and Kreuter (2005). The fourth and
final level is emerging. This level includes ongoing works, practice-based summaries, or
evaluation works in progress (e.g., pilot studies).
5. Is the intervention an appropriate fit for the priority population? Intervention strategies need
to be designed to “fit” the priority population. Each priority population has certain
characteristics that impact how it will receive an intervention. Two processes that help
to “fit” an intervention to the priority population are tailoring and segmenting. The
rationale for tailoring an intervention activity is based on research that shows people
pay more attention to information that is personally relevant to them (NCI, n.d.).
Because we presented information on tailoring earlier in the chapter in our discussion
of health communication section, we will use this space to present information
on segmenting. Segmenting is the process of dividing a broader population into
smaller groups with similar characteristics that are likely to exhibit similar behavior/
reaction to an intervention (see information in Chapter 11 about segmenting a priority

T
A
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8
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231

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p
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li
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n
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ci
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it
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s
•
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re
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tw
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s/
b
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A
b
l
e
8
.5
c
on
tin
ue
d
232

Chapter 8 Interventions 233
population). Segmentation allows planners to create an intervention to fit the needs
and characteristics of a priority population (Pasick, D’Onofrio, & Otero-Sabogal, 1996).
Following are a few examples of how priority population segmentation can be applied.
If program planners are developing written materials as part of their intervention, they
need to make sure that the materials are written at an acceptable reading level for the
priority population. From a developmental stage perspective, it is not reasonable to
expect kindergartners to sit still for a one-hour lesson. Interventions also need to “fit”
culturally within the priority population (Pérez & Luquis, 2014) and be culturally
sensitive. Culturally sensitive interventions are those “that are relevant and acceptable
within the cultural framework of the population to be reached” (Frankish, Lovato, &
Shannon, 1998). In attempts to be culturally sensitive, because culture is often context
specific, planners need to be careful not to perpetuate harmful cultural stereotypes.
One final item to consider when thinking about the appropriateness of an
intervention strategy for the priority population is to ask if there is any chance that the
strategy could cause any unintended effects in the priority population. For example,
could the strategy threaten the physical safety or raise undue anxiety in the priority
population (CDC, 2003)?
6. Are the necessary resources available to implement the intervention selected? Obviously some
intervention strategies require more money, time, personnel, or space to implement
than others. For example, it may be prudent to provide each person in the priority
population with a $100 incentive for participating in the health promotion program,
but it may not be possible because of budget limitations.
7. Would it be better to use an intervention that consists of a single strategy or one that is made
up of multiple strategies? Again, we refer to the principle of multiplicity. A single-strategy
intervention would most likely be easier and less expensive to implement and easier to
evaluate. There are, however, some real advantages to using several strategies at multiple
levels of influence: (1) “hitting” the priority population with a message in a variety of ways
from multiple levels of influence; (2) appealing to the variety of learning styles within
any priority population; (3) keeping the health message constantly before the priority
population; (4) hoping that at least one strategy appeals enough to the priority population
to help bring about the expected outcome; (5) appealing to the various senses (such as
sight, hearing, or touch) of each individual in the priority population; and (6) increasing
the chances that the combined strategies would help reach the goals and objectives of the
program (e.g., communication used to publicize a policy change) (CDC, 2003). When
interventions include multiple strategies offered at multiple levels of influence to multiple
groups, they often include several interacting components or “active ingredients.” Such
interventions are now being referred to as complex interventions (Hawe, 2015). Probably the
biggest drawback to using complex interventions is the difficulty of separating the effects
of one strategy from the effects of others in evaluating the impact of the total program and
of individual components. However, Glasgow, Vogt, and Boles (1999) have developed an
evaluation model titled RE-AIM (acronym for reach, efficacy, adoption, implementation,
and maintenance) for use with multi-strategy interventions.
Limtations of Interventions
Finally, before leaving this chapter on interventions we would be negligent if we did not
mention that even well-planned interventions are not always successful in achieving the
expected outcomes. That is, most interventions come with some limitations. In a keynote

234 Part 1 Planning a Health Promotion Program
address on the impact of injuries as a public health problem, Sleet (2015) identified some of
the limitations associated with the three major approaches to intervening to prevent injuries
namely—innovations in engineering and technology, legislation and enforcement, and
education for behavior change. Sleet (2015) noted in order for engineering and technology
innovations to be successful in preventing injuries they must be: effective and reliable; ac-
ceptable to those for whom they were intended; easy to use; and used properly. Consider
how these criteria apply to child-resistant cigarette lighters and medicine bottles, bicycle
helmets, smoke and carbon monoxide detectors, and microwave-safe baby bottles.
In order for legislative and enforcement interventions to prevent injuries the laws must:
be widely known to the people; be fair and acceptable to the people; insure that the prob-
ability of being caught for not obeying is high; and outline punishment that is swift and
certain if the law is broken. Think about how these criteria might limit laws associated with
child-safety restraints for motor vehicles, safety belts, motorcycle helmets, and speeding.
In order for educational interventions to be effective in preventing injuries people must: be
exposed to the information; understand and believe the information; have the resources to
make the necessary changes; and be reinforced when they make the changes. Reflect on how
these criteria may limit educational programs on smoke detector maintenance, drinking and
driving, and texting while operating a motor vehicle. Although Sleet’s (2015) examples were
restricted to injury prevention and three major intervention strategies, the same or similar
limitations could be applied to the other categories of intervention strategies presented in
this chapter.
Summary
Interventions are those actions that are designed to prevent disease or injury or promote
health in the priority population. Interventions are also sometimes referred to as treatments.
Although many times an intervention is made up of a single strategy, it is more common
for planners to use a variety of strategies aimed at multiple levels of influence to make up
an intervention for a program. In this chapter, intervention strategies were categorized into
the following groups: (1) Health communication strategies; (2) Health education strategies;
(3) Health policy/enforcement strategies; (4) Environmental change strategies; (5) Health-
related community service strategies; (6) Community mobilization strategies, and (7) Other
strategies. Additionally, this chapter presented three avenues for designing health promo-
tion interventions including adopting, adapting, or creating a new intervention. And, fi-
nally, the chapter provided some limitations of interventions.
Review Questions
1. What is an intervention?
2. What are the advantages of using a multistrategy intervention (i.e., principle of
multiplicity) over one that includes a single strategy? Are there any disadvantages? If
so, what are they?
3. What does dose mean in terms of an intervention?

Chapter 8 Interventions 235
4. What are the major categories of interventions? Explain each.
5. Define each of the following terms as they relate to health education strategies:
curriculum, scope, sequence, unit of study, lessons, and lesson plans.
6. What is motivational interviewing? How can it best be used in a health promotion
program?
7. State and briefly describe the five stages of Kinzie’s (2005) modified framework for
instructional design.
8. Define health literacy and health numeracy and explain how they impact health
promotion programs.
9. What is health advocacy?
10. What special issues are there related to incentives with which planners working in the
worksite setting need to be concerned? How can behavioral economics be used to shape
incentives?
11. Why should program planners be concerned with program guidelines that have been
developed by professional organizations and other groups?
12. What is the difference between adopting and adapting an evidence-based intervention?
13. Identify and briefly explain the five steps in the framework for adapting an evidence-
based intervention for a new setting.
14. Briefly discuss the questions set forth in this chapter that should be considered before
creating a new intervention.
15. What are some of the limitations associated with interventions?
Activities
1. Create a multi-strategy intervention for a program you are planning.
2. Create a multi-strategy intervention for a program that has as its goal “to get third-
grade students to wear helmets while riding their bicycles.”
3. Using evidence found at the Guide to Community Preventive Services, adapt a multi-
strategy intervention for a setting of your choice.
4. Create a multi-strategy intervention for a program that has as its goal “the rehydration
of young children in the small village of Y in the developing country of Q.”
5. Design and present on an 8½” 3 11” piece of paper a bulletin board that could be used
as part of the multi-activity intervention you are planning. Divide the piece of paper
that represents the bulletin board into six equal sections and indicate what you will
include in each section.
6. Interview a classmate to find out information about his or her health risks. Then,
assuming you are a patient educator in a health clinic, create a one-page tailored letter
to the person, urging him or her to seek an appropriate screening for the health risk(s).
7. Develop a three-fold pamphlet that can be used as an informational piece for a program
you are planning.
8. With other students in your class, write a PSA script for a program you are planning.
Then rehearse the script and record it.

236 Part 1 Planning a Health Promotion Program
9. Write a two-page, double-spaced news release that describes a program you are
planning.
10. Write a letter to your state or federal senators or representatives and request their
support of a piece of health-related legislation that is currently being considered.
Weblinks
1. http://www.cdc.gov/socialmedia/
Social Media at CDC
This page on the CDC’s Website deals with the use of social media. From here you can
link to the various social media tools of CDC and to a page that provides guidelines that
have been developed to provide critical information on lessons learned, best practices,
clearance information, and security requirements.
2. http://nccc.georgetown.edu
National Center for Cultural Competence (NCCC)
At this site you will find a lot of resource material dealing with cultural competence
including a listing of publications, self-assessments, and current projects and initiatives.
3. http://www.cdc.gov/healthliteracy/
Health literacy
This page on the CDC’s Website focuses on health literacy. The site provides
information, tools, and links on health literacy research, practice, and evaluation. It also
provides links to the National Action Plan to Improve Health Literacy, CDC’s Action Plan
to Improve Health Literacy, and the federal Plain Writing Act.
4. http://www2a.cdc.gov/phlp/
Public Health Law Program
This page on the CDC’s Website focuses on public health law and policy. From here you
can link to public health law news and other materials and resources that examine the
authority of the government at various jurisdictional levels to improve the health of the
general population within societal limits and norms.
5. http://www.thecommunityguide.org/index.html
Guide to Community Preventive Services
This Webpage includes evidence-based recommendations for programs and policies to
promote population-based health.
6. http://www.cdc.gov/healthcommunication/index.html
Gateway to Health Communication & Social Marketing Practice
This page on the CDC’s Website provides resources to help build health communication
or social marketing campaigns and programs. It includes tips for analyzing and
segmenting an audience, choosing appropriate channels and tools, and evaluating the
success of messages or campaigns.

http://www.cdc.gov/socialmedia/

http://nccc.georgetown.edu

http://www.cdc.gov/healthliteracy/

http://www2a.cdc.gov/phlp/

http://www.thecommunityguide.org/index.html

http://www.cdc.gov/healthcommunication/index.html

237
There are a number of different processes involved in planning health promotion
programs and those processes vary based upon the circumstances of the planning situation.
The processes selected and used to plan programs are in part predicated on the level of the
influence (i.e., intrapersonal, interpersonal, and/or community), and the level of influence
is often predicated on the size of the priority population. For example, certain processes
are  more useful when planning programs for relatively small groups or communities of
people such as those found in worksites, clinics, and schools, whereas other processes must
be considered when working with larger communities. By community, we do not mean only
those groups of people within a certain geographic area, though that could define a com-
munity, but more specifically, a community is defined as “a collective body of individuals
identified by common characteristics such as geography, interests, experiences, concerns,
or values (Joint Committee on Health Education and Promotion Terminology, 2012, p. 15).
Israel and colleagues (1994) have stated that communities are characterized by the follow-
ing elements: (1) membership—a sense of identity and belonging; (2) common symbol
systems—similar language, rituals, and ceremonies; (3) shared values and norms; (4) mutual
influence— community members have influence and are influenced by each other; (5) shared
needs and commitment to meeting them; and (6) shared emotional connection—members
share common history, experiences, and mutual support. Thus communities can be defined
by location, race, ethnicity, age, occupation, interest in particular problems (e.g., domestic
9
Chapter Community Organizing
and Community Building
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁⦁ Define community, community organizing,
community building, task forces, and coalitions.
⦁⦁ Outline the processes for organizing and
building a community.
⦁⦁ Explain the term mapping community capacity.
Key Terms
active participants
bottom-up
citizen-initiated
coalition
community
community building
community organizing
executive participants
gatekeepers
grassroots
mapping community
capacity
occasional
participants
ownership
potential building
blocks
primary building
blocks
secondary building
blocks
supporting
participants
task force

238 Part 1 Planning a Health Promotion Program
violence), outcomes (e.g., breast cancer survivors), or other common bonds (e.g., people with
a disability) (Turnock, 2012). Today, we can also talk about a cyber community (Minkler,
Wallerstein, & Wilson, 2008).
Although many of the planning processes are applicable regardless of the size of the com-
munity, when working with large communities an additional process is needed in order to
have a successful program. This additional process is organizing those in the community to
come together to work as a group to deal with the needs of the community. This chapter ad-
dresses the fundamental elements of organizing communities for action. Box 9.1 identifies
the responsibilities and competencies for health education specialists that pertain to the
material presented in this chapter.
Community Organizing Background and Assumptions
In recent years, there has been a shift in the focus of the work of planners and others in the
helping professions. Where once the work of planners focused almost solely on the indi-
vidual, today the focus is on broadening to the community. Community-based, community
empowerment, community participation, community partnerships and systems change are among
the many terms that are being used more frequently by health agencies, outside funders, and
policy makers (Minkler, 2012). There are good reasons for the use of these terms and most
revolve around the need for communities to organize.
With the evidence to show that interventions aimed at the community level (also
referred to as population-based approaches) can have a positive affect on the health of a
community, it is important that health education specialists have community organiz-
ing skills. In the early history of the United States, a sense of community was inherent in
everyday life (Green, 1989). It was natural for communities to pool their resources to deal
with shared problems. More recently, the need to organize communities has seemed to
increase. “Advances in electronics (e.g., handheld digital devices) and communications
(multifunction cell phones and Internet), household upgrades (e.g., energy efficiency),
and increased mobility (e.g., frequency of moving and ease of worldwide travel) have
resulted in a loss of a sense of community. Individuals are much more independent than
ever before. The days when people knew everyone on their block are past. Today, it is not
uncommon for people to never meet their neighbors” (McKenzie & Pinger, 2015, p. 135).
Because of these changes in community social structure and the resources necessary to
meet the needs of communities, it now takes a concerted effort to organize a community
to act for the collective good.
“The term community organization was coined by American social workers in the late 1880s
to describe their efforts to coordinate services for newly arrived immigrants and the poor”
(Minkler & Wallerstein, 2012, p. 38). More recently, community organization has been used
by a variety of professionals, including health education specialists, and refers to various
methods of intervention to deal with social problems. “Community organization is impor-
tant in fields like health education and social work partially because it reflects one of their
fundamental principles, that of ‘starting where the people are’ (Nyswander, 1956)” (Minkler
& Wallerstein, 2012, p. 37-38). “The health education professional who begins with the com-
munity’s felt needs, is more likely to be successful in the change process and in fostering true
community ownership of programs and actions” (Minkler et al., 2008, p. 288).

Chapter 9 Community Organizing and Community Building 239
9.1
Responsibilities and Competencies for Health Education Specialists
This chapter focuses on the fundamental elements of organizing communities. As such, the
content presented cuts across several different areas of responsibility for health education
specialists. The responsibilities and competencies related to these tasks include:
RESponSiBility i: Assess Needs, Resources, and Capacity for Health Education/Promotion
Competency 1.1: Plan assessment process for health education/
promotion
Competency 1.2: Access existing information and data related to health
Competency 1.4: Analyze relationships among behavioral,
environmental, and other factors that influence health
RESponSiBility ii: Plan Health Education/Promotion
Competency 2.1: Involve priority populations, partners, and other
stakeholders in the planning process
Competency 2.2: Develop goals and objectives
Competency 2.3: Select or design strategies/interventions
Competency 2.4: Develop a plan for the delivery of health education/
promotion
Competency 2.5: Address factors that influence implementation of
health education/promotion
RESponSiBility iii: Implement Health Education/Promotion
Competency 3.3: Implement health education/promotion plan
RESponSiBility iV: Conduct Evaluation and Research Related to Health Education/Promotion
Competency 4.1: Develop evaluation plan for health education/promotion
RESponSiBility V: Administer and Manage Health Education/Promotion
Competency 5.3: Manage relationships with partners and other
stakeholders
Competency 5.4: Gain acceptance and support for health education/
promotion programs
Competency 5.5: Demonstrate leadership
Competency 5.6: Manage human resources for health education/
promotion
RESponSiBility Vi: Serve as a Health Education/Promotion Resource Person
Competency 6.2: Train others to use health education/promotion skills
Competency 6.3 Provide advice and consultation on health education/
promotion issues
RESponSiBility Vii: Communicate, Promote, and Advocate for Health, Health Education/
Promotion, and the Profession
Competency 7.1: Identify, develop, and deliver messages using a
variety of communication strategies, methods, and techniques
Competency 7.2: Engage in advocacy for health and health education/
promotion
Competency 7.3: Influence policy and/or systems change to promote
health and health education
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education
Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health
Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE).
Box

240 Part 1 Planning a Health Promotion Program
Community organizing has been defined as “the process by which community groups
are helped to identify common problems or change targets, mobilize resources, and develop
and implement strategies to reach their collective goals” (Minkler & Wallerstein, 2012, p. 37).
It is not a science but rather an art of building consensus within the democratic process (Ross,
1967). (See Box 9.2 for definitions of related terms.) Although community organization may
not be as “natural” as it once was, communities can still organize to analyze and solve problems
through collective action. In working toward this end, those who assist communities with orga-
nizing must make several assumptions. Ross (1967, pp. 86–92) has stated these as follows:
1. Communities of people can develop the capacity to deal with their own problems.
2. People want to change and can change.
3. People should participate in making, adjusting, or controlling the major changes taking
place in their communities.
9.2
terms Associated with Community organizing
Citizen Participation The bottom-up, grassroots mobilization of citizens for
the purpose of undertaking activities to improve the
condition of something in the community.
Community Capacity “Community characteristics affecting its ability to
identify, mobilize, and address problems” (Minkler &
Wallerstein, 2012, p. 45).
Community Development “A process designed to create conditions of
economic and social progress for the whole
community with its active participation and the
fullest possible reliance on the community’s
initiative” (United Nations, 1955, p. 6).
Empowerment “Social action process for people to gain mastery over
their lives and the lives of their communities” (Minkler
& Wallerstein, 2012, p. 45).
Grassroots Participation “Bottom-up efforts of people taking collective actions
on their own behalf, and they involve the use of a
sophisticated blend of confrontation and cooperation in
order to achieve their ends” (Perlman, 1978, p. 65).
Macro Practice The methods of professional change that deal with
issues beyond the individual, family, and small group
level.
Participation and Relevance
Social Capital
“Community organizing that ‘starts where the people
are’ and engages community members as equals”
(Minkler & Wallerstein, 2012, p. 45).
“The processes and conditions among people and
organizations that lead to their accomplishing a
goal of mutual social benefit, usually characterized
by interrelated constucts of trust, cooperation,
civic engagement, and reciprocity, reinforced by
networking” (Last, 2007, p. 347)
Fo
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Box

Chapter 9 Community Organizing and Community Building 241
4. Changes in community living that are self-imposed or self-developed have a meaning
and permanence that imposed changes do not have.
5. A “holistic approach” can deal successfully with problems with which a “fragmented
approach” cannot cope.
6. Democracy requires cooperative participation and action in the affairs of the
community, and that the people must learn the skills that make this possible.
7. Frequently communities of people need help in organizing to deal with their needs, just
as many individuals require help in coping with their individual problems.
The Processes of Community Organizing
and Community Building
There is no single unified model of community organizing or community building (Minkler
& Wallerstein, 2012). In fact, Rothman and Tropman (1987, pp. 4–5) have stated, “We should
speak of community organization methods rather than the community organization method.”
The early approaches to community organization used by social workers emphasized the use of
consensus and cooperation to deal with community problems (Garvin & Fox, 2001). However,
the best known categories of community organization were the three put forth by Rothman
(2001) and include locality development, social planning, and social action. More recently, the
strategies have been renamed planning and policy practice, community capacity development, and
social advocacy (Rothman, 2007). At the heart of the planning and policy practice strategy are
data. By using data, community/public health workers generate persuasive rationales that lead
toward proposing and enacting particular solutions (Rothman, 2007).
The community capacity development strategy is based on empowering those impacted by a
problem with knowledge and skills to understand the problem and then work cooperatively
together to deal with the problem. Group consensus and social solidarity are important
components of this strategy (Rothman, 2007). The third strategy, social advocacy, is used to
address a problem through the application of pressure, including confrontation, on those
who have created the problem or stand as a barrier to a solution to the problem. This strategy
creates conflict (Rothman, 2007). Although each of these strategies has unique components,
each of the strategies can be combined with the others to deal with a community problem. In
fact, Rothman has offered a 3 3 3 matrix to help explain the combinations (Rothman, 2007).
Regardless of whether one talks about the “old models” or the “new models,” they all revolve
around a common theme: The work and resources of many have a much better chance of
solving a problem or meeting a goal than the work and resources of a few.
Minkler and Wallerstein (2012) have done a nice job of summarizing the newer perspec-
tives of community organizing with the older models by presenting a typology that incorpo-
rates both needs- and strength-based approaches. That typology is presented in Figure 9.1.
Their typology is divided into four quadrants with strength-based and needs-based on the
vertical axis and consensus and conflict on the horizontal axis. Though this typology sepa-
rates and categorizes the various methods of community organizing and building, Minkler
and Wallerstein (2012) point out that when they
. . . look at primary strategies, we see that the consensus approaches, whether needs based
or strengths based, primarily use collaboration strategies, whereas conflict approaches use
advocacy strategies and ally building to support advocacy efforts. Several concepts span these

242 Part 1 Planning a Health Promotion Program
Social Action
(Alinsky Model)
Community
Development
Community Building
and Capacity Building
(Power With)
Community Capacity
Leadership
Development
Critical Awareness
Empowerment-Oriented
Social Action
(Challenging Power Over)
Grassroots organizing
Organizing coalitions
Lay health workers
Building community identity
Political and legislative actions
Culture relevant practice
ConflictConsensus
Strategies
Collaboration Advocacy
Needs based
Strengths based
⦁▲ Figure 9.1 Community Organization and Community-Building Typology
Source: Minkler, M., & Wallerstein, N. (2012). Improving health through community organization and community building: Perspectives from health education
and social work. In M. Minkler (Ed.). Community organizing and community building for health and welfare (3rd ed., p. 43). New Brunswick, NJ: Rutgers
University Press.
two strengths-based approaches, such as community competence, leadership development, and
multiple perspectives on gaining power. Again, as with the Rothman model, many organizing
efforts use a combination of these strategies at different times throughout the life of an
organizing campaign and community building process (p. 44).
Because the purpose of this chapter is to provide an overview of the community organiz-
ing and community-building processes, and at the risk of oversimplifying the processes, we
would like to present a very general or generic approach to community organizing and com-
munity building (see Figure 9.2). It does not include everything planners need to know about
community organizing and community building, but it does present the basic elements.
For further information about community organizing, refer to any of several references
(Minkler, 2012; Minkler et al., 2008; Ross, 1967; Rothman 2007; Snow, 2001) that are de-
voted entirely to the subject. Also, there are several works that deal specifically with the ap-
plication of community organization to health promotion activities (Karwalajtys et al., 2013;
Minkler, 2012; Minkler et al., 2008).
Before presenting the generic process for community organizing and community build-
ing, we would like to comment on the role of the planner in this process. For many years,
the planner was seen as a “leader” of the community organizing effort. However, more often

Chapter 9 Community Organizing and Community Building 243
Determining the priorities and setting goals
Arriving at a solution and selecting intervention strategies
Implementing the plan
Evaluating the outcomes of the plan of action
Maintaining the outcomes in the community
Looping back
Assessing the community
Organizing the people
Gaining entry into the community
Recognizing the issue
⦁▲ Figure 9.2 Summary of the Steps in Community Organizing and Building

244 Part 1 Planning a Health Promotion Program
than not, the planner is an “outsider” with regard to the community being organized and, as
such, has trouble gaining the credibility to serve as a leader. Yes, he or she may work in the
community (remember that a community is often defined by something other than geo-
graphical boundaries) but often lives outside the community in which the organizing effort
is needed. Thus, the role that the planner should take is that of a facilitator or assistant rather
than the leader. Experience has shown that it is best if the leaders come from within the com-
munity. Keep this thought in mind as you read through the general model.
Recognizing the issue
The processes of community organizing and building begin when someone recognizes that
an issue exists in the community and that something needs to be done about it. This recogni-
tion may occur as a result of someone reviewing health data on the community and seeing a
need (e.g., an unusually high number of teenage pregnancies), by someone actually observ-
ing a specific situation in the community that needs attention (e.g., injuries at a particular in-
tersection), or as the result of a community crisis (e.g., lack of resources to deal with a natural
disaster). “This person (or persons) is referred to as the initial organizer. This individual may
not be the primary organizer throughout the community organizing/building process. He or
she is the one who gets things started” (McKenzie & Pinger, 2015, p. 138). For the purposes
of this discussion, assume that the concern is a health problem, but remember that the com-
munity organization process may be used with any type of problem found in a community.
Concerns can be as specific as trying to get a certain piece of legislation passed or as general as
advocating for a drug-free community.
The recognition of an issue can occur from inside or outside the community. A citizen or
a church leader from within the community may identify the issue, or it may first be iden-
tified by someone outside the community, such as an employee of a local or state health
department, a state legislator, a politically active group, or someone from a local voluntary
health agency. However, the community organizing efforts that have been most successful
have been those that are recognized from the inside. The primary reason for this is that those
within the community are much more likely to take ownership of the effort. It is difficult
for someone from the outside coming in and telling community members that they have
problems or issues that need to be dealt with and they need to organize to take care of them.
When there is internal recognition of the issue or concern, it is referred to as grassroots,
citizen-initiated, or bottom-up organizing.
Gaining Entry into the Community
The second step of this generic process of community organizing and community building
may or may not be needed. If the issue identified in the previous step is recognized by some-
one from within the community, then this step of the process will, more than likely, not be
needed. We say “more than likely” because those within a community do not need to gain
entry into it. But there may be some cases when someone from within a community may
identify the issue but has not lived in the community long enough, lacks the political power,
or does not know enough about the interactions of the community to proceed with the pro-
cess. In these later cases, the person may be treated or feel like an “outsider” and may have to
proceed as an outsider would.

Chapter 9 Community Organizing and Community Building 245
If the issue is identified by someone from outside the community this becomes a most
critical step in the process. Recognition of a concern does not mean that people should
immediately set about correcting it. Instead, they should follow a set of steps to deal with
it; gaining proper “entry” into the community is the first step. Braithwaite and colleagues
(1989) have stressed the importance of tactfully negotiating entry into a community with
the individuals who control, both formally and informally, the “political climate” of the
community. These individuals are referred to as gatekeepers. The term infers that one must
pass through the “gate” in order to get at the people in the community (Wright, 1994). These
“power brokers” know their community, how it functions, and how to accomplish tasks
within it. Longtime residents are usually able to identify the gatekeepers of their community.
They may include people such as business leaders, education leaders, heads of law enforce-
ment agencies, leaders of community activist groups, parent and teacher groups, clergy,
politicians, and others. Their support is absolutely essential to the success of any attempt to
organize a community.
Organizers must approach the gatekeepers on the gatekeepers’ terms and “play” the
gatekeepers’ “game.” However, before making this contact, organizers must first be famil-
iar with the community with which they are working. “They must be culturally sensitive
and work toward cultural competence. That is, they must be aware of the cultural differences
within a community and effectively work with the cultural context of the community”
(McKenzie & Pinger, 2015, p. 139). Tervalon and Garcia (1998) stress the need for cultural
humility—openness to others’ culture. In other words, community organizers must have
a thorough knowledge of the community and the people living there before they try to
enter the informal boundaries of the community (Braithwaite et al., 1989). Having a thor-
ough understanding of the community and tactfully approaching its gatekeepers will help
community organizers develop credibility and trust with those in the community, and, as
noted earlier, it is not easy to bring a concern to the attention of those in the community.
Few people are glad to know they have a problem, and fewer still like others to tell them
they have a problem. Move with caution, and do not be too aggressive!
When people from outside the community are working to facilitate the organizing efforts,
they will find it advantageous to enter the community through an already established, well-
respected organization or institution in the community, such as a church, a service group, or
another successful local group. If those who make up an existing organization/institution in
the community can see that a problem exists and that solving the problem will improve the
community, it can help smooth the way to gaining entry and achieving the remaining steps
in the process.
organizing the people
Obtaining the support of the community members to deal with the concern is the next
step in the process. It is best to begin with those individuals who are already interested
in addressing the concern. This is not the time to try to convert people to the cause or to
make sure that all the key players of the community are involved. The initial group must
be made up of those people most affected by the problem and who want to see change
occur. For example, if the identified problem is teenage drug use, then teens needed to
be included in the group. If the issue is housing for individuals with low-incomes, then

246 Part 1 Planning a Health Promotion Program
those individuals need to be included. If the problem is something that a community
agency or organization (e.g., the local health department or a social service agency) has
dealt with for a period of time but is unable to solve, then this group should be involved.
Or, if a group of parents, or another defined group, has been struggling with the problem
without resolution, then its leaders should be invited to participate. More often than not,
this core group will be small and consist of people who are committed to the resolution
of the concern, regardless of the time frame. Brager and colleagues (1987) have referred
to this core group as executive participants. From among the core group, a leader
or coordinator must be identified. If at all possible, the leader should be someone with
leadership skills, good knowledge of the concern and the community, and most of all,
someone from within the community. One of the early tasks of the leader will be to help
build group cohesion.
Not everyone is cut out to be an organizer or a leader. Researchers have found that good
organizers are successful because of a combination of skills and attributes. These skills and at-
tributes fall into three main areas: change vision attributes, technical skills, and interactional
or experience skills. Change vision attributes are closely aligned with an organizer’s view of the
world political terms. These people see a need for change and are personally dedicated and
committed to seeing the change occur—so much so that they are willing to put other priori-
ties aside to see the project through (Mondros & Wilson, 1994).
Technical skills include two areas: those related to efficacy on issues and those related to
organizational health and effectiveness. The former includes being able to analyze issues,
opponents, and power structure; develop and implement change strategies; achieve goals;
and possess outstanding communication and public relation skills. Organizational health
and effectiveness skills include building structures for the recruitment and involvement of
others, forming and maintaining task groups, and implementing skills of fundraising and
organizational management (Mondros & Wilson, 1994).
The third characteristic of a good organizer is possessing interactional or experience skills.
These include an ability to respond with empathy, to assess and intervene with individuals
and groups, and to be able to identify, develop, educate, and maintain organizational mem-
bers and leaders (Mondros & Wilson, 1994).
With the core group and leader in place, the next step is to expand the group to build
support for dealing with the concern—that is, to broaden the constituency. Brager and col-
leagues (1987) have noted that other group participants will include active, occasional, and
supporting participants. The active participants (who may also be executive participants)
take part in most group activities and are not afraid to do the work that needs to be done.
The occasional participants become involved on an irregular basis and usually only
when major decisions are made. The supporting participants are seldom involved but
help swell the ranks and may contribute in nonactive ways or through financial contribu-
tions. When expanding the group, look for others who may be interested in helping, and
ask current group members for names of people who might be interested. Look for people
who may already be dealing with the concern, affected by the problem through their pres-
ent work, or who have resources to contribute. This search should include existing social
groups, such as voluntary health agencies, agricultural extension services, religious orga-
nizations, hospitals, health care providers, political officeholders, policy makers, police,
educators, lay citizens, or special interest groups. (See Box 9.3 on tips for understanding the
diversity in a working group.)

Chapter 9 Community Organizing and Community Building 247
9.3
Understanding Diversity
Members of a group come from many different backgrounds. Some members may be
much older or much younger than other members; some may represent different cultural,
racial, or ethnic groups; some may represent different educational levels and abilities.
Extra awareness and flexibility are required for the facilitator and other group members
to remain sensitive to different backgrounds. Below we suggest a few ways to improve
your awareness of differences. In general, new information is acquired so that different
perspectives can be understood and appreciated.
⦁⦁ Become aware of differences in the group by asking questions and getting involved in
small group discussions.
⦁⦁ Seek involvement and input and listen to persons of different backgrounds without
bias, and avoid being defensive.
⦁⦁ Learn the beliefs and feelings of specific groups about particular issues.
⦁⦁ Read about current and emerging issues that concern different groups, and read
literature that is popular among different groups.
⦁⦁ Learn about the language, humor, gestures, norms, expectations, and values of
different groups.
⦁⦁ Attend events that appeal to members of specific groups.
⦁⦁ Become attuned to cultural clichés, stereotypes, and distortions you may encounter in
the media.
⦁⦁ Use examples to which persons of different cultures and backgrounds can relate.
⦁⦁ Learn the facts before you make statements or form opinions about different groups.
Source: Centers for Disease Control and Prevention, USDHHS, (no date), p. A2–15.
Fo
cu
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Box
Over the last 50 years, in many communities the number of people interested in volunteer-
ing their time has decreased. Today, if you ask someone to volunteer, you may hear the reply,
“I’m already too busy.” There are two primary reasons for this response. First, there are many
families in which both husband and wife work outside the home. Second, there are more
single-parent households. (See Box 9.4 for tips on working with volunteers.)
Sometimes these expanded community groups become task forces or coalitions. A task
force has been defined as “a self-contained group of ‘doers’ that is not ongoing. It is con-
vened for a narrow purpose over a defined timeframe at the request of another body or com-
mittee” (Butterfoss, 2013, p. 7). A coalition is “a formal alliance of organizations that come
together to work for a common goal” (Butterfoss, 2007, p. 30)—often, to compensate for
deficits in power, resources, and expertise. Coalitions “develop an internal decision-making
and leadership structure that allows member organizations to speak with a united voice and
engage in shared planning and implementation activities. Links to outside organizations
and communication channels are formal. Member organizations are willing to pull resources
from existing systems, as well as seek new resources to develop a joint budget. Agreements,
benchmarks, roles, and assignments are often written” (Butterfoss, 2007, p. 30). The under-
lying concept behind coalitions is collaboration; for several individuals, groups, or orga-
nizations with their collective resources have a better chance of solving the problem than
any single entity. “Building and maintaining effective coalitions have increasingly been
recognized as vital components of much effective community organizing and community

248 Part 1 Planning a Health Promotion Program
building” (Minkler, 2012, p. 20). Much has been written about the importance and use of co-
alitions. Aitaoto, Tsark, and Braun (2009) found that the key to sustaining coalitions include
having a champion, a supportive organizational home, and access to technical assistance
and resources. Woods and colleagues (2014) presented a case study on the importance of
training and technical assistance on coalition functioning and sustainability. Butterfoss
(2009) has created a longer list of characteristics of successful coalitions (see Box 9.5), while
Kegler and Swan (2011) have tested the community coalition action theory (CCAT) for
consistency of its constructs with working community coalitions. Brown, Feinberg, and
Greenberg (2012) have created a Web-based, self-report questionnaire that can be used to
provide feedback to coalitions and technical assistance providers about coalition function-
ing. For those who want more information about coalition development, Butterfoss (2007,
2009, 2013), Butterfoss and Kegler (2012), and Goldstein (1997), provide nice overviews of
the processes of building and sustaining coalitions.
Assessing the Community
Earlier in this chapter we noted that there were a number of strategies that have been used
for community organizing. Many of those community organizing strategies operate “from
the assumption that problems in society can be addressed by helping the community be-
come better or differently organized, and each strategy perceives the problems and how or
whom to organize somewhat differently” (Walter, 2005, p. 66). In contrast to those strategies
tips on Working with Volunteers
Volunteers work for self-satisfaction, personal growth, fun, and other intangible rewards.
Each volunteer should be treated as a colleague and recognized as an official part of the
team. However, offer volunteers more flexibility than you can to employees, and adjust
your expectations accordingly. For example, because volunteers cannot contribute as much
time as paid, full-time workers do, they cannot complete tasks as quickly. When scheduling
activities, be realistic about how long a busy participant will need to complete it.
Get to know each volunteer personally so that you can learn about special abilities
and limitations and match responsibilities to skills. Vary responsibilities as desired by
volunteers.
Be sure to assign specific and clearly defined tasks and to explain procedures and
expectations. Develop a work plan or job description for the volunteer to help ensure that
roles and responsibilities are understood. Provide training and give credit for work done.
Give lots of feedback, encouragement, and signs of appreciation. Be willing to change
the placement of volunteers, if that seems appropriate, or even dismiss a volunteer if
necessary.
Keep in mind the following key points of working with volunteers. They want to be:
⦁⦁ appreciated for the work that they do.
⦁⦁ busy with worthwhile and varied tasks.
⦁⦁ provided with clear communication about tasks and expectations.
⦁⦁ developed through training.
Source: Centers for Disease Control and Prevention (no date), p. A2–17.
H
ig
hl
ig
ht
s
Box
9.4

Chapter 9 Community Organizing and Community Building 249
Characteristics of Successful Coalitions
⦁⦁ Continuity of coalition staff, in particular the coordinator position
⦁⦁ Ownership of the problem by coalition members and the community
⦁⦁ Community leaders support the coalition and its efforts
⦁⦁ Active involvement of community volunteer agencies
⦁⦁ High level of trust and reciprocity among members
⦁⦁ Frequent and ongoing training for coalition members and staff
⦁⦁ Benefits of membership outweigh the costs
⦁⦁ Active involvement of members in developing coalition goals, objectives, and
strategies
⦁⦁ Development of a strategic action plan rather than a project-by-project approach
⦁⦁ Consensus is reached on issues instead of voting
⦁⦁ Productive coalition meetings
⦁⦁ Large problems are broken down into smaller, solvable pieces
⦁⦁ Steering committee of elected leaders and staff guides coalition
⦁⦁ Task or work groups of members design and implement strategies
⦁⦁ Rules and procedures are formalized
⦁⦁ Local media are actively involved
⦁⦁ Coalition and its activities are evaluated continuously
Source: “Building and Sustaining Coalitions.” F. D. Butterfoss, from Community Health Education Methods: A Practical Guide. R. J. Bensley and J. Brookins-Fisher
(Eds.). Copyright © 2009 by Jones & Bartlett Learning. Reprinted with permission.
Fo
cu
s
O
n
Box
9.5
is community building. Community building “is an orientation to practice focused on
community, rather than a strategic framework or approach, and on building capacities, not
fixing problems” (Minkler, 2012, p. 10). Community building is intended to affirm strong
community-rooted traditions, and to build on the good work already going on in commu-
nities (Kretzmann & McKnight, 1993). One of the major differences between community
organization and community building is the type of assessment that is used to determine
where to focus the community’s efforts. In the community organization approach, the as-
sessment is focused on the needs of the community, whereas in community building, the
assessment focuses on the assets and capabilities of the community. A clearer picture of the
community will be revealed, and a stronger base will be developed for change, if the assess-
ment includes the identification of both the needs and assets, and involves those who live in
the community.
You may recall (in Chapter 4) we outlined the procedures for conducting a needs as-
sessment and described how the resulting needs could be placed on a map (i.e., mapping)
to provide a visual representation of the needs of a community. Figure 9.3 provides an ex-
ample of such a map. However, an assessment that focuses entirely on needs/deficiencies
presents only half of the information that is needed in community organizing and building
(McKnight & Kretzmann, 2012). Organizers also need to know the capacities and assets.
McKnight and Kretzmann (2012) point out “communities have never been built upon their
deficiencies. Building community has always depended on mobilizing the capacities and as-
sets of a people and a place” (p. 183).

250 Part 1 Planning a Health Promotion Program
In order to map community assets—a process referred to as mapping community
capacity—McKnight and Kretzmann (2012) have categorized assets into three different
groups based on their availability to the community and refer to them as building blocks.
Primary building blocks are the most accessible assets (see Figure 9.4). They are located in
the neighborhood and are largely under the control of those who live in the neighborhood.
Primary building blocks can be organized into the assets of individuals and those of organiza-
tions or associations. (See Box 9.6 for examples of each.) The next most accessible building
blocks are secondary building blocks, which are assets located in the neighborhood but
largely controlled by people outside. The least accessible assets are referred to as potential
building blocks. They are resources originating outside the neighborhood and controlled
by people outside. Figure 9.4 presents an example of an asset map using the three types of
building blocks. Knowing both the needs and assets of the community, organizers can work
to identify the true concerns of the community and the capacity to deal with them.
Slum housing
S
lu
m
h
o
u
si
n
g
T
ru
a
n
cy
Crime
Mental
illness
Rat
bites
Drug
abuseTeenage
pregnancy
Lead
poisoning
Welfare
dependency
Domestic
violence
Alcoholism
AIDS
Dropouts
Pollution
Unemployment
Boarded-up
buildings
Broken
families
Child abuse
Homelessness
Abandonment
Illiteracy
Gangs
⦁▲ Figure 9.3 Neighborhood Needs Map
Source: Kretzman, John P. and John L. McKnight. “Figure 10.1: Neighborhood Needs Map,” “Mapping Community Capacity” in Community Organizing
and Community Building for Health and Welfare. Copyright © 2012 by Meredith Minkler. Reprinted by permission of Rutgers University Press.

Chapter 9 Community Organizing and Community Building 251
Public information
P
u
b
lic
in
fo
rm
a
tio
n
LIBRARIES
FIRE
DEPTS.
PARKSPersonal
incomePUBLIC
SCHOOLS
Cultural
organizations
Associations
of business
Capital
improvement
expenditures
POLICE
VACANT
BLDGS.,
LAND,
ETC.
SOCIAL
SERVICE
AGENCIES
Gifts of
labeled
people
Religious
organizations
Citizens
associations
HIGHER
EDUCATION
INSTITUTIONS
Home-based enterprise
ENERGY/
WASTE RESOURCES
Welfare expenditures
Individual
capacities
Individual
businesses
H
O
S
P
I
T
A
L
S
Primary Building Blocks:
Legend
Secondary Building Blocks:
Potential Building Blocks:
Assets and capacities in the neighborhood,
largely under neighborhood control.
Assets in the community, largely controlled by
outsiders.
Resources outside the neighborhood, controlled
by outsiders.
⦁▲ Figure 9.4 Neighborhood Assets Map
Source: Kretzman, John P. and John L. McKnight. “Figure 10.2: Neighborhood Assets Map,” “Mapping Community Capacity” in Community Organizing
and Community Building for Health and Welfare. Copyright © 2012 by Meredith Minkler. Reprinted by permission of Rutgers University Press.

252 Part 1 Planning a Health Promotion Program
9.6
Building Blocks (Assets) of Communities
primary Building Blocks
Individual assets
⦁⦁ Skills and abilities of residents
⦁⦁ Individual businesses
⦁⦁ Home-based enterprises
⦁⦁ Personal income
⦁⦁ Gifts of labeled (disabled) people
Organizational assets
⦁⦁ Associations of businesses (e.g., chamber of commerce)
⦁⦁ Citizens’ associations (e.g., neighborhood watch)
⦁⦁ Cultural organization (e.g., Old West End Festival, British Club)
⦁⦁ Communications organizations (e.g., newspapers, TV, radio)
⦁⦁ Religious organizations
⦁⦁ Financial institutions
Secondary Building Blocks
Private and nonprofit organizations
⦁⦁ Higher education institutions
⦁⦁ Hospitals
⦁⦁ Social service groups (e.g., Rotary, Kiwanis)
Public institutions and services
⦁⦁ Public schools
⦁⦁ Police and fire departments
⦁⦁ Libraries
⦁⦁ Parks
Physical resources
⦁⦁ Vacant land, vacant commercial and industrial structures, vacant housing
⦁⦁ Energy and waste resources
potential Building Blocks
Welfare expenditures
Public capital-information expenditures
Public information
Source: “Mapping Community Capacity” by J. L. McKnight and J. P. Kretzmann from Community Organizing and Community Building for Health,
Ed. M. Minkler. Copyright © 2005 by Rutgers, the State University Press.
Fo
cu
s
O
n
Box
Determining priorities and Setting Goals
Once the community has been assessed, the community group is ready to develop its
goals. The goal-setting process includes two phases. The first phase consists of identifying
the priorities of the group—what the group wants to accomplish. The priorities should be
determined through consensus rather than through formal voting. (See Box 9.7 for tips on
how to reach consensus.) The second phase consists of using the priority list to write the

Chapter 9 Community Organizing and Community Building 253
9.7
Reaching Consensus
Groups sometimes find it hard to reach a consensus, or general agreement. Remind
participants of the following guidelines to group decision making.
⦁⦁ Avoid the “one best way” attitude; the best way is that which reflects the best
collective judgment of the group.
⦁⦁ Avoid “either, or” thinking; often the best solution combines several approaches.
⦁⦁ A majority vote is not always the best solution. When participants give and take,
several viewpoints can be combined.
⦁⦁ Healthy conflict, which can help participants reach a consensus, should not be
smoothed over or ended prematurely.
⦁⦁ Problems are best solved when participants try to both communicate and listen.
If a group has trouble reaching consensus, consider using some special techniques such
as brainstorming, the nominal group process, and conflict resolution.
Source: Centers for Disease Control and Prevention (no date), p. A2–12
Fo
cu
s
O
n
Box
goals. To help ensure that the ideals of community organization take hold, the stakehold-
ers (those in the community who have something to gain or lose from the community
organizing and building efforts) must be the ones to establish priorities and set goals. This
may sound simple, but in fact it may be the most difficult part of the process. Getting the
stakeholders to agree on priorities takes a skilled group facilitator because there is sure to be
more than one point of view.
When working with coalitions and task forces, one is likely to face some challenges
(Clark, Friedman, & Lachance, 2006). One challenge that may surface when determining
priorities and setting goals is turf struggles (disagreements over the control of resources
and responsibilities). Even though individuals or representatives of their organizations
have come together to solve a problem, many people will still be concerned with finding
specific solutions to the problems faced by their organization. For example, in the case
of drug abuse in the community, consensus may indicate that the majority of people
believe the solutions lie in the educational system, but people who work in drug treat-
ment centers may believe that they lie in the treatment of drug abuse. The facilitator
will need special skills to keep these treatment center people involved after the priority-
setting process does not identify their concern as a problem the group will attack. One
means of dealing with this is to have subgoals that can be worked on by special interest
subcommittees. Such an arrangement will allow the subcommittee to have a feeling of
ownership in the process.
Miller (2009) and Staples (2012) have identified criteria that community organizers need
to consider when determining priorities and setting goals. The concern/issue/problem: must
be winnable, ensuring that working on it does not simply reinforce fatalistic attitudes and
beliefs that things cannot be improved; must be simple and specific so that any member of
the organizing group can explain it clearly in a sentence or two; must unite members of the
organizing group; and must involve them in a meaningful way in achieving concern/issue/
problem resolution.

254 Part 1 Planning a Health Promotion Program
Arriving at a Solution and Selecting intervention Strategies
To achieve the goals that it has set, the group will need to identify alternative solutions and—
again, through consensus—choose a course of action. Most community problems/issues/
concerns can be dealt with in any of several ways; however, each alternative has advantages
and disadvantages. The group should examine the alternatives in terms of probable outcomes,
acceptability to the community, probable long- and short-term effects on the community, and
the cost of resources to solve the problem. Most of the intervention strategies discussed earlier
(in Chapter 8) are means by which the group can address the problem/issue/concern.
Much of the work to identify the appropriate solution(s) can be accomplished through
subcommittees. Subcommittees can complete specific tasks that will contribute to the larger
plan of action. Their work should yield specific strategies that are culturally sensitive and ap-
propriate for the community. The plan of action is usually written in a proposal format and
will be given final approval at a meeting of the full committee or coalition. It is important to
take care in putting together this proposal; as many as possible of the ideas of the various sub-
committees should be included. This will help to ensure approval of the entire plan. In the
end, the real test of the course of action selected is whether it can provide whatever it is the
people are seeking (Brager et al., 1987).
Final Steps in the Community organizing and Building processes
The final four steps in community organizing and building processes include implementing
the plan, evaluating the outcomes of the plan of action, maintaining (or sustaining) the out-
comes in the community, and, if necessary, “looping” back to the appropriate point in the
process to modify the steps and restructure the work plan. Implementation of the interven-
tion strategy includes identifying and collecting the necessary resources for carrying out the
solution and creating an appropriate time line for implementation. Often the resources can
be found within a community and thus horizontal relationships (the interaction of local units
with one another) are needed (Warren, 1963). Other times the resources must be obtained
from units located outside the community and in this case vertical relationships (those where
local units interact with extra-community systems) are needed (Warren, 1963). An example
of this latter relationship is the interaction between a local chamber of commerce and its
state affiliate. More detailed information on implementation is presented later (Chapter 12).
The evaluation step of the community organizing and building process includes two types
of evaluation: formative and summative evaluation. Briefly, formative evaluation deals with the
measurement of the process used to improve the quality of the effort, whereas summative evalu-
ation focuses on comparing the outcomes of the process to the earlier stated goals (see Chapters
13 and 14 for more on evaluation). When reporting on the work of coalitions, Clark and her
colleagues (2006) stated process evaluation (a form of formative evaluation) “was the easier type
of assessment to conduct. Effective tools are more available, data collection is more immedi-
ate, and problems of association and correlation are less daunting than those associated with
outcome evaluation. Outcome evaluation requires time, patience, and the willingness to accept
that in complex community settings, definitive conclusions are elusive” (p. 152S).
Maintaining or sustaining the outcomes may be one of the most difficult steps in the en-
tire process. Maintaining or sustaining the outcomes are challenged by (1) the energy and ef-
fort necessary to stay organized, (2) continuing the interest and involvement of the members
(Clark et al., 2006), (3) the training and technical assistance provided (Woods et al., 2014),

Chapter 9 Community Organizing and Community Building 255
(4) continuing need for funding to sustain the efforts, and (5) “ensuring the lasting impact
of their work through policies, cross-facility agreements, standardized protocols, and so on”
(Clark et al., 2006, p. 151S). At this point organizers need to seriously consider the need for
long-term capacity for a lasting solution.
Through the steps of implementation, evaluation, and maintenance/sustainability of
the outcomes, organizers may see a need to “loop back” to a previous step in the process to
rethink or rework before proceeding onward in their plan. And finally, once the work of the
group has been completed (that is, either the issue has been solved or community empower-
ment achieved), the group can either disband or reorganize to deal with other issues.
Summary
Community organization refers to various methods of intervention whereby individuals,
groups, and organizations engage in planned collective action to deal with social concerns.
The literature on community organizing and building is not distinct; it is often intertwined
with such terms as community-based, community empowerment, community participation, com-
munity partnerships, and systems change. The process of community organization has been
used for many years in the area of social work, but its history in the area of health promotion
is much more recent. This chapter presented generic processes for community organizing
and building, which should be an adequate introduction to the process.
Review Questions
1. What is meant by the term community?
2. How does community organization relate to community empowerment?
3. From which discipline did community organization originate?
4. What is the underlying concept of community organization?
5. What are some of the assumptions under which planners work when organizing a
community?
6. What are the basic steps in the community organizing and building processes?
7. What is the difference between a task force and a coalition?
8. What is meant by the term gatekeepers?
9. What is the difference between a needs assessment and a capacities and assets assessment?
10. What is meant by mapping community capacity?
11. What are the differences among primary, secondary, and potential building blocks (assets)?
Activities
1. Assume that a core group of individuals have come together to deal with concern about
the high rate of teenage pregnancy in a community. Identify (by job title/function)
others who you think should be invited to be part of the larger group. In addition,
provide a one-sentence rationale for inviting each. Assume that this community is large
enough to have most social service organizations.

256 Part 1 Planning a Health Promotion Program
2. Provide a list of at least 10 different community agencies that should be invited to make
up an antismoking coalition in your hometown. Provide a one-sentence rationale for
including each.
3. Ask your professor if he or she is aware of any ongoing coalitions in the local community.
If some exist, along with several of your classmates, select one of interest and contact the
chairperson to see if it would be okay to attend a coalition meeting. After the meeting,
write a two page paper that includes the following: (a) name of coalition, (b) purpose of
the coalition, (c) goal(s) of the coalition, (d) list of coalition members, (e) strategies used
to accomplish the goal(s), and (f) accomplishments of coalition to date. If you are missing
any of this information after the meeting, stay after the meeting and ask the chairperson
if he or she would provide such information.
4. Assume that you want to make entry into a community with which you are not familiar
in order to help to organize and build the community. Describe such a community, and
then write a two-page paper to tell what steps you would take to gain entrance into the
community.
5. If you wanted to find out more about your community’s resources regarding exercise
programs, with whom would you network? Provide a list of at least five contacts, and
provide a one-sentence rationale for why you selected each.
6. Ask your professor if he or she is aware of any community organizing or building efforts
in a local community. If such exists, make an appointment along with some of your
classmates to interview the organizers. Ask the organizers to respond to the following
questions: (a) What concern is the group tackling? (b) Who identified the initial
concern? (c) Who makes up the core group? How large is it? (d) Did the group complete
an assessment? (e) What type of intervention is being used? and (f) What type of
community organizing or building model was used?
7. To get a feel for the process of mapping community capacity, obtain a map of your
college/university and “map” the health-related assets on your campus. Try to identify
the assets in terms of primary, secondary, and potential building blocks for the campus
as defined by McKnight and Kretzmann (2012). After your map is complete, analyze
what you have found. Where are most of the assets located? Did the results surprise you?
If your campus were going to increase its health capacity, what would you recommend?
Why?
Weblinks
1. http://www.abcdinstitute.org
Asset-Based Community Development (ABCD) Institute, Northwestern University
The ABCD, a part of the Center for Civic Engagement, was founded by Jody Kretzmann
and John L. McKnight. The Website provides a variety of information on community
building including training videos and podcasts, a tool kit with templates for community
mapping, and an overview of the research projects in which its staff is involved.
2. http://ctb.ku.edu/en
The Community Tool Box (CTB), University of Kansas
The CTB provides practical information to support work in promoting community
health and development. This Website is maintained by the Work Group on Health

http://www.abcdinstitute.org

http://ctb.ku.edu/en

Chapter 9 Community Organizing and Community Building 257
Promotion and Community Development at the University of Kansas in Lawrence,
Kansas, and offers a list of chapters that provide step-by-step guidance for community-
building skills. Within each chapter are a number of sections that include background
information, examples, tools and checklists, and PowerPoint® slides. It also includes
databases of best practices.
3. http://here.doh.wa.gov/professional-resources/planning
Health Education Resource Exchange (H.E.R.E.), Washington State Department of Health
H.E.R.E. is a Website of the Washington State Department of Health designed as
an online clearinghouse of public health and health promotion materials, events,
resources, and news. It is designed to assist individuals who perform population-based
health promotion activities in a variety of settings. It includes a number of resources on
community engagement and mobilization.

http://here.doh.wa.gov/professional-resources/planning

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The chapters in this section present information used
in implementing a health promotion program. The
chapters identify important components related to
implementation and address the challenges one may face
during the implementation process.
Part II ImplementIng a
HealtH promotIon program
Chapter 10

261
Identification and allocation
of resources
Chapter 11

291
Marketing: Developing
Programs that respond
to the Wants and Needs of
the Priority Population
Chapter 12

319
Implementation: Strategies
and associated Concerns

This page intentionally left blank

261
10
Chapter Identification and allocation
of resources
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁⦁ Define resources.
⦁⦁ List the common resources used in most health
promotion programs.
⦁⦁ Identify the tasks to be carried out by program
personnel.
⦁⦁ Explain the difference between internal and
external personnel.
⦁⦁ Explain how technical assistance, volunteers,
teamwork, and cultural factors are related to
program personnel.
⦁⦁ Define culturally competent.
⦁⦁ Explain what is meant by the term canned
health promotion programs.
⦁⦁ Identify questions to ask vendors when they are
selling their programs, products, and services.
⦁⦁ List and explain common means of financing
health promotion programs.
⦁⦁ Identify and explain the major components
of a grant proposal.
⦁⦁ Define budget.
⦁⦁ Explain what is meant by direct and indirect costs.
Key Terms
adjourning
budget
budget narrative
canned program
cultural competence
curriculum
direct cost
external personnel
flex time
forming
full-time equivalent
(FTE)
gift
grant
grantsmanship
hard money
indirect cost
in-house materials
in-kind contributions
internal personnel
memorandum of
understanding
(MOU)
norming
peer education
performing
profit margin
proposal
reforming
request for
applications
(RFAs)
request for proposals
(RFPs)
resources
SAM
seed dollars
sliding-scale fee
soft money
speakers’ bureaus
storming
team
technical assistance
vendors
volunteers
For a program to reach its identified goals and objectives, it must be supported with the
appropriate resources. Resources include the “human, fiscal, and technical assets available”
(Johnson & Breckon, 2007, p. 296) to plan, implement, and evaluate a program. The resources
needed to plan, implement, and evaluate a program depend on the scope and nature of the

262 Part 2 Implementing a Health Promotion Program
program. Most resources carry a “price tag,” which planners must take into account. Thus
planners face the task of securing the financial resources necessary to carry out a program.
However, several different resources are provided by organizations, mostly voluntary or govern-
mental health organizations, that are free or inexpensive. This chapter identifies, describes, and
suggests sources for obtaining the resources commonly needed in planning, implementing, and
evaluating health promotion programs. Box 10.1 identifies the responsibilities and competen-
cies for health education specialists that pertain to the material presented in this chapter.
10.1
Responsibilities and Competencies for Health Education Specialists
This chapter focuses on identifying and allocating resources needed to plan, implement,
and evaluate a program. Because resources are needed for all aspects of the program,
Chapter 10 cuts across several different areas of responsibility. The responsibilities and
competencies related to these tasks include:
RESponSiBility i: Assess Needs, Resources, and Capacity for Health Education/Promotion
Competency 1.1: Plan assessment process for health education/
promotion
RESponSiBility ii: Plan Health Education/Promotion
Competency 2.1: Involve priority populations, partners, and other
stakeholders in the planning process
Competency 2.4: Develop a plan for the delivery of health education/
promotion
Competency 2.5: Address factors that influence implementation of
health education/promotion
RESponSiBility iii: Implement Health Education/Promotion
Competency 3.1: Coordinate logistics necessary to implement plan
Competency 3.3: Train staff members and volunteers involved in
implementation of health education/promotion
RESponSiBility iV: Conduct Evaluation and Research Related to Health Education/
Promotion
Competency 4.1: Develop evaluation plan for health education/
promotion
Competency 4.2: Develop a research plan for health education/promotion
RESponSiBility V: Administer and Manage Health Education/Promotion
Competency 5.1: Manage financial resources for health education/
promotion programs
Competency 5.2: Manage technology resources
Competency 5.3: Manage relationships with partners and other
stakeholders
Competency 5.6: Manage human resources for health education/
promotion programs
RESponSiBility Vi: Serve as a Health Education/Promotion Resource Person
Competency 6.2: Train others to use health education/promotion skills
Competency 6.3: Provide advice and consultation on health education/
promotion issues
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education
Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health
Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE).
Box

Chapter 10 Identification and allocation of resources 263
Box 10.2 lists the major categories of resources and accompanying questions that need to
be answered in order to have the necessary resources to plan, implement, and evaluate a pro-
gram. If you are currently planning a health promotion program, take a few minutes to read
through the list and attempt to answer the questions as they pertain to the program you are
planning before you read the rest of the chapter.
10.2
What Resources Are needed to plan, implement, and Evaluate
a program?
personnel
⦁⦁ Who is needed to plan the program? Professionals? Advisory committee?
⦁⦁ Who is needed to implement the program? Facilitators? Support staff? Volunteers? Will
you use a vendor?
⦁⦁ Who will evaluate the program? Someone associated with the program? Someone from
outside?
⦁⦁ Is there a need for a partnership? If so, who would be appropriate partners?
Curriculum and other instructional resources
⦁⦁ What educational materials are needed to implement the program? Will the planners
create them? Will they be purchased? Will they be donated? Can the materials be
adopted or adapted from another program?
⦁⦁ Is there a need for a curriculum?
⦁⦁ Will a canned program be used?
Space
⦁⦁ What space is needed to implement the program? How will you obtain the space? Will
there be a charge for the space? Will it be donated? If donated, are there hidden costs
like paying for custodial services?
Equipment
⦁⦁ What equipment is needed to plan the program? Is office equipment such as computers
and copy machines needed?
⦁⦁ Is equipment needed for implementation such as tables and chairs, instructional
equipment (e.g., computer and projector), exercise equipment, etc.?
Supplies
⦁⦁ What supplies are needed for planning the program such as typical office supplies? Are
postal and mailing supplies needed?
⦁⦁ What supplies are needed for implementation? Who will provide them? Planners?
Participants? Outside group?
⦁⦁ What supplies are needed for evaluation? For example, supplies needed for data
collection.
Financial resources
⦁⦁ How will the program be paid for? Will the planning group pay for it? Will the program
participants pay for it? Will some third party pay for it (i.e., sponsoring group or
agency, grant funded)? Or will it be paid for by a combination of sources?
⦁⦁ Who is responsible for creating and monitoring the budget?
A
pp
lic
at
io
n
Box

264 Part 2 Implementing a Health Promotion Program
Personnel
The key resource of any program is the individuals needed to carry out the program. Instead
of trying to identify all the individuals necessary to ensure a program’s success (because
many times the same person is responsible for several different program components), plan-
ners should focus on the tasks that need to be completed by the program personnel. These
tasks include: planning; identifying resources; advertising; marketing; conducting the pro-
gram, including having the necessary interpreters for those who speak a different language
than the one in which the program is offered and accommodating those with disabilities;
monitoring the program progress; evaluating the program; making arrangements for space
and program materials; handling clerical work; and keeping records (for program sign-up,
collection of fees, attendance, and budgeting).
In some cases, the program participants themselves constitute a program resource. For
example, in the case of a worksite health promotion program, planners will need to find out
whether the employees will participate on company time, on their own time before or after
work hours, on a combination of company time and employee time, or on their own any-
time during the work day as long as they put in their regular number of work hours. This last
option is known as flex time. The current trend in worksite health promotion programs is
to ask the employees to participate at least partially on their own time. The reasoning behind
this trend is that this investment by the participant helps to promote a sense of program
ownership (“I have put something into this program, and therefore I am going to support it”)
and thus build loyalty among participants.
internal personnel
When identifying the personnel needed to conduct a program, planners have three basic op-
tions. One, referred to as internal personnel, uses individuals from within the planning
agency/organization or people from within the priority population to supply the needed
labor. These individuals may be hired specifically to serve as program personnel or existing
employees may be trained to handle specific tasks. An example of using internal personnel
would be when a local health department was planning a health promotion program in a
community, the employees of the health department might handle the planning, implemen-
tation, and evaluation of the program. If that same health department was planning a health
promotion program for the faculty and staff of a school district, there would likely be many
school employees (e.g., school nurse, health and/or physical education teacher, family and
consumer science teacher) who have the expertise (knowledge and skills) to carry out much
of the program. If the department was planning a worksite program, there would probably
be some employees who would be qualified to conduct at least a portion of the program (for
example, an employee who is certified to teach first aid or cardiopulmonary resuscitation).
Another internal resource that health promotion planners are using successfully in a
variety of settings, especially in schools (from kindergarten to college), is peer education.
The process is simple: Individuals who have specific knowledge, skills, or understanding of
a concept help to educate their peers. For example, college students may work with other
college students to help educate them about the dangers of drinking and driving. The major
advantages of peer education are its low cost and the credibility of the instructor. Children,
for example, are greatly influenced by slightly older peers.

Chapter 10 Identification and allocation of resources 265
10.3
Selecting Health promotion Vendors
Planners must be careful when selecting vendors because the quality of vendors can vary
greatly. Harris, McKenzie, and Zuti (1986) created a checklist to help planners screen
potential vendors to ensure they are a good match for the program being planned. Eight
major areas to consider before selecting and entering into a contract with a vendor
include:
1. Initial experience with the vendor—Was the vendor prepared for the first meeting?
Can the vendor show how his/her product meets your needs? Did the vendor listen to
you? Will the vendor provide a proposal? Does the vendor have a good reputation? Will
the vendor provide the names of other customers?
2. Product quality—Does the vendor have evidence to show the effectiveness of the
product? Will the vendor customize the product to fit your needs? Is the product up to
date with regard to professional standards?
3. Professionals involved in service delivery—Are those who deliver the product
qualified to do so? Are their credentials up-to-date? Are those who deliver the product
evaluated?
4. Product/service delivery and satisfaction—Is the information about the product/service
provided in a written document? Is there a contract to sign? Can the product/service
be delivered as needed?
5. Vendor technological capability—Does the vendor have the technology to deliver the
product/service as needed?
6. Evaluation and reporting—Does the vendor have the capability to collect, analyze, and
report the data needed for the program?
7. Product cost and value—Is the cost competitive? Are there any hidden costs? Does the
price per unit go down when more product/service is purchased?
8. General concerns—Does the vendor carry liability insurance? Is the vendor the best fit
for the program?
Adapted from: “How to Select the Right Vendor for Your Company’s Selecting Health Promotion Program.” J. H. Harris, J. F. McKenzie, and W. B. Zuti, from
Fitness in Business 1. Copyright © 1986 by American School Health Association. Reprinted with permission.
Fo
cu
s
O
n
Box
External personnel
Individuals from outside the planning agency/organization or priority population who
would conduct part or all of the program make up a second source of personnel for a pro-
gram. Such individuals are considered external personnel. Typically, these individuals are
brought in when it is found that there is a gap between what can be provided internally and
what ultimately must be provided to accomplish the program goals and objectives (Harris,
2001). Many companies now offer or sell programs, services, or consulting to groups wanting
health promotion programs. These companies are referred to as vendors. Some vendors are
for-profit groups—such as hospitals, consulting agencies, health promotion companies, or
related businesses—whereas others are nonprofit organizations—such as voluntary health
agencies, YMCAs, YWCAs, governmental health agencies, universities/colleges, extension
services, or professional organizations. Planners must be careful when choosing vendors (see
Box 10.3) because the quality of vendors can vary greatly.
Experts available through speakers’ bureaus are often an untapped inexpensive source
of personnel for health promotion programs. Most local offices of voluntary health agencies

266 Part 2 Implementing a Health Promotion Program
(e.g., American Cancer Society, American Heart Association), hospitals, and other health-
related organizations maintain speakers’ bureaus. The services of these experts are usually
available at little or no cost to groups. With some inquiry and a little networking, it is not dif-
ficult for planners to identify organizations that have individuals available to speak on a vari-
ety of health-related topics, or health care organizations willing to send their medical experts
into the community to share their knowledge. The speakers’ bureau is a win-win concept for
both the group offering the service and the one receiving it. Groups that take advantage of a
speakers’ bureau gain access to expert information, but those delivering the information gain
in terms of public relations and recognition.
There are advantages and disadvantages connected with using either internal or exter-
nal personnel to conduct health promotion programs. table 10.1 lists the pros and cons
of each.
Combination of internal and External personnel
The third option for obtaining personnel to carry out a program is using a combination of
internal and external personnel. This option is the most common because it allows program
planners to make use of the advantages of the first two options, while avoiding many of the
disadvantages.
table 10.1 advantages and Disadvantages of Using Internal and external personnel
advantages Disadvantages
Internal Program
Personnel
1. Reduced costs.
2. Internal arrangements can be made to
free needed personnel from their work
schedules.
3. More control over those involved
1. Limited by the interest and
abilities of those on staff.
2. May have to train personnel or be
limited by the expertise of those
on staff.
3. Might spend more time developing
the program than implementing it,
thus reaching fewer people.
External Program
Personnel
1. Known expertise.
2. The responsibility for conducting the
program becomes the work of another.
3. Can request product (program)
guarantees.
4. Sometimes external personnel are more
respected than internal personnel simply
because they are from the outside.
5. Bring global knowledge to the program
because they have worked with a variety
of entities and cultures (Harris, 2001).
6. Have the resources for sophisticated
tools and programs because they can
spread the cost across many clients
(Harris, 2001).
7. Can reach a priority population that is
geographically dispersed (Harris, 2001).
1. often more costly than using
internal personnel.
2. Subject to the limitations of any
given vendor.
3. Sometimes less control over the
program.

Chapter 10 Identification and allocation of resources 267
items Related to personnel
In addition to determining the source of personnel for a program there are other person-
nel matters to which planners must attend. Four of these—technical assistance, volunteers,
teamwork, and cultural factors—are discussed below.
tECHniCAl ASSiStAnCE
Sometimes there are enough people willing and able to handle the tasks associated with
planning, implementing, and evaluating a program but for whatever reason they do
not have the capability (i.e., knowledge, skills, and know how) to carry out the tasks. Or
personnel may have knowledge and skills but need help in completing the tasks more
effectively. Such situations call for technical assistance to enhance group members’ capac-
ity to complete the work. Technical assistance (TA), also known as technical support or
capacity-building assistance (CBA), can be defined as a relationship in which individuals with
specific knowledge and skills share their expertise, via advice and training, with those who
need it. TA often comes from consultants or may be a part of a support program offered by
a funding agency. For example, it is not uncommon for the Centers for Disease Control and
Prevention (CDC) to offer technical assistance to groups that receive CDC funding for their
programs, or to state or local health departments that need to enhance their capabilities.
Technical assistance providers must be more than just experts. They must demonstrate
that they are good listeners and effective helpers to the people who will be actually conduct-
ing the planning tasks (Butterfoss, 2007). For effective TA to take place there must be a col-
laborative working relationship between the two parties. TA is typically provided after some
sort of needs assessment (i.e., completing a checklist or questionnaire) of those who need the
assistance. Once the needs are known (e.g., priority setting, intervention planning and effec-
tiveness, evaluation techniques) the actual TA can be planned and delivered. Delivery can be
completed using a number of different training strategies and can range from providing in-
formation via a telephone call, to supplying written or self-help materials, to referring those
in need to other resources, to pairing those in need with a peer group (i.e., another group of
planners who have completed a similar project), to more elaborate face-to-face training ses-
sions that may last from a few hours to a few days at one time.
VoluntEERS
There are times when paid staff members (i.e., professionals) are not available in sufficient
numbers to carry out all the tasks necessary in planning, implementing, and evaluating
health promotion programs. In such cases is not unusual to turn to volunteers for help.
Volunteers are individuals who provide a service to others without being forced to do so.
Volunteers do not get paid. Although volunteers are not paid they are not free of cost. There
are costs associated with identifying, recruiting, selecting, training, and supervising volun-
teers (Shi & Johnson, 2014). In health promotion programs, common duties performed by
volunteers include data collection for assessments and evaluation, facilitation of interven-
tions, and clerical tasks. However, duties are only limited by the knowledge and skills of the
volunteers. Often volunteers contribute services that otherwise would not be performed
because of lack of funding.
As with other personnel, planners should create a job description that outlines the tasks
that need to be performed before recruiting volunteers. (See Box 10.4 for an example job
description for a volunteer.) Do not reduce all the volunteer jobs to simply running errands;

268 Part 2 Implementing a Health Promotion Program
some volunteers are happy doing that type of work but others want to be engaged and given
meaningful tasks to complete (Fallon & Zgodzinski, 2012). Defining real jobs is very impor-
tant (Wurzbach, 2002). “Volunteers that are not utilized quickly lose interest and find other
outlets for their spare time” (Fallon & Zgodzinski, 2012, p. 116). In identifying the tasks to
be completed by and creating job descriptions for volunteers, program planners need to
remember that volunteers are motivated by different factors than those that motivate paid
employees (Issel, 2014). The reasons vary. Some individuals are interested in volunteering as
a means of giving back, sharing of their gifts and talents, or just helping others in the com-
munity. Others volunteer to gain experience or “get their foot in the door” of an organiza-
tion where they hope to work some day. Some volunteer to do something worthwhile, stay
active, or just for the social interaction (Van Der Wagen & Carlos, 2005). Still others may
10.4
Sample Job Description for a Volunteer
Position Title: Health Education Volunteer
Reports to: Senior Health Education Specialist
Responsible for: Distribution of health education materials at the patient
education desk
Position Summary: To assist patients of the Stonecrest Clinic in getting the
education materials they need.
Duties: ⦁⦁ Greet all patients and significant others who approach the
patient education desk.
⦁⦁ Use materials available at the patient education desk to “fill”
the patient education prescription provided by the health care
providers in the Stonecrest Clinic.
⦁⦁ Help obtain appropriate educational materials for use at the
Stonecrest Clinic.
⦁⦁ Monitor and maintain inventory; help to re-stock the
education materials at the patient education desk, as needed.
⦁⦁ Provide excellent customer service as outlined in the core
values of the Stonecrest Clinic.
⦁⦁ Answer the phone at the patient education desk.
Qualifications: ⦁⦁ Education
—High school diploma or equivalent
⦁⦁ Knowledge
—Basic medical terminology
⦁⦁ Skills
— Communication: Good verbal and nonverbal skills
— Computer: Typing speed of 40 wpm; able to search
Internet; use word processing and database programs
—Problem solving
Desirable: ⦁⦁ Health education experience
⦁⦁ Customer service experience
Fo
cu
s
O
n
Box

Chapter 10 Identification and allocation of resources 269
volunteer to enhance their knowledge or learn a new skill. The key for planners is to match
the potential volunteers’ motivation to the volunteer opportunities.
Once a suitable job description has been created planners are ready to recruit volunteers.
Depending on the how many and what type of individuals are needed, a variety of techniques
can be used to recruit volunteers. The most traditional way of recruiting is via a mass media
outlet (e.g., radio, television, and newspapers), but posting flyers in high-traffic areas where
desired volunteers pass can be effective as well. In addition, viral recruiting can be used via
social media or personal word-of-mouth invitations. Places where planners may find potential
volunteers include religious organizations, community service organizations (e.g., Jaycees,
Rotary), senior citizen centers, and colleges and universities. In fact, many educational institu-
tions require community service or service learning as part of graduation requirements.
Potential volunteers should not be accepted automatically for a position; instead they
should be interviewed, just as a prospective employee would be. It is important to make sure
that the person is right for the job, and that the person’s philosophy is consistent with that
of the organization where they will volunteer (Wurzbach, 2002). After the interview process,
planners may find that they have attracted good people but those individuals may not have all
the knowledge and skills to complete the work. This makes training the volunteers particularly
critical to the success of a health promotion program (Issel, 2014). In order to provide appro-
priate training, it is not uncommon to conduct a needs/assets assessment with the volunteers.
This is something that can be completed as part of the interviewing process. With such data,
a thorough training plan can be can be put together for new volunteers. Common topics for
volunteer training sessions include: background information on the organization including
goals, values, and organizational culture; human resource policies; privacy and confidentiality
policies: HIPAA, GINA, and the Family Educational Rights and Privacy Act (FERPA); knowledge
and skills to carry out volunteer tasks; and background on the attitudes, reactions, culture, and
daily lives of those in the population being served (Shi & Johnson, 2014).
Once on the job, volunteers need to be supervised and periodically evaluated. The person
to whom they report can handle this. If a program needs a large number of volunteers, it may
be necessary to hire a volunteer coordinator (Wurzbach, 2002).
Good volunteers are not easy to find so every effort should be made to retain them. For
the most part, if volunteers are happy and satisfied with the work they will continue. To
increase the chances of this happening, include volunteers in staff meetings and functions
when it is appropriate, and show appreciation for their help by saying thank you often, pro-
viding positive feedback, and publicly recognizing their achievements and service through
newsletters, news releases, and/or recognition ceremonies (Wurzbach, 2002).
Before leaving our discussion of volunteers, we want you to be aware that volunteer help
does not always work out as planned. Organizations have “the right to decide on the best place-
ment of a volunteer, to express opinions about poor volunteer performance in a diplomatic
way, and to release an inappropriate volunteer” (Van Der Wagen & Carlos, 2005, p. 180). And
finally, when volunteers resign, always hold an exit interview with them to get their comments
on the good and bad aspects of their volunteer work (Wurzbach, 2002) so that you can improve
future volunteer experiences.
WoRking AS A tEAm
Because of the multiple tasks associated with planning, implementing, and evaluating health
promotion programs and the need for a variety of resources to have effective programs,

270 Part 2 Implementing a Health Promotion Program
health education specialists often work as part of a group or team. Further, teamwork is be-
coming a preferred approach in many work settings because “organizational problems and
issues are so complex today that no one person can grasp all the information nor have all
the skills to adequately and thoroughly analyze and choose the best solutions. The complex-
ity of problems also requires innovations and diversity of viewpoints to see all the options
and consequences involved” (Kilingner et al., 2010, p. 224). A team had been defined as
“a small group of people with complementary skills who are committed to a common pur-
pose, a set of performance goals, and an approach for which they hold themselves mutually
accountable” (Gomez-Mejia & Balkin, 2012, p. 384). Teams differ from working groups in
that working group members are accountable for individual work but are not responsible for
the output of the entire group (Gomez-Mejia & Balkin, 2012). Teams can vary in size and be
as small as two people; however, the sizes of high-performing teams range between 5 and 12
members (Gomez-Mejia & Balkin, 2012).
In a 2009 study, Lovelace and colleagues found that health education specialists “partici-
pated in an average of four teams per individual; three of these were interorganizational teams.
Moreover, 40% of the respondents participated in five or more teams” (p. 428). These authors
further stated that in order to be effective, health education specialists “must be able to work
collaboratively with community members and other professionals” (p. 429). “In fact, words
like boundary-spanning, collaborative public management, bridge building, and facilitative leadership
all attest to the way that contemporary work is conducted” (Kilingner et al., 2010, p. 224).
Team creation can come about in a couple of different ways. When teams are created within
an organization, say within a local health department, member assignments may occur for-
mally when a supervisor or manager organizes a team based on the people and their skills. If
interorganizational teams are assembled, typically the team is composed of whomever each
organization assigns to the team. This is a more informal means of team composition in that
no one individual selects team members for their individual knowledge and skills. Whichever
way is used, each team will need a leader or leaders to guide the work of the team.
“Teams are not instantly functional and effective” (Butterfoss, 2007, p. 164); they take
time to develop. Understanding how teams develop and what stage a team is in can help
planners be more efficient in the planning process. To help explain the development,
Tuckman (1965) identified the development sequence of small groups and created a model
to explain it (Tuckman, 2001). The original model included four stages—forming, storm-
ing, norming, and performing. Several years later, Tuckman and Jensen (1977) added a fifth
stage—adjourning. More recently, the fifth stage has been called mourning (Butterfoss, 2007)
or reforming (UNRCE, 2003). Over time, the “stages of group development” terminology has
changed a bit and the five stages are now associated with team development.
The first stage, forming, can be thought as an orientation stage. As such, little real work is
accomplished. In this stage members are introduced, meet, and get to know each other. During
this stage the ground rules for the group are established, such as defining the purpose of the
team, team structure (e.g., roles and responsibilities), logistics for operation (e.g., procedures,
meeting times), and expectations (Gomez-Mejia & Balkin, 2012). As such, “two important
things must be accomplished in this first stage: members must feel welcome and included and
have a sense that their opinions will be respected; and they need to develop a consensus, or
group agreement, about the basic mission or goal they are working toward” (Butterfoss, 2007,
p. 164). In the second stage, storming, members will have different opinions about team
goals, assigned tasks and responsibilities, and procedures (Gomez-Mejia & Balkin, 2012). The

Chapter 10 Identification and allocation of resources 271
conflict may be uncomfortable, turf wars can occur, and some members may feel frustrated.
Good teams with good leadership will be able to work through this stage, but if the conflict is
too great and cannot be resolved, teams may disband.
The teams that emerge will enter into stage three, norming. In this stage, “team mem-
bers finally understand their roles and establish closer relationships, intensifying the cohe-
sion and interdependence of members” (Gomez-Mejia & Balkin, 2012, p. 390). In the fourth
phase, performing, teams are involved in “constructive action” (Tuckman, 1965); they are
working toward the team goals. “This is the stage where a great deal of work can occur, and
the team may become creative. As new tasks emerge, members confidently tackle them. The
whole team works together or may delegate work to task groups and individuals” (Butterfoss,
2007, p. 165). After the performing stage, teams may enter into the adjourning (or mourn-
ing) stage or decide to move to reforming. In the former, the team has reached its goal, thus
completing its work. As such it may decide to disband. However, the disbanding may not be
easy, thus the term mourning. In the latter, reforming, the team may continue on by refocus-
ing its efforts on other tasks or problems.
There is no single prescription for creating effective working teams; however, several
authors have identified characteristics that are important. Gomez-Mejia and Balkin (2012)
have identified five behavioral characteristics of effective teams: (1) cohesiveness, (2) se-
lecting high-performance norms, (3) cooperation, (4) exhibiting interdependence, and (5)
trusting one another. Getha-Taylor (2008) asserts that there are three factors associated with
collaborative competencies that set exemplars apart from average performers. Those factors
include interpersonal understanding, teamwork and understanding, and team leadership. In
identifying these three factors Getha-Taylor indicated that interpersonal understanding is
the most important and only comes about through time and experience.
CultuRAl FACtoRS
Regardless of who is involved in planning, implementing, and evaluating a health promo-
tion program, there is a need to be aware of the importance of cultural factors. Cultural fac-
tors arise from guidelines (both explicit and implicit) that individuals “inherit” from being
a part of a particular society, racial or ethnic group, religious community, or other group.
In order for planners to be effective, they need to strive to be culturally competent (Davis
& Rankin, 2006; Luquis, Pérez, & Young, 2006; Pérez & Luquis, 2014; Selig, Tropiano, &
Greene-Moton, 2006). Cultural competence is “a developmental process defined as a
set of values, principles, behaviors, attitudes, and policies that enable health profession-
als to work effectively across racial, ethnic, and linguistically diverse populations” (Joint
Committee on Health Education and Promotion Terminology, 2012, p. 16). Luquis and
Pérez (2003) and Martinez-Cossio (2008) have discussed some of the issues surrounding cul-
tural competence and some strategies by which planners can become more culturally com-
petent. One strategy is becoming familiar with Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care (Office of Minority Health, 2013)
(see Weblinks at the end of this chapter for the Website). The National CLAS Standards were
created to advance health equity, improve quality, and help eliminate health care disparities
by establishing a blueprint for individuals and organizations to implement culturally and
linguistically appropriate services (OMH, 2013). In addition, if planners are not familiar with
the culture of those in the priority population we would recommend that they work with in-
digenous health workers and/or those who are well trained and are bilingual and bicultural.

272 Part 2 Implementing a Health Promotion Program
Curricula and Other Instructional Resources
Earlier (in Chapter 8), the word curriculum was defined as a “planned set of lessons or courses
designed to lead to competence in an area of study” (Gilbert et al., 2015, p. 437). When it comes
to selecting the curriculum and other instructional materials that will be used to present the
content of the program, planners can proceed in four ways: (1) by developing their own materi-
als (in-house) or having someone else develop custom materials for them; (2) by purchasing or
obtaining various instructional materials from outside sources; (3) by purchasing or obtaining
entire “canned” programs from outside vendors; or (4) by using any combination of in-house
materials, materials from outside sources, and canned program materials.
Developing in-house materials or having someone else develop custom materials has
the major advantage of allowing the developers to create materials that very closely match
the needs of the priority population. The more “unique” the priority population, the more
important this approach may be—especially if the priority population possesses cultural
differences. Materials must be relevant and culturally appropriate to the priority popula-
tion (Luquis, 2014). However, a serious drawback is the time, money, and effort necessary to
develop an original curriculum and other instructional materials. The exact amount of time
necessary would obviously depend on the scope of the program and the expertise of those
doing the work. No matter who does the work, however, the commitment of time and re-
sources is sure to be considerable. In putting together an in-house program, planners should
be aware of several different sources from which they can obtain free or inexpensive materi-
als to supplement the ones they develop. Planners might also find that there is no need to
create in-house materials because of the wide array of materials available. For example, most
voluntary and governmental health agencies have up-to-date pamphlets on a variety of sub-
jects that they are willing and eager to give away in quantity. Also, most communities have
a public library with a video/DVD section that includes some health videos and DVDs. If the
public library does not carry health videos and DVDs, almost all local and state health de-
partments offer such a service. Planners who are working in K–12 school settings will want to
use the Health Education Curriculum Analysis Tool (HECAT) (CDC, 2013) that can be used
to identify a curriculum that best meets the needs of the children being served (see Weblinks
at the end of this chapter for the Website). Planners who are unsure about what sources of
information are available in their community can begin by checking the Yellow Pages of the
local telephone directory or the Internet.
Planners need to remember that just because a piece of instructional material exists does
not mean it is appropriate for the priority population with which they are working. To help
ensure that materials are suitable for the priority population, we would recommend the use
of SAM: a suitability assessment of materials instrument (Doak, Doak, & Root, 1996) (see
Figure 10.1). This validated instrument “was originally designed for use with print material
and illustrations, but it has also been applied successfully to video- and audiotaped instruc-
tions. For each material, SAM provides a numerical score (in percent) that may fall in one of
three categories: superior, adequate, or not suitable” (Doak et al., 1996, p. 49). Here are the
steps for using SAM (Doak et al., 1996):
1. Read through the SAM factor list and the evaluation criteria.
2. Read the material (or view the video) you wish to evaluate and write brief statements as
to its purpose(s) and key points.

Chapter 10 Identification and allocation of resources 273
2 points for superior rating
1 point for adequate rating
0 points for not suitable rating
N/A if the factor does not apply to this material
COMMENTSSCOREFACTOR TO BE RATED
1. CONTENT
(a) Purpose is evident
(b) Content about behaviors
(c) Scope is limited
(d) Summary or review included
2. LITERACY DEMAND
(a) Reading grade level
(b) Writing style, active voice
(c) Vocabulary uses common words
(d) Context is given �rst
(e) Learning aids via “road signs”
3. GRAPHICS
(a) Cover graphic shows purpose
(b) Type of graphics
(c) Relevance of illustration
(d) List, tables, etc. explained
(e) Captions used for graphics
4. LAYOUT AND TYPOGRAPHY
(a) Layout factors
(b) Typography
(c) Subheads (“chunking”) used
5. LEARNING STIMULATION, MOTIVATION
(a) Interaction used
(b) Behaviors are modeled and speci�c
(c) Motivation—self-ef�cacy
6. CULTURAL APPROPRIATENESS
(a) Match in logic, language, experience
(b) Cultural image and examples
Total SAM score:
%, Percent score:Total possible score:
⦁▲ Figure 10.1 SaM Scoring Sheet
Source: Teaching Patients with Low Literacy Skills, 2nd Edition. C. C. Doak, L. G. Doak, & J. H. Root. Copyright © 1996 by J. B. Lippincott Company. Reprinted with permission
of the authors.

274 Part 2 Implementing a Health Promotion Program
3. For short materials, evaluate the entire piece. For long materials, select samples that are
central to the purpose of the document to evaluate.
4. Evaluate and score each of the 22 SAM items, rating them as “superior” and assigning
a score of two, “adequate” and assigning a score of one, “not suitable” and assigning a
score of zero, or marking an item “N/A” if the factor does not apply to the material.
5. Calculate the total suitability score by summing the scores from the rated items and
dividing by the total number of items rated. Do not include the items marked N/A.
Multiply the score by 100 to get a percentage.
70–100% = superior material
40–69% = adequate material
0–39% = not suitable material
6. Decide on the impact of deficiencies of the material and what action to take about
whether to use or not use the material.
Purchasing or obtaining entire canned programs from vendors has the advantage of sav-
ing the time and money needed to create programs. A canned program is one that has
been developed by an outside group and includes the basic components and materials nec-
essary to implement a program. Because some vendors are for-profit groups whereas others
are nonprofit organizations, the cost of these programs can range from literally nothing at
all to thousands of dollars. For example, there are both not-for-profit (e.g., American Cancer
Society and American Lung Association) and for-profit organizations that have created
canned programs for smoking cessation.
Most canned programs have five major components:
1. A participant’s manual (printed material that is easy to follow and read and is handy for
participants)
2. An instructor’s manual (a much more comprehensive document than the participant’s
manual, which includes the program content, background information, and lesson and
unit plans with ideas for presenting the material)
3. Audiovisual materials that help present the program content (usually including
videotapes/DVDs and audiotapes, PowerPoint® presentations, charts, or posters)
4. Training for the instructors (a concentrated experience that prepares individuals to
become instructors)
5. Marketing (the “wrapping” that makes the program attractive to both the participants
and the planners who will purchase it to market to the participants)
The advantages and disadvantages of canned programs are just the opposite of those for
materials developed in-house. No time is spent on development; however, the program may
not fit the needs or the demographic characteristics of the priority population. For example,
using the same canned smoking cessation program with middle-aged adults who realize the
long-term hazards of cigarettes and with teenagers who are required to attend a smoking ces-
sation program for disciplinary reasons may not be advisable. Most adults who enter smok-
ing cessation programs are there because they do not want to smoke. Obviously, this is not
the case with teenagers who have been caught smoking. The approaches taken with these
two programs would have to be very different if both are to be successful. Another example of
when use of a canned program would not be advisable is use of a program that was designed

Chapter 10 Identification and allocation of resources 275
for upper-middle-class suburban adults in a program for low-income inner-city populations.
The lifestyles of the two groups are just too different for the same program to be appropriate
in both situations. Because of the possible mismatch between the needs and peculiarities
(i.e., age, culture, ethnicity, norms, race, sex, socioeconomic status) of a particular priority
population, planners are urged to move with caution when deciding on the use of a canned
program
Canned programs often come attractively packaged and seemingly complete, but this
does not mean that they are well-conceived and effective programs. Before using canned pro-
grams, planners should consider the following seven questions:
1. Is the program based on best practices? If not, why not?
2. Is there evidence to show the program is effective?
3. Does the program include a long-term behavior modification component? There are no
“quick fixes” with regard to many health behavior changes. If behavior modification is
used, it should be based on sound health behavior practice over an appropriate time frame.
4. Is the program educationally sound? Not only should the program be based on sound
psychological and sociological theory but it should also be based on valid educational
theory.
5. Is the program motivational? Health behavior change is not easy to accomplish, and so
all programs need to include activities that motivate people to get and stay involved.
6. Is the program enjoyable? Planned programs should be enjoyable. Some people like hard
work, but it is difficult to sustain hard work for a long time without some enjoyment.
7. Can the program be modified (i.e., adapted—see Chapter 8 for information on adapting
an intervention) to meet the specific needs and peculiarities of the priority population?
As mentioned earlier, not all populations have the same needs, beliefs, traditions, and
ways of approaching a problem.
Space
Another major resource needed for most health promotion programs is sufficient space—a
place where the program can be held. Depending on the type of program and the intended
audience, space may or may not be readily available. For example, an employer may make
space available for a worksite program, or a school system may furnish space for a school pro-
gram. If space is a problem, planners may be able to locate inexpensive space in local schools,
colleges and universities, religious facilities, and in “community service rooms” (rooms that
are available free of charge to community groups as a community service) of local businesses.
In addition, planners may find educational institutions and local businesses that are willing
to co-sponsor programs and thus contribute the space necessary to conduct the program.
It may also be possible to obtain space by trading for it. For instance, a planner might trade
expertise, such as serving as consultant for a program, in return for the use of suitable space.
Or it might be possible to trade one space for another, such as trading the use of school class-
rooms for time in the local YMCA/YWCA pool.
One final note of caution about space: Even if space is provided free of charge for a pro-
gram, make sure to ask if there are any associated costs for the “free space.” It is not uncom-
mon for an organization offering the space (e.g., a school district) to do so with the obligation

276 Part 2 Implementing a Health Promotion Program
for the users to pay for the custodial time to clean up the space once it has been used. Thus, a
charge such as two hours of overtime pay for the custodial staff may be an obligation in order
to use the free space.
Equipment and Supplies
Most health promotion programs will need both equipment and supplies in order to be
planned, implemented, and evaluated. Though often the words equipment and supplies are used
to mean the same thing, from planning and budgeting perspectives they are usually considered
two different types of commodities, and not all organizations define the words the same. Some
organizations define equipment and supplies by costs. That is, equipment may be anything
costing more than $500, whereas supplies are anything costing between $1 and $499. Thus, a
computer may be equipment, while paper or even a chair may be a supply. These same organiza-
tions usually have a dollar amount definition for major equipment items (sometimes referred
to as capital expenditures or capital equipment) as anything costing more than so many thousands
of dollars depending on the nature of the organization. Other organizations may define equip-
ment and supplies based on the “life” of the commodity. For example, equipment may be any-
thing that will last three years or more, and supplies anything that lasts fewer than three years.
Thus, under this type of classification a computer may be considered a supply. Or, an organiza-
tion may define equipment as something that is not consumable, like a desk, and a supply to be
something that is consumable like photocopy paper. It is not so important how the words are
defined, but planners need to know how they are defined and work within those parameters.
Some programs may require a great deal of equipment and supplies. For example, first aid
and safety programs need items such as CPR mannequins, splints, blankets, bandages, dress-
ings, and video equipment. Other programs, such as a stress management program, may
need only paper, pencils, and a CD player. Whatever the kinds and amounts of equipment
and supplies required, planners must give advance thought to their needs so as to:
⦁⦁ Determine the necessary equipment and supplies, in the correct amount/number, to
facilitate the program
⦁⦁ Identify the sources where the equipment and supplies can be obtained
⦁⦁ Find a way to pay for the needed equipment and supplies
Financial Resources
To hire the individuals needed to plan, implement, and evaluate a health promotion pro-
gram and to pay for the other resources required, planners must obtain appropriate financial
support. Most programs are limited by the financial support available. In fact, few programs
are financed at such a level that planners would say they have all the money they need.
Because of this, the planners are often faced with making decisions about how to allocate
the funds that are available. Some typical financial questions that planners generally must
address are the following:
⦁⦁ Is it better to run an adequately financed program for a few people or to run a poorly
financed program for more people?

Chapter 10 Identification and allocation of resources 277
⦁⦁ If funds are limited where could cuts be made?
⦁⦁ Should a program be started knowing funding will fall short, or should the program be
delayed until appropriate funding is available?
⦁⦁ Is it better to have fewer instructors or to make do with fewer supplies?
Programs can be financed in several different ways. Some sources of financial support are
very traditional, whereas others may be limited only by the creativity and imagination of
those involved. Following are several established ways of financing programs.
participant Fee
This method of financing a program requires the participants to pay for the cost of the
program. Depending on whether the program is offered on a profit-making basis, this fee
may be equal to expenses or may include a profit margin. Participant fees not only are a
means by which programs can be financed but they also help motivate participants to stay
involved in a program. If people pay to participate in a program, then they may be more
likely to continue to participate because they have made an investment—that is, a commit-
ment. This concept has also been referred to as ownership (see the discussion on behavioral
economics in Chapter 8). Many participants who pay a fee feel like they are part “owners” of
the program. However, it should be noted that not everyone shares in the ownership con-
cept. There are some participants who still would prefer a free or almost free program that
has been paid for by others. An example of the ownership and cost issue is the participant
fees associated with smoking cessation programs. If planners were looking for vendors of
smoking cessation programs, they would find that the costs of such programs range from
zero (e.g., American Cancer Society’s FreshStart program) to modest (e.g., American Lung
Association’s Freedom from Smoking program) to expensive (e.g., those offered by private
health promotion companies).
Deciding to finance a program through a participant fee may sound easy, but plan-
ners need to give serious thought to how much they will charge and who will be charged.
Often, those most in need of a health promotion program are the least able to pay.
Planners do not want to create a barrier to program participation by charging a fee or
setting the fee too high. If a fee is necessary, then planners should consider creating a fee
structure on “ability to pay.” One form of this is a sliding-scale fee—that is, the less
one’s income, the lower the participant fee. Or, planners may want to consider offering
“scholarships” to those unable to pay.
third-party Support
Most individuals are familiar with insurance companies’ acting as third-party payers to cover
the costs of health care. Although health insurance is not often used to pay for health promo-
tion programs, others can be third-party payers. Third-party means that someone other than
participants (the first-party) or planners (the second-party) is paying for the program. Third-
party payers that may cover the cost of health promotion programs are:
⦁⦁ Employers that pick up the cost for employees, as is often the case in worksite health
promotion programs

278 Part 2 Implementing a Health Promotion Program
⦁⦁ Agencies other than the groups sponsoring the program—for example, when local
service or civic groups “adopt” a pet program
⦁⦁ A professional association or union that financially supports a program
The money used by third-party payers can be generated from a special fund-raising event,
from sale of concessions, or with money saved from reduced health care costs, absenteeism,
or the remodeling of employee benefit plans.
Cost Sharing
A third means of financing a program involves a combination of participant fee and third-
party support. It is not unusual to have an employer pay 50% to 80% of a program’s costs and
have employees pay the remaining 50% to 20%. Or, an employer may have a reimbursement
policy for program participation. With such policies, employees are responsible for paying
the participation fee, and then based on either attendance at the program (e.g., the employee
must attend at least 80% of the program sessions) or completion of the program (e.g., em-
ployee must produce a certificate of completion), the employer reimburses the employee for
either all or a portion of the participant fee. Such arrangements have the advantages of both
ownership and a fringe benefit.
Cooperative Agreements
There are times when two parties (e.g., groups, organizations, individuals, agencies) es-
tablish agreements that offer mutual benefits to both parties when they share resources
and work together to offer a program or service. Often these agreements do not involve
the transfer of money from one party to the other (though they may), but rather access to
and sharing of resources (Fertman et al., 2010). For example, one agency may be willing to
provide educational literature to another agency in return for space to present a program
or the use of an employee’s time. It is not uncommon for such agreements to be spelled out
in a written document and signed by an individual of each agency with authority to do so.
The written document may be a letter of agreement, which once signed by both parties be-
comes legally binding, or something less formal (i.e., not legally binding) like a memoran-
dum of understanding (MOU) or memorandum of agreement (MOA). A memorandum
of understanding is defined as “a document that describes the general principles of an
agreement between parties, but does not amount to a substantive contract” (Dictionary
.com, 2015). It is not unusual for such an MOU or MOA to help support a grant proposal
(see the discussion of grants below).
organization/Agency Sponsorship
Many times, the sponsoring organization/agency bears the cost of the program as a part
of its programming or operating budget. In such cases, the source of the money to fund a
program would depend on how the agency is funded. For example, many health promo-
tion programs are offered or sponsored by governmental (i.e., public) health agencies. The
primary source of funding of governmental health agencies is tax dollars. As such, many
governmental health agency programs are free or relatively inexpensive compared to
similar programs offered by for-profit groups for those who live in the jurisdiction of the

Chapter 10 Identification and allocation of resources 279
agency. Depending on which agency is offering the program, tax dollars to pay for it could
come from multiple levels. For example, in local (i.e., city or county) health departments
(LHD) in the United States it would not be unusual for two-thirds to three-fourths the
department’s revenue to come from a combination of local, state, and federal tax dollars.
The remainder of a LHD’s revenue would come from several sources including fees (e.g.,
for birth and death certificates), fines (e.g., for failure to implement policy such no smok-
ing ordinance), insurance payments (e.g., health insurance for health care provided), and
private foundations.
In the case of a voluntary health agency being the sponsoring organization/agency the
source of the funding would be primarily donations that have been made to the agency.
For example, the American Cancer Society offers a program called Reach To Recovery® to
help people with breast cancer free of charge. Program materials are provided free and an
American Cancer Society volunteer conducts the program. The program is paid for with the
society’s community service funds.
grants and gifts
Another means of financing health promotion programs is through grants and gifts from
other agencies, foundations, groups, and individuals. A grant is an award of financial as-
sistance, the principal purpose of which is to transfer a thing of value from the grantor to
a recipient to carry out a specific purpose, whereas a gift (or contributions) can be sums of
money or non-monetary items that are given voluntarily without compensation in return.
Nonmonetary gifts are known as in-kind contributions and include such things as mate-
rials, equipment, supplies, training, donated space, or other services that are used to operate
programs. Both grants and gifts are often referred to as external money, or soft money. The
term soft money refers to the fact that grants and gifts are usually given for a specific period
of time and at some point will no longer be received. This is in contrast to hard money,
which is an ongoing source of funds that is part of the operating budget of an organization
from year to year.
Grant money has become an important source of program funding, especially for those
working in voluntary or governmental health agencies. It thus becomes necessary for plan-
ners to develop adequate grantsmanship skills. These skills include (1) discovering where
the grant money is located, (2) finding out how to get (apply for) the money, and (3) writing
a proposal requesting the money.
loCAting gRAnt monEy
There are four basic types of grant makers: foundations, corporations, voluntary agencies,
and government. These grant makers are found at three different levels: local, state, and
national. They are not the only grant makers, however. Planners may also find a variety of lo-
cal organizations (such as service groups like the Lion’s Club or the Jaycees, or a community
group like the United Way) that may be willing to support specific local causes through a
grant. Philanthropic foundations are not-for-profit organizations that award grants to serve
the public interest. A number of large national foundations support health promotion (e.g.,
Robert Wood Johnson Foundation, Rockefeller Foundation, W. K. Kellogg Foundation), but
planners may find state and local foundations as well.

280 Part 2 Implementing a Health Promotion Program
Not all corporations have giving programs, but many do as a part of a community service
or public relations program. Planners will need to contact the corporations to “ask who is in
charge of charitable giving, what subjects they consider for grants, and how the company
giving program operates” (Guyer, 1999, p. 1). Library or Internet searching will possibly help
answer these questions.
Voluntary health agencies also have grant programs. Though most grants from voluntary
organizations at the national level are specified for research efforts, planners may find the
local or state offices of these organizations are willing to provide seed dollars (start-up dol-
lars) or in-kind contributions (such as providing free materials or other resources) for local
programs.
Government is the largest grant maker. Government, at all three levels—local, state, and
federal—makes grants for many purposes. With the other three grant makers (foundations,
corporations, and voluntary agencies), planners can ask them to fund any project. However,
with the government, only grants that are in one of the subjects specified by the government
have a chance of being funded.
When looking for grant makers, planners need to look for a pattern in giving by asking
key questions: Has this funder made grants in the past for programs like mine? In my geo-
graphic area? In the amount I need? For the things I need funded? (Guyer, 1999) The an-
swers to these questions, often found at Internet Websites of the grant makers, will indicate
whether it is a good idea to contact the funder. After doing this initial “research,” planners
should call or email funding sources to ask questions and to obtain any guidelines, grant
request forms or applications, and printed material about their grant making. This contact
will also help establish a relationship with the funder. Planners not only can obtain needed
information but they can also introduce their organization to the funder. This can be done
by sending publications about the planners’ organization, making personal contacts, and
staying in touch (Guyer, 1999).
Planners can identify possible funding sources in several different ways. The first is by
networking with others who have been successful in obtaining grant funding in the past.
Because seeking grant funding is a competitive process, planners may have to network with
others who are not seeking funding from the same grant maker. A second means of identify-
ing funding sources is through “research.” A variety of books on grants may be found online
or in college and university libraries as well as many larger public libraries. For example,
there are directories of grant makers for foundations and corporations, and there is usually a
directory that lists grant funders that are specific to a state. Most of these books are indexed
by subject area.
Three good places to begin searches for government grants are the Catalog of Federal
Domestic Assistance (CFDA), the Federal Register, and Grants.Gov. (See the Weblinks at the
end of the chapter.) The CFDA, which is updated biweekly, is an online catalog database
of all Federal programs available to state and local governments (including the District of
Columbia); federally-recognized Indian tribal governments; territories (and possessions)
of the United States; domestic public, quasi-public, and private profit and nonprofit orga-
nizations and institutions; specialized groups; and individuals. The CFDA allows planners
to search the database for programs meeting their needs and for which they are eligible.
However, to apply for one of the programs, planners need to contact the office that adminis-
ters the program they are interested in.

Chapter 10 Identification and allocation of resources 281
The Federal Register is the official daily publication for rules, proposed rules, and notices of
Federal agencies and organizations, as well as executive orders and other presidential docu-
ments. It would list the latest grant opportunities. Grants.Gov is a Website where planners
can find and apply for federal government grants. The site was created in 2002 to improve
government services associated with grants. At this Website planners will find over 1,000
grant programs from 26 federal grant-making agencies.
A third way of identifying funding sources is through the Internet. There are several
advantages to using the Internet for seeking grant makers: convenience, time saving, and
being able to reach several grant makers at the same time. In addition, some Websites per-
mit an applicant to complete one form for grant consideration at several different funders
(Breen, 1999).
The fourth way of identifying grant makers is the least difficult—identifying requests
for proposals or requests for applications. Request for proposals (RFPs) or request for
applications (RFAs) are issued by organizations/agencies in order to solicit for services to
complete a specific project. A RFP or RFA outlines the specific services that are needed, the
process for applying, the timeline for applying, the terms of the contract when awarded,
and how the proposal/application should be presented. For example, a state health depart-
ment may issue a RFP to solicit proposals to train lay personnel to deliver immunization
education programs in the community. Those who feel qualified to deliver the training
could submit a proposal for review.
SuBmitting gRAnt pRopoSAlS
As noted in the previous section, most funding agencies have specific guidelines outlining
who is qualified to submit a proposal (perhaps only nonprofit groups can apply, or only prac-
titioners who hold certain certifications) and the format for making an application. Those
seeking money can request or apply for the money by writing a proposal. A proposal can be
thought of as a written document that represents a request for money. A good proposal is one
that is well written and explains how the group wishing to receive the money can meet the
needs of the funding agency. To increase their chances of writing a good proposal, planners
should call the funding agency first and speak with the grant officer to find out specifically
what he or she is looking for and the format desired.
Because there is a great deal of competition for grant money, it is more than likely that
proposals will be read by a busy, impatient, skeptical person who has no reason to give any
one proposal special consideration and who is faced with many more requests than he or she
can grant, or even read thoroughly. Such a reader wants to find out quickly and easily the
answers to these seven questions:
1. What do you want to do, how much will it cost, and how much time will it take?
2. How does the proposed project relate to the sponsor’s interests?
3. What will be gained if this project is carried out?
4. What has already been done in the area of the project?
5. How do you plan to do it?
6. How will the results be evaluated?
7. Why should you, rather than someone else, conduct this project?

282 Part 2 Implementing a Health Promotion Program
As noted, funding agencies request proposals/applications in a variety of different forms.
However, several components are contained in most proposals no matter what the funding
agency. Box 10.5 presents these components.
Combining Sources
It should be obvious that planners should not be limited to any single source for financing a
health promotion program. In fact, it is more than likely that most programs will be funded
via a variety of sources—that is, any combination of the sources listed previously.
preparing and monitoring a Budget
Simply put, a budget is a statement of the estimated revenues and expenditures with an
itemized listing of the nature of each (Johnson & Breckon, 2007; Last, 2007) for a program.
A budget represents the decision makers’ intentions and expectations by allocating funds to
achieve desired outcomes (program goals and objectives) (Fallon & Zgodzinski, 2012).
A budget can be prepared for any length of time. When programs are planned, budgets
are usually created for the entire length of the program. However, when a program is pro-
jected to last longer than a year, the overall program budget is typically broken down into
12-month periods.
10.5
the Components of a grant proposal
1. Title (or cover) page. When writing the title, be concise and explicit; avoid words that
add nothing.
2. Abstract or executive summary. Provides a summary of the proposed project. May be
the most important part of the proposal. Should be written last and be about 200–300
words long.
3. Table of contents. May or may not be needed, depending on the length of the
proposal. It is a convenience for the reader.
4. Introduction. Should begin with a capsule statement, be comprehensible to the
informed layperson, and include the statement of the problem, significance of the
program, and purpose (or aims) of the program.
5. Background. Should include the proposer’s previous related work and the related
literature.
6. Description of proposed program. Should include the objectives, description of
intervention, evaluation plan, and time frame.
7. Description of relevant institutional/agency resources. Should identify the resources
the proposer’s organization will bring to the project.
8. List of references. Should include references cited in the proposal.
9. Personnel section. Should include the biographical sketch (i.e., biosketch), curriculum
vitae, or résumés of those who are to work with the program.
10. Budget and Narrative. Should include financial needs for personnel (salaries and
wages), equipment, materials and supplies, travel, services, other needed items,
and indirect costs, as well as an explanation for the amounts needed and how the
amounts were calculated.
Fo
cu
s
O
n
Box

Chapter 10 Identification and allocation of resources 283
Developing a budget is an essential and critical step of the planning process (Johnson &
Breckon, 2007; Fallon & Zgodzinski, 2012). Typically, those planning the program and any
other key decision makers who control resources that will be used in the program develop a
program budget. The process begins by examining the financial objective of the program.
From a financial standpoint, programs can make money (a profit), lose money, or break
even. If a program must make money, the revenue will have to be greater than the expendi-
tures, and the intended profit (profit margin) will need to be included in the budgeting pro-
cess. Figure 10.2 presents a sample budget sheet that lists line items that are often included in
health promotion program budgets.
Revenue and Support
Contribution from sponsors
Gifts
Grants
Participant fee
Sale of curriculum material
Direct Costs
Personnel
Supplies
Meeting costs
Equipment
Travel
Postage
Advertising
Total of direct costs
Total income
Total of indirect costs
Total expenditures
Balance
Indirect costs (includes rent, insurance,
telephone, & other utilities)
Salary & wages
Fringe benefits
Instructional materials
Incentives
Consultants
Expenditures
Amount
⦁▲ Figure 10.2 Sample budget Sheet

284 Part 2 Implementing a Health Promotion Program
Once the financial objective of the program is known, planners can then turn their atten-
tion to the estimated revenues of the program. In other words, from where will the income
come? If a program is being paid for by a grant, gift, or contributions from sponsors, the
planners may know exactly how much money they will have to work with. However, if the
revenue for a program is coming, either in part or whole, from participant fees, an estimate
will have to be made of how many participants are expected to take part. At this point bud-
geting becomes a bit more complicated. Hopefully, there may be some history from previ-
ous programs to guide planners in estimating participation and thus estimate revenue, but
sometimes planners may have to make decisions based on “best guesses.” Whether revenue is
estimated based on previous programs or best guesses, it is not uncommon to see a budget line
in the revenue portion of the budget for participants’ fees as X number of participants times
the cost of participation. For example 22 participants @ $50 each = $1,100.
After the revenue for the program has been determined, planners need to estimate what
expenditures are necessary for the program. An expenditure is a cost incurred while plan-
ning, implementing, or evaluating a program. The labels given to the various categories of
expenditures (e.g., personnel, instructional materials, equipment) and the detail to which
the expenditures are listed in a budget will vary based on the accounting practices of the
organization. The two types of costs that are most often found in budgets are direct costs and
indirect costs. A direct cost is the portion of cost that is directly expended in providing a
product or service (VentureLine, 2015) and is expressed in a budget as the actual number
of dollars expected to be spent. Included would be things like wages, salaries, and supplies.
An indirect cost is the portion of cost that is indirectly expended in providing a product
or service (VentureLine, 2015). The purpose of indirect cost is to capture overhead costs
incurred by an organization that offers several programs and whose administrative costs can-
not be connected directly to a program. Items covered in indirect costs include things such
as the cost of telephones, other utilities, insurance, space, and equipment maintenance. An
example would be an organization running several different programs at the same time but
using just one telephone line to service all of the programs. So what percent of the telephone
bill should be associated with each program? To handle this situation in the budget it is typi-
cal to determine the indirect costs as a percentage of the direct costs. The actual percentage
used varies depending on the practices of the organization; however the percentage typically
ranges between 10% and 50%. Thus, a budget that has direct costs of say $50,000 and an in-
direct cost rate of 30% would enter $15,000 in the budget for indirect costs.
In putting a budget together many of the direct cost items’ dollar value is pretty straight-
forward. For example, if it is estimated that 20 500-page reams of photocopy paper are
needed to conduct a program and a ream paper costs $4.00, the cost of paper in the budget
will be $80 (20 × $4.00). A direct cost that is not as straightforward to calculate is the cost
of personnel to carry out a program. For example, when planners are calculating person-
nel costs they need to account for salaries or wages, Social Security taxes, and fringe ben-
efits (e.g., health and disability insurance, vacation days, sick days). While the exact dollar
amount may be known for the salary or wages based on number of hours worked and for the
Social Security taxes based on the prevailing rate, it is more difficult to put an exact value on
the costs of the fringe benefits. Instead, the cost of fringe benefits is calculated for a budget as
a percentage of an employee’s salary or wage. Thus, a fringe benefit line of a budget may read:
0.30 of $30,000 = $9,000. This means that the person preparing the budget estimates that
the value of providing fringe benefits to a full-time employee making $30,000 per year is an

Chapter 10 Identification and allocation of resources 285
additional $9,000. Another complicating factor in calculating personnel expenditures for a
program is that a person may not be dedicated full time to a program, but the program is just
one of many duties assigned to the employee.
The term used to quantify the number of people working on a program is full-time
equivalent (FTE). A full-time equivalent is a unit of measurement that is calculated by
dividing the average number of hours a person works per week by the average number
of hours worked by a full-time employee per week. Thus, a person who works full-time
is counted as 1.0 FTE. If a full-time employee averages 40 hours per week and a part-time
employee works 20 hours per week, the part-time employee would count as 0.5 FTE. FTEs
can also express the amount of time a person works on a program. For example, an FTE of
say 0.40 would indicate that a person is working 40% of his or her time on the program.
Therefore in a budget, it is not uncommon to see a salary budget line presented as: 0.20 FTE
of $40,000 = $8,000. This means that 20% of a full-time equivalent (FTE) employee who
makes $40,000 a year is being charged to the program. Regardless of the format used to cre-
ate a budget, the budget should be put together in sufficient detail so that all revenue and
expenditures are accounted for.
Depending on the source of funding for a program, planners may also be required to
include a budget narrative (or budget justification) along with their budget. This is espe-
cially true if the funding is coming from a grant, but many organizations require a budget
narrative as part of the annual budgeting process. A budget narrative is a statement that
explains the need for the costs in a budget and how the costs were estimated. Although, of-
ten the format for a budget narrative is provided by the organization providing the funding,
there are two basic ways of structuring a budget narrative. One option is to place the budget
narrative on the budget sheet, inserting a brief explanation under each item (Grant Central
Station, n.d.). “Another option is to number items in the left margin or attach footnote-
style numbers to each line and to follow the numeric budget with: ‘Notes to the Budget.’
Regardless of the format, the categories in the narrative should use budget headings, follow
the exact order in which the items are listed in the numerical budget, and include semi-
totals” (Grant Central Station, n.d., para. 8). Here is an example line item in a budget and
the budget narrative that follows.
Consultant − Program Evaluator: $100/hour × 2 hours/week × 52 weeks = $10,400.
The program evaluator will be responsible for designing and implementing an evaluation
to determine program effectiveness and user satisfaction. In addition, the evaluator will be
responsible for creating written bi-monthly reports to be shared with all stakeholders.
After a program is up and running, the budget must be monitored. This duty often falls
to the person who oversees the financial resources of those planning the program. It may be
one of the program planners, but will more than likely be a person who has financial respon-
sibilities for the planning organization. This person may be responsible for both preparing
and distributing the financial reports. At a minimum, those receiving the reports should in-
clude the decision makers and those responsible for the day-to-day operation of the program.
The financial reports are usually generated and distributed on a regular basis (i.e., monthly,
bimonthly, quarterly), and each report usually includes actual revenue and expenditures for
the period, year-to-date totals on actual revenue and expenditures, and year-to-date bud-
geted revenue and expenditures. Such data allows decision makers and planners to know
exactly where they are with regard to financial resources (see Figure 10.3).

286 Part 2 Implementing a Health Promotion Program
⦁▲ Figure 10.3 example First-Quarter budget report
Note: 3 months = 25% of budget Total
Budget
Ytd
3/31/16
Percent of
Budget
Budget
Balance
Revenue & Support
Contributions 1,747.50 1,247.00 71.35% 500.50
Grant #0428 1,000.00 0.00 0.00% 1,000.00
Grant #1205 62,000.00 23,000.00 37.10% 39,000.00
Grant #1107 120,000.00 60,000.00 50.00% 60,000.00
Participant fees 4,500.00 3,505.00 77.89% 995.00
Interest income 100.00 27.98 23.98% 72.02
Total revenue & Support 189,347.50 87,779.98 46.36% 101,567.52
Expenditures
Personnel
Salary & Wages—Administration 10,000.00 2,400.00 24.00% 7,600.00
Salary & Wages—Educators 70,000.00 18,000.00 25.71% 52,000.00
Salary & Wages—Clerical 30,000.00 7,600.00 25.33% 22,400.00
Subtotal salary & Wages 110,000.00 28,000.00 25.45% 82,000.00
Payroll taxes 19,000.00 5,000.00 26.32% 14,000.00
Health insurance 15,500.00 3,500.00 22.58% 12,000.00
State unemployment taxes 8,000.00 2,000.00 25.00% 6,000.00
Workers comp. insurance 500.00 125.00 25.00% 375.00
Subtotal personnel 153,000.00 38,625.00 25.25% 114,375.00
Operating expenses
Supplies 1,300.00 600.00 46.15% 700.00
Instructional materials 2,500.00 2,000.00 80.00% 500.00
Incentives 750.00 200.00 26.67% 550.00
Meeting costs 1,200.00 400.00 33.33% 800.00
Equipment—copier lease 1,200.00 400.00 33.33% 800.00
Travel 4,000.00 1,800.00 45.00% 2,200.00
Postage 300.00 125.00 41.67% 175.00
Advertising 400.00 150.00 37.50% 250.00
Subtotal operating expenses 11,650.00 5,675.00 48.71% 250.00
Total direct costs 164,650.00 44,300.00 26.91% 5,975.00
Total indirect costs (rate=15%) 24,697.50 6,646.10 26.91% 18,051.40
Total expenditures 189,347.50 50,946.10 26.91% 138,401.40
Net surplus or (deficit) -.– 36,833.88 -.– -.–

Chapter 10 Identification and allocation of resources 287
Summary
This chapter identified and discussed the most often used resources for health promotion
programs: personnel, curriculum and other instructional materials, space, equipment and
supplies, and funding. In addition, information was presented on how to secure and allocate
resources, how to obtain funding, and how to create and monitor a budget.
Review Questions
1. What are the major categories of resources that planners need to consider when
planning a health promotion program?
2. What are the advantages and disadvantages of using internal personnel? External
personnel?
3. How are technical assistance, volunteers, teamwork, and cultural factors associated
with program personnel?
4. Define the terms ownership, flex time, vendor, and canned programs.
5. What are some key questions that planners should ask vendors when they try to sell
their product?
6. How might program planners obtain free or inexpensive space for a program?
7. What is the SAM? What is it used for?
8. List and explain the different means by which health promotion programs can be
funded.
9. What is meant by the term profit margin?
10. What is a budget? What are the major components of a budget?
11. What is the difference between direct and indirect costs? How is each calculated?
Activities
1. Identify and describe the resources you anticipate needing to carry out a program you are
planning. Be sure to answer the following questions that apply to your program:
a. What personnel will be needed to carry out the program? List the individuals and the
duties to be carried out.
b. What curriculum or educational materials will you use in your program? Why did you
select it or them?
c. What kind of space allocation will your program require? How will you obtain the
space? How much will it cost?
d. What equipment and supplies do you anticipate using? How will you obtain them?
e. How do you anticipate paying for the program? Why did you select this method?
f. What would be the major sources of income and expenses that would be associated
with the program you are planning? Prepare a one-year budget sheet for the program.

288 Part 2 Implementing a Health Promotion Program
2. Visit the local office of a voluntary agency and find out what type of resources it makes
available to individuals planning health promotion programs. Ask for a sample of the
materials. Also, ask if the agency offers any canned programs. If it does, find out as much
as you can about the programs and ask for any available descriptive literature.
3. Through the process of networking and using the Internet and/or local telephone book,
find where in your community there is free or inexpensive space available for health
promotion programs.
4. Call three different voluntary agencies and one hospital in your community and find
out if they have a speakers’ bureau. If they do, find out how to use the bureaus and what
topics the speakers can address.
5. Prepare a mock grant proposal for a program you are planning. Make sure it includes all
the components noted in Box 10.5.
6. Using the outline provided below, create a job description for a volunteer position that
could assist in a program you are planning.
a. Position title:
b. Reports to:
c. Responsible for:
d. Position summary:
e. Duties:
f. Qualifications:
– Required:
– Preferred:
Weblinks
1. http://www.cancer.org/
American Cancer Society (ACS)
The ACS Website presents the most up-to-date information on cancer including
treatment and prevention. The site also provides information about the ACS and the
resources it can provide for cancer survivors and program planners. [Note: The ACS
Website is the only Website of a voluntary health agency listed in the Weblinks of this
chapter. Be aware that most all other voluntary health agencies have similar resources
available at their Website.]
2. http://www.welcoa.org
Wellness Councils of America (WELCOA)
WELCOA’s Website provides a variety of resources for those interested in worksite
wellness programs.
3. http://www.cdc.gov/Healthyyouth/HECAt/
Centers for Disease Control and Prevention, Adolescent and School Health
This page at CDC’s Website provides an overview the Health Education Curriculum
Analysis Tool (HECAT) and links to many documents that can help planners use the tool.

http://www.cancer.org/

Home

http://www.cdc.gov/Healthyyouth/HECAt/

Chapter 10 Identification and allocation of resources 289
4. http://www.aarp.org
AARP
AARP is a nonprofit membership organization dedicated to addressing the needs and
interests of persons 50 years of age and older. The organization’s Website provides
information that is applicable to those planning programs for seniors. This site also has a
special section on health.
5. http://www.nih.gov
National Institutes of Health (NIH)
The NIH’s Website not only includes information about NIH and links to all the
institutes, centers, and offices but also includes health information, grant opportunities,
and scientific resources.
6. http://www.cdc.gov/learning/
Centers for Disease Control and Prevention (CDC)
This page at CDC’s Website provides a wealth of information about various products and
resources developed by CDC and CDC partners for the public health community.
7. http://www.healthfinder.gov
healthfinder
Of all the Weblinks provided in this chapter, the healthfinder Website offers information
on the greatest variety of health topics. It includes information on prevention, wellness,
diseases, health care, and alternative medicine. It also includes medical dictionaries, an
encyclopedia, journals, and more.
8. http://www.grants.gov
Grants.gov
This Website allows planners to electronically find and apply for competitive grant
opportunities from all federal grant-making agencies. The site provides all the
information planners need to apply for a grant and walks them through the process, step-
by-step to their preferred practice setting.
9. http://www.minorityhealth.hhs.gov
Office of Minority Health (OMH)
The OMH Website presents information on cultural competence. The OMH was
mandated by the U.S. Congress in 1994, via P.L. 101–527, to develop the capacity of
health care professionals to address the cultural and linguistic barriers to health care
delivery and increase access to health care for limited English-proficient people. This site
provides many different resources including, but not limited to, standards, materials,
minority population profiles, grant opportunities, and links to other websites to assist
health professionals in becoming more culturally competent.

http://www.aarp.org

http://www.nih.gov

http://www.cdc.gov/learning/

http://www.healthfinder.gov

http://www.grants.gov

http://www.minorityhealth.hhs.gov

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291
As you read each chapter in this text, you are learning how to develop, implement, and
evaluate health promotion interventions that will influence behavior and ultimately improve
individual and community health status. In this chapter you will learn how you can use social
marketing as a planning approach to develop consumer-based programs and interven-
tions. In other words, how to design programs that are based on a priority population’s wants,
needs, desires, preferences, and so forth. Box 11.1 identifies the responsibilities and competen-
cies for health education specialists that pertain to the material presented in this chapter.
Marketing and Social Marketing
Social marketing uses marketing principles to design programs that facilitate voluntary
behavior change for the purpose of improved personal or societal well-being (Andreasen,
1995; Kotler & Zaltman, 1971). In contrast, commercial marketing is defined by the
American Marketing Association as a set of processes for creating, communicating, and de-
livering value to customers. It is concerned with outcomes, typically financial, that benefit
11
Chapter Marketing
Developing Programs That Respond to the Wants
and Needs of the Priority Population
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁ Define market, marketing, and social marketing.
⦁ Explain the exchange process.
⦁ Describe the segmentation process.
⦁ List and explain the factors that are used to
segment an audience.
⦁ Explain the relationship between a needs
assessment and a social marketing program.
⦁ Explain the marketing mix or four Ps of
marketing.
⦁ Explain the six elements that make the social
marketing approach unique.
Key Terms
barriers
benefit
competition
consumer-based
consumer orientation
exchange
market
marketing
marketing mix
place
pretesting
price
product
promotion
segmentation
social marketing

292 Part 2 Implementing a Health Promotion Program
11.1
Responsibilities and Competencies for Health Education Specialists
The content of this chapter includes information on several tasks that occur during
the social marketing process. These tasks are related to four areas of responsibility for
the health education specialist and are centered on involving the priority population,
collecting data, and designing a strategy.
RESponSiBility i: Assess Needs, Resources, and Capacity for Health Education/
Promotion
Competency 1.3: Collect primary data to determine needs
RESponSiBility ii: Plan Health Education/Promotion
Competency 2.1: Involve priority populations partners, and other
stakeholders in the planning process
Competency 2.3: Select or design strategies/interventions
RESponSiBility iV: Conduct Evaluation and Research Related to Health Education/
Promotion
Competency 4.4 Collect and manage data
Competency 4.5: Analyze data
Competency 4.7: Apply findings
RESponSiBility Vii: Communicate, Promote, and Advocate for Health, Health Education/
Promotion, and the Profession
Competency 7.1: Identify, develop, and deliver messages using a
variety of communication strategies, methods, and techniques
Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc.
(NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc. (NCHEC)
and the Society for Public Health Education (SOPHE). AAHE (2015).
Box
the organization or its stakeholders. Regardless of the intended outcome, the key marketing
principles that ensure success are the same for marketing and social marketing. This chapter
will focus on social marketing’s unique contribution to health promotion by examining
six key areas that make this approach unique from other planning approaches: consumer
orientation, audience segmentation, exchange theory, the marketing mix, competition, and
continuous monitoring (Thackeray & McCormack Brown, 2005).
When people hear the word marketing, what often comes to mind are images such as highway
billboards, humorous television commercials aired during the Super Bowl, or colorful advertise-
ments in their favorite magazines. While these communication materials are an important part of
a marketing strategy, they represent only the promotion piece of the marketing mix (also referred
to at the 4Ps—see table 11.1). Marketing, as it relates to health promotion programs, is really a
consumer-based planning approach (Neiger, Thackeray, Barnes, & McKenzie, 2003).
A consumer-based planning approach is one of several approaches for developing inter-
ventions (see Chapter 8). When using a social marketing approach to design interventions,
planners make it easy and convenient for the priority population to do a behavior. They do
this by providing the priority population with opportunities and choices, also known as
products, or tangible items and services (Rothschild, 1999). This approach is in contrast to
educational or communication campaigns or other persuasion techniques to facilitate the
behavior change. It is also different than advocating for and enacting laws and policies to
coerce people to change behavior. Although these are all viable intervention methods, and
often a multifaceted approach is needed to effectively address a community health problem,

Chapter 11 Marketing 293
Table 11.1 The Marketing Mix/4Ps for Social Marketing
Source: Adapted from Schultz, et al., 2015.
Behavior: Purchase and install one LED blub in a recessed can light.
4Ps Definition Example
Product
(tangible
item
or service)
What the planners are offering meets the
consumers’ needs, makes it easy and convenient
to do the behavior, and provides a benefit that
consumers value
LED lightbulbs
(core) Benefits that are associated with using a
product or service
Protect the environment
Save money on electrical bill
Price What it costs the consumer to obtain the
product and its associated benefits
$20USD
Effort to install
Place Where the consumer has access to the product Events at local Home Depot and Costco
stores during october
Promotion The communication strategy, including the
message and associated visuals or graphics as
well as the channels, used to let the priority
population know about the product, how to
obtain or purchase it, and the benefits they
will receive
In-store signage
Flyers in customer bags
Direct mail postcards
Email notifications to energy customers
Sticky notes on newspapers
a social marketing-based intervention focuses on providing products to make it easy to do a
behavior. Box 11.2 compares social marketing with other intervention approaches to protect
the environment through reducing carbon emissions.
The Marketing Process and Health Promotion Programs
Exchange
The marketing process operates on the underlying concept of exchange theory (Bagozzi, 1975).
That is, there are buyers who have needs and sellers who have products that can fill those needs.
In order for the exchange between the buyer and the seller to be successful the seller has to offer
Different intervention Approaches to a Carbon Emissions
Reduction program
Social Marketing: Provide recycling bins at low cost to all neighborhood homes, making
it easy and convenient to conserve energy.
Education: Teach school-aged children the benefits of saving energy though a series of
five interactive lessons
Communications: Conduct a media campaign using channels of television, radio, and
social media to encourage people to take public transportation as a way to reduce a
person’s carbon footprint
Law Policy: Develop a policy that requires people who exceed their allotment of energy
each month to pay higher prices for the excess electricity they consume
Source: Categories based on Rothschild, 1999.
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11.2

294 Part 2 Implementing a Health Promotion Program
a product to the buyer that meets a need at a price he or she is willing to pay. The product bene-
fits must be greater than what it costs the buyer to obtain the product. Additionally, the benefits
must be outcomes that are important and of value to the buyer.
In health promotion, the priority population is the buyer, also called the consumer, target
audience, or market. Kotler and Clarke (1987, p. 108) define market as “the set of all people
who have an actual or potential interest in a product or service.” In this chapter we will use
the terms consumer and priority population interchangeably. In health promotion, the seller
(i.e., program planner) has a product, which is either a tangible item or service that meets
consumers’ needs, provides a benefit that they value, and will help support their efforts to
make a positive behavior change. The seller’s goal is to make it possible for consumers to get
the product and the associated benefits at a reasonable cost and with minimal effort. This
process is referred to as the exchange.
For example, a women’s health program may have as one of its impact objectives to
increase the number of working women who breastfeed their children (behavior). To help
women to do this behavior, the program offers a breast pump rental service (product). The
program is offering the breast pumps in exchange for women paying a small rental fee (the
cost). This provides women with the benefit of providing the highest-quality nutrition to
their children while continuing to work.
Consumer orientation
To successfully facilitate a product exchange, planners must have an understanding of
the  consumers. This consumer orientation means that all marketing-related program
decisions—including the type of product that is developed, how it is offered, how much it
will cost, how it is promoted, and the benefits promised—are based on what planners know
about the priority population and their preferences. If planners are making decisions with-
out knowing who is in the priority population, including things such as how they see the
world, what makes them tick, how they spend their time, and what is important to them,
then planners are not practicing marketing.
In the above breastfeeding example, it would be important for planners to know that
women consider the opportunity to bond with their children as a key benefit to breastfeed-
ing (Lindenberger & Bryant, 2000). This benefit is of greater importance than the health
benefits program planners often promote, such as “your baby will be healthier,” or “breast-
feeding will cost less money.” Although those health benefits are true, what matters most to
women is “bonding with my child.”
The process of knowing and understanding the priority population is part of the forma-
tive research process (see Chapter 3). This formative research may be included as part of the
needs assessment process (see Chapter 4). However, while similar data collection methods
are used for gathering primary and secondary data, the focus of formative research as per-
formed in social marketing is a bit different than that of a traditional needs assessment for
a program. The types of data planners try to uncover in formative research are, as described
in the SMART model (see Chapter 3), related to consumer analysis (wants, needs, and prefer-
ences of the priority population, barriers and facilitators to behavior change, as well as using
the product), market analysis (identifying competing behaviors, messages, and programs),
and channel analyses (communication preferences). Planners conducting formative research
may want to consider asking questions such as those as outlined in table 11.2.

Chapter 11 Marketing 295
CompEtition
People always have choices for how they are going to fill a need. These alternative choices
are the competition. Knowing what the priority population perceives is the competition
and the benefits that they get from choosing that option can help planners make strategic
decisions about products to offer that will provide a greater benefit at a lower cost than the
competitive option. In addition to helping planners make product related decisions, under-
standing the competition also helps planners to know how to price products and how to
frame messages for a promotional campaign. Planners should identify the competition dur-
ing the formative research phase.
For example, if people need to quench their thirst, they can drink water, milk, soda pop,
or fruit juice. If people need new running shoes, they can choose different brands such as
Nike, Adidas, or New Balance, and so forth. In social marketing, people have choices for
what behaviors they will participate in and products they will use to fulfill their needs. For
instance, if people have a desire or need to lose weight so that they can wear a new swimsuit
during their summer vacation, they could choose from two behaviors to lose weight: (1) eat
fewer calories and/or (2) engage in more physical activity. There are several tangible products
that could help them do this behavior, including purchasing a book that outlines a specific
diet plan, attending a weight management class offered by the local community center, hir-
ing a personal trainer, buying a gym membership, using a pedometer to keep track of steps
Table 11.2 Types of Questions to Ask During Formative Research
Topic Questions
Behavior • What is keeping members of the priority population from doing the
desired behavior?
Needs • What needs do members of the priority population have?
Competition • What are the members of the priority population choosing to do right
now to fill their needs?
• What do they see as the benefits of that choice?
Product • What type of products would help the priority population make
behavior changes?
• What would make it easy for the priority population to obtain the
product?
Benefits • What benefit does the priority population want as a result of doing
the desired behavior?
• What benefit does the priority population think the product
provides?
Barriers • What would make it difficult for or keep the priority population from
using the product?
• What makes it difficult for or keeps the priority population from
doing the desired behavior?
Price • What would the priority population be willing to give up or pay to
obtain the product and accompanying benefits?
Place • Where would the priority population like the product offered?
Promotion • What is the best way to communicate information to the priority
population about the product?

296 Part 2 Implementing a Health Promotion Program
walked each day, and so forth. Each of these alternative behavioral choices and tangible
products comes with both costs and benefits.
On another level, competition can come from other programs or services that are offering
similar programs or products or that are sending messages that are in conflict with the behaviors
program planners are trying to promote (Wayman et al., 2007). For weight loss, competitive
messages might come from fast food restaurants advertising low-cost, convenient foods (prod-
ucts) that are high in fat and calories. Competing programs would be any number of different
organizations or agencies that offer similar weight loss classes. Competing products would in-
clude ways, other than a pedometer, to track physical activity such as a smartphone app.
Box 11.3 is an example of competition as it relates to choices for keeping newborns warm
when there is no incubator available.
Segmentation
Program planners may think that everyone can benefit from health promotion interven-
tions, so they should try to reach everyone. However, not everyone is interested in re-
sponding, or even ready or willing to respond. Additionally, motivations for responding
to interventions vary by individuals. Segmentation is a way to divide the priority popu-
lation into smaller, more homogeneous or similar groups. The goal of segmentation is to
create groups of people who share similar characteristics or qualities who will respond in a
similar way to the intervention.
There are several advantages to segmenting the priority population. Segmentation helps
planners to narrow the focus of the marketing strategy. It is more likely that the right prod-
uct will be developed to meet the specific needs and desires of the priority population, thus
greatly increasing the chances for an exchange between the two parties. It helps planners to
be more effective and efficient with limited resources because they are able to identify groups
of the priority population who have similar needs and will respond to the marketing strategy
in a similar way. Segmentation also helps planners to make the best decisions in terms of
where to offer a product, how to make the price affordable, and how to tailor the promo-
tional strategy including messages and communication channels to the priority population.
Warm Embrace as an Example of Competition
Jane Chen and the social enterprise group Embrace discovered that newborn infants in
developing countries were dying due to the lack of access to incubators. As part of their
formative research they interviewed women, health care providers, and other people in the
community. The data revealed that women lived too far from the hospital and an incubator
was too expensive for villages to purchase. Researchers found that as an alternative choice
(the competition) parents were engaging in unsafe and ineffective behaviors including
putting their babies under a light bulb or using a water bottle to keep them warm. The
solution to this problem that met the parents’ need to keep their infants alive was a new
product called the Warm Embrace. The Warm Embrace is an infant-sized sleeping bag
equipped with meltable wax that keeps the baby’s body at a constant temperature for four
to six hours. It costs less than 1% of a regular incubator and is saving lives.
Source: Adapted from http://embraceglobal.org/
11.3
Box
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Chapter 11 Marketing 297
For example, a segmentation process discovered that among women who did not
regularly receive mammograms, a lack of knowledge about how often they should get a
mammogram was a key factor. One group did not know that they should have an annual
mammogram, while the other one did (Forthofer & Bryant, 2000). Therefore, each segment
of the population needed a unique marketing strategy. For those who already knew about
the importance of an annual mammogram, the strategy might include providing a mobile
mammography screening unit in places that are convenient for the women, such as their
workplace. The marketing strategy for the segment who were not aware that they need an
annual mammogram may include a promotional strategy with messages to first increase
awareness that annual mammograms are recommended for women of their age and then
offer mobile mammography screening units at their workplace.
Planners developing an alcohol prevention program discovered three different segments
among youth (Dietrich, Rundle-Thiele, Leo, & Connor, 2015). The first segment included
both males and females. They had low intentions to drink alcohol and their attitudes toward
binge drinking of alcohol were considered low-risk. Segment number two were primarily
males who had high-risk attitudes toward drinking and intentions to drink. The final seg-
ment were females who had low-risk attitudes towards binge drinking and had neutral inten-
tions about whether or not they would drink. Interventions could be developed for these
three groups that reflect their attitudes and behaviors toward alcohol and binge drinking.
Planners can segment groups of people using information gathered from secondary data
such as literature and epidemiological data (a priori) or after collecting primary data using
focus groups, interviews, and surveys (a posteriori). In this chapter you will learn a simple pro-
cess that you can use as a framework for conducting audience segmentation that begins with
a priori segmentation.
Factors or variables on which to base segmentation include demographics, geographics,
geodemographics, lifestyle/psychographics, benefits sought, and behavior (readiness to
change, knowledge, attitudes, beliefs, or behaviors) (see Box 11.4). Planners will need to ex-
periment with several variables to determine what works best for them.
Planners most often start the segmentation process by using secondary data that include
demographic variables such as age, gender, income, marital status, occupation, religion,
ethnicity, and socioeconomic status. Nevertheless, just because people share similar demo-
graphics does not mean that they will engage in the same behaviors. So while these data
are usually the most accessible and may describe who is at greatest risk, these data do not
always explain why people engage in behaviors or predict whether they will respond to the
marketing efforts. Variables related to consumers’ motives, personality attributes, and life-
styles can be “the most powerful segmentation variables in social marketing” (Slater, Kelly, &
Thackeray, 2006, p. 171). For example, one segmentation study found that the most impor-
tant factor that influenced the number of hours a person spent watching television was the
lifestyle of eating dinner in front of the television (King et al., 2010). Demographic factors
such as ethnicity or where they lived in the country did not make a difference. Knowing this
information would help planners to create interventions to increase physical activity and
reduce screen time.
Before beginning the segmentation process planners should have completed the needs
assessment process (see Chapter 4), selected a priority topic, and written a goal statement
(see Chapter 6). In addition, planners should have conducted formative research, as noted
earlier, to gain an understanding of the priority population, including who is most affected

298 Part 2 Implementing a Health Promotion Program
Example of Segmentation Categories and Variables
Demographic
Age: 25 to 29; 30 to 34; 35 to 39; 40 to 44; 45 to 49; 50 to 54; 55 to 59; 60 to 64; 65 to 69;
70 to 74; 75 years or greater
Gender: Male; female
Educational attainment: GED or high school graduate; some college; associate’s degree;
bachelor’s degree; master’s degree; professional degree; doctoral degree
Income: <10,000; 10-19,999; 20-29,999; 30-39,999; 40-49,999; 50-59,999; 60-69,999; 70-79,999; 80,000 or greater; or high, medium, low income; or below poverty line, at poverty line, above poverty line Religion: Catholic; Protestant; Mormon; Jehovah Witness; Jewish; Buddhist; Hindu; Muslim Race/Ethnicity: White; Black; Asian; Pacific Islander; Hispanic/Latino Geographic There could be several segmentation levels based on where people live including: country; province; state; counties; neighborhoods; census tracks; zip codes Behavioral Perceived risk: High at risk, medium risk, low risk, not at risk Health status: Excellent, very good, good, fair, poor Frequency of behavior: Daily, few times a week, once a week, 2–3 times a month, monthly psychosocial Variables Intrinsic motivation* Self-efficacy* Social support* Perceived barriers to doing the behavior (depends on target behavior) Perceived benefits from doing behavior (depends on target behavior) Stage of readiness to change: Pre-contemplation, contemplation, preparation action, maintenance Attitude toward behavior: Positive, neutral, negative Knowledge level: High, medium, low * The classification for these variables could be based on how they are measured. For example the variable could be measured on a Likert or similar scale ranging from high to low, or present to non-existent. 11.4 Box Fo cu s O n and the associated risk factors. This information provides the foundation and will be used in decision making throughout the segmentation process. Ideally, planners use multiple variables to identify audience segments. This often requires use of statistical software programs that can analyze data and create clusters or groups of people based on shared characteristics. For example, in segmenting Hispanic consumers, researchers Chapter 11 Marketing 299 used variables including language preference, generation (1st, 2nd, 3rd), length of time in the United States, education, income, identification with American way of life and Hispanic heri- tage, and attitudes toward family. Using statistical tests to cluster the groups they discovered four distinct segments. The primary differences between the groups were language preference, identification with American culture or Hispanic heritage, and generation (Alvarez, Dickson, & Hunter, 2014). However, even without statistical tests simple segmentation using primary and secondary data is still possible as described in the following five steps. The first step in segmentation is to review the formative research data to identify be- haviors that influence whether people experience morbidity or mortality associated with the health topic. For example, if a program is focused on reducing diabetes-related morbid- ity, planners would review the secondary data and determine which behaviors influence whether someone experiences diabetes-related illnesses. They may find out that daily moni- toring of blood glucose, regular physical activity, eating five servings of fruits and vegetables a day, and visits to the doctor for an annual eye exam are all behaviors that reduce the risk for diabetes complications. Second, once planners have identified all the possible behaviors, program staff and other stakeholders must decide which behavior will be the program’s focus. This will become the impact objective. Questions to consider when choosing between the possible behaviors include: 1. Is the behavior modifiable? 2. What is the relative impact that changing the behavior will have on the health status or risk factor; in other words, does the literature suggest that changing one behavior will result in greater outcomes than another behavior? 3. What are the current rates of the behavior in the priority population? 4. Is it possible to create a product that will make it easy or convenient to change the behavior, or are education or laws and policies more effective approaches? The third step is to again review the data and literature, this time to identify which seg- mentation factors (see Box 11.4) are associated with and influence whether people participate in that particular behavior. If the behavior is a visit to the health care provider for an annual eye exam, planners may discover that having health insurance, making less than $25,000 dol- lars a year, being of Hispanic ethnicity, and a belief that eye exams are not important are all associated with whether or not someone receives an annual eye exam. The fourth step is to group people together who share similar characteristics as it relates to the behavior. There is no right or wrong way to identify population segments. Planners will want to choose factors that distinguish how the priority population will respond to the marketing strategy. The segmentation process planners develop for the priority population must be useful to the organization and relevant for program planning decisions. If planners have used statistical methods to create clusters then groups are naturally created. If planners are using primary and secondary data, they can simply group people by one or two variables that most influence or are associated with the behavior. In one study, researchers were interested in creating segments of the population for a global warming engagement campaign (Maibach, Leiserowitz, Roser-Renouf, & Mertz, 2011). The variables they used to create their segments were global warming motivations (includ- ing beliefs about the issue and degree of involvement), behaviors, and policy preferences. 300 Part 2 Implementing a Health Promotion Program The  segmentation process revealed six distinct segments of the population with varying levels of beliefs about whether global warming is actually happening and if it is a problem, steps they are personally taking to reduce global warming, and what actions they think the government, businesses and individuals should take. At this point, planners may decide that they need to have additional information about these potential audience segments so they collect primary data. These data may include psy- chographics (attitudes, values, and lifestyle), risk factors, health history, or personal health behaviors. Additional a posteriori segmentation could be completed after the primary data are collected and analyzed. Lastly, once planners have identified potential segments, they have to choose one seg- ment to focus on. There is no right or wrong, or simple and easy, way to choose between segments. Planners must weigh the data against the organization’s abilities and its goals or what they are trying to achieve, then make the best decision. One approach to take—once all the possible segments are identified—is to review the segments by considering the extent to which segments exhibit each of the following five criteria (Kotler & Keller, 2016): 1. Measurable. With this criterion planners consider how many people are in the segment and whether important characteristics (or factors) can be measured. For example, can you measure readiness to change among the population? 2. Substantial. This criterion includes whether the segment is large enough and profitable enough, meaning will enough people be reached with the intervention to make a difference. Will the efforts be effective and efficient? The segmentation process for mammography discussed earlier actually resulted in seven segments, but they found that the majority of the population was in only two of the segments (Forthofer & Bryant, 2000). 3. Accessible. This criterion assesses whether or not planners will be able to reach the segment and then deliver the services. Perhaps the product is a mobile mammography unit. One segment identified is located in a remote area of the state. Due to time and distance factors program staff are not able to reach them to deliver the service. 4. Differentiable. Are the segments unique or different enough so that each segment responds in its own way to the marketing strategy? If the segments will respond the same, then they are really not unique groups. In developing a program to increase use of folic acid by women of childbearing age, planners found that women 18–24 were not receptive to messages about pregnancy whereas older women were more amenable to discussing the possibility of becoming pregnant (Lindsey et al., 2007). A marketing strategy for these two groups would be unique. 5. Actionable. Here planners decide whether programs can be developed that will attract and serve segments. Because of segment characteristics or organizational abilities, planners may not be able to create a product that adequately meets a segment’s needs or provides benefits its members want. Planners in the United Kingdom learned that one of the main reasons that low-income people smoked was that smoking was a way to cope with stress and anxiety and it was one of their only pleasures in life (MacAskill, Stead, MacKintosh, & Hastings, 2002). In evaluating this segment, planners would have to decide whether they could develop a smoking cessation intervention that would be appealing and provide a benefit that helped people cope with stress and gave them greater pleasure. Another alternative to choose between segments is to use the criteria suggested by Andreasen (1995) that share similar items: segment size, problem incidence, problem Chapter 11 Marketing 301 severity, defenselessness, reachability, general responsiveness, incremental costs, response to marketing mix, and organizational capability. Box 11.5 spotlights the results of the segmentation process conducted by the Centers for Disease Control and Prevention related to women and pre-conception health care practices. marketing mix Once audience segments are selected, planners are ready to make strategic decisions related to four marketing variables: product, price, place, and promotion—the four Ps. These vari- ables are what planners use to design interventions that will help achieve their objective(s) and are referred to as the marketing mix (see table 11.1). To realize the greatest effect in a marketing strategy there must be a combination of all market mix components, not just promotion (Belch & Belch, 2015). pRoDuCt The product is what the planners are offering that will meet the consumers’ needs, make it easy and convenient to do the behavior, and provide a benefit that consumers value. Products can be either tangible items or services and are sometimes referred to as augmented products. See Box 11.6 for examples of social marketing–related products. These products pro- vide the priority population with choices to help them change their behavior. The benefits that are associated with using a product or service are called core products or the bundle of benefits (Lee & Kotler, 2016). People choose to buy certain products for the value or benefit the product provides. A common illustration of this point is the person who goes to a home improvement store and buys a drill; what he or she is really purchasing is the benefit of using that drill to have a hole in the wall. Similarly, a person who buys a hotel room is purchasing a restful night’s sleep. The products or services provided by planners as part of a social marketing program must also provide a value that is of benefit to the priority Segmentation for preconception Health Care Planners at the Centers for Disease Control and Prevention conducted a segmentation study to identify women for a campaign focused on increasing the number of women who practiced healthy behaviors prior to becoming pregnant (e.g., get a flu shot every year, take a multivitamin with 400 micrograms of folic acid, get screening and treated for HIV/ AIDS, and so forth). They used multiple data sources, including surveys and previous literature to create a profile of these women. Segmentation variables included age, whether or not they were intending to become parents in the next 12 months (intenders/non- intenders), awareness of preconception health practices, health insurance status prior to pregnancy, receptivity to preconception health terminology and motivation for practicing preconception health behaviors. The planners identified two initial segments (intenders and non-intenders). They then described differences between the two groups based on other variables; for example, intenders were 14% of women ages 18–44 and non-intenders were 86%. For intenders, motivating factors to practice preconception health behaviors were desires to be pregnant, to have a healthy pregnancy, and to have a healthy baby. For non-intenders, motivating factors were personal health and well-being. A social marketing strategy to promote behaviors among these two segments would be clearly different. Source: Adapted from Lynch, et al, 2014 11.5 Box A pp lic at io n 302 Part 2 Implementing a Health Promotion Program products (tangible items and Services) in Social marketing programs Insecticide treated nets Contraceptives Nutritional supplements Food Battery collection cage Bike helmet Clay pot Glasses Hand-washing facilities/containers Medicine Mosbar soap Recycling container Software program Water disinfectant Testings or screenings Exams Source: Adapted from Thackeray, Fulkerson, & Neiger (2012). 11.6 Box Fo cu s O n population. Those values are determined during the formative research process. These core benefits are one of the most important things to discover, as they will become the motiva- tion for people using the products to help them change behavior. These core benefits will also become part of the promotional strategy, discussed later in this chapter. See Box 11.7 for examples of core products in social marketing campaigns. The following two social marketing case studies illustrate products and their associated benefits. The Road Crew offered a transportation service to young males in rural Wisconsin to encourage them to not drive after a night of drinking alcohol (Rothschild, Mastin, & Miller, 2006). The Road Crew used older luxury vehicles to provide transportation for the men to and from the town as well as between bars during the night. The price for this service was $15 per night. The benefits that it provided the men included a fun way to get around town, the oppor- tunity to have a last drink while going home, and less worry about getting a ticket or being in a crash as a result of drinking, all things that were important to the priority population. In Florida, program planners were concerned with reducing eye injuries among local citrus workers while harvesting fruit. They discovered that among the barriers that kept the workers from wearing protective eyewear was a belief that most workers expected the glasses would re- duce their productivity and therefore reduce their income. Their solution was to provide safety goggles that were comfortable and did not fog up or fall off while being worn. The core benefit they provided was “pick rapidly without fear of daily irritation” (Monaghan et al., 2008, p. 80). pRiCE Price is what it costs the priority population to obtain the product and its associated ben- efits. It is what they have to “give up.” In other words, price is the sum of costs the consumer must accept to engage in the exchange process (Neiger & Thackeray, 1998). The cost to the priority population may be financial, but often with health promotion interventions the Chapter 11 Marketing 303 Example of Benefits or Core products in Social marketing Studies “Don’t lose your dreams” “Have iron. Have power” Makes us healthy Avoid costly fines and penalties from noncompliance Close loving bond; emotional benefits Crew dependability on fire scene Avoidance of HIV infections Keep the family healthy and energetic; women charming; children more intelligent Don’t worry about getting home at end of the evening; continue to enjoy themselves; a way to have more fun during an evening out Enhance women’s beauty and health; decreased anemia Financial savings; health and energy to spend with children and grandchildren; more fit, so able to do leisure activities Find and develop relationships Harvest without fear of injury or daily irritation Hope and peace of mind Maintain pride and self-esteem as they earn WIC benefits and learn about nutrition and other ways to help their families Well-being; energy; ability to perform their roles better Opportunity to keep their relationship (family) intact by ending the violence toward their partner Peace of mind and life-saving benefit of early detection Protect individual health; sense of altruism; information provision Reduce traffic congestion; defer need to build road infrastructure; reduce environmental consequences of car use; increase physical activity and health outcomes; increase use of walking and cycling infrastructure and public transport Safety of family or workers, financial concerns, impact of debilitating injuries Spending time with friends, playing, having fun, have opportunity to be active with parents, recognition from peers and adults, opportunity to discover and explore world around them Source: Adapted from Thackeray, Fulkerson, & Neiger (2012). 11.7 Box Fo cu s O n costs are nonfinancial, that is, they involve social, mental, emotional, behavioral, or psycho- logical costs. For example, if a program focused on getting Hispanic women with diabetes to regularly check their glucose, a low-cost glucometer could be offered to the priority popula- tion. In order to get this product and the associated benefit of a peace of mind that their blood sugar is in range so they will be less likely to damage their eyesight, the women would have to pay a certain amount of money. In addition to this financial cost, the women would have to give up time to go purchase the glucometer and learn how to use it. They would also have to take time every day to check their blood glucose. As discussed earlier with the exchange process, in designing a marketing strategy, plan- ners must make sure that the benefits the priority population receives are greater than what it costs them to obtain the product. Even if the costs are not actually less, planners have to make them appear less than what they are getting in return. Likewise, as part of the 304 Part 2 Implementing a Health Promotion Program promotional strategy, planners must convey how the benefits received are much greater than what they cost. For example, for a mother to bring her child in to be immunized might cost her time away from other tasks, time to drive to the clinic, the effort to get to the clinic, and being willing to put up with a cranky baby for a few hours after the immunization is received. In communicating about this product (immunizations), the health education specialist has to convey that the benefits of knowing that her child is safe from childhood diseases are greater than a few minor inconveniences (her cost). Price is not the same thing as barriers. Barriers are what keep people from responding to an intervention or doing a behavior. The cost or price of the product may be one factor that keeps people from obtaining it and using it to make a desired behavior change. But there may be other factors as well. In addition to price, barriers to using LED light blubs (see Table 11.1) were being unfamiliar with options, having the product available, and uncertainty about the benefits of using LED lights. Researchers have found that among young people, barriers to getting tested for sexually transmitted infections are access to testing services, stigma associated with the infections and fear of results (Friedman et al., 2014). Thus interventions had to address these barriers in order to increase the number of youth screened. In another example, when planners asked people about what would keep them from at- tending a nutrition education class, they said that the major reasons were that they lacked transportation and there was nobody to babysit their children (John, Kerby, & Landers, 2004). These are barriers but not costs: the people do not have to give up transportation or childcare to participate in the exchange. However, either thing will keep them from obtain- ing the product. They would have to give up money for transportation or to pay a sitter. In designing the product or intervention, planners have to make sure that they reduce the bar- riers and lower the cost—both for the same purpose—to make it easy for people to obtain the product or service and engage in the desired behavior. In this case, the planners may want to offer a baby-sitting service at the same location where the class is being held. From an economic standpoint, price refers to charging the appropriate amount for the prod- uct being provided. Planners who were promoting the use of LED light bulbs found that price was a barrier to people wanting to purchase the bulbs (Schultz et al., 2015). Therefore, their pricing strategy included providing a rebate with bulb purchase, reducing the price range from US$20–US$59 to US$2–US$21. Offering the bulbs at an affordable price increased sales. There are many ways to finance a program (see Chapter 10). The price must match the consumer’s ability and willingness to pay and should not be so high that it becomes a barrier to them using the product or service. When considering the amount to be charged for a prod- uct, planners should answer seven questions: 1. Who are the clients? 2. What is their ability to pay? 3. Are co-payers involved? 4. Is the program covered under an insurance program? 5. What is the mission of the planner’s agency? 6. What are competitors charging? 7. What is the demand for the program or product? Chapter 11 Marketing 305 The price of a program and who pays for it help determine how a program should be marketed. Whether the program is intended to make a profit will have a great impact on the price. Does the program have to make money? Break even? Or can it lose money? It is a real art not to overprice or underprice the program. Demand and location (place) will also influ- ence price. If a program is in high demand, obviously the price can be raised. For example, a stress-management program in a large metropolitan area may be able to command a higher price than one located in a small rural area. Not only do the demand and the location influence the amount one might charge for a program, but so can the psychological mindset of those in the priority population. Some individuals would not participate in a free or inexpensive program because they question how such a program could be any good. They may believe they have to spend a lot of money to get anything of worth. Also, sometimes when programs are offered free of charge, people are less likely to attend regularly because they have not invested finan- cially in the program. On the other hand, there are some people who, if given the choice of a free program versus one with a cost, will always take the free program, even if they are financially able to pay. Being able to segment the priority population with regard to these economic issues can help set the right price. plACE The third marketing variable is place, which can be thought of as where the priority population has access to the product. When considering place, planners make sure that it easy for the consumer to obtain the product or service. In addition, it is important to avoid areas where people do not normally go or places where they would not feel com- fortable or safe. For example, in New Mexico, the HABITS for Life program discovered that barriers to annual health screenings and eye exams were time, cost, and easy access (Brown-Connolly, Concha, & English, 2014). To address these barriers they provided mo- bile screening units at worksites, faith-based programs, senior centers, and health fairs. Another example is a partnership between bar owners and public health researchers who aimed to make it easier for people to get a taxi ride home, thereby discouraging drinking and driving. They provided cab drivers with a special spot to wait (which also guaranteed them passengers). The area was well-lit, covered, and in a generally safe place, all impor- tant things to the customers (Bhatt, 2006). When a product is offered it is closely associated with its place. If the priority population has to go to a specific location to obtain the product, planners might think about when it will be most convenient for the priority population to do so. For example, if consumers have to come to the local health department to have their car seat checked to ensure that it is prop- erly installed, making the service available at times that are convenient for the priority popu- lation will reduce a barrier and make it more likely that consumers will take action to use this service. If it is a program, then planners might consider the optimum time of day to offer the program. If a worksite program is offered in the evening, so that the workers have to return to the worksite after dinner, that probably would not be much different from driving across town from work to attend a program. Offering a program right after a shift or on a lunch hour would probably be much more appealing to most workers. Obviously, planners should be concerned about placing their program in a desirable locale (where they are wanted and needed) at the best possible time. 306 Part 2 Implementing a Health Promotion Program pRomotion The fourth marketing variable is promotion. As mentioned at the beginning of this chap- ter, promotion is what most people think of when they hear the word marketing. But promo- tion is just one component of the overall marketing mix. Promotion is the communication strategy, including the message and associated visuals or graphics as well as the channels, used to let the priority population know about the product, how to obtain or purchase it, and the benefits they will receive. Promotion is not about a general awareness campaign or related health communication intervention strategies. Promotion, also referred to as market- ing communications, has four primary purposes (McDonald & Wilson, 2011): 1. Inform—increase product awareness or inform consumers 2. Persuade—convince people to purchase the product 3. Reinforce—remind them that the product exists 4. Differentiate—position the product as being different from the competition There are various tools and associated channels that planners can use to achieve these purposes. Traditionally, promotional tools have included advertising, direct marketing, digi- tal communications, sales promotion, personal selling, and publicity/public relations (Belch & Belch, 2015; McDonald & Wilson, 2011). The following section gives a general overview of these tools. Advertising is marketing communication that is paid and nonpersonal, meaning it is not trying to reach one person but rather large groups of people. Common channels for adver- tising have included broadcast media (television and radio), print media (newspapers and magazines), outdoor media (billboards, bus wraps, and so forth). The national 5-a-day cam- paign used point-of-purchase advertising in grocery store produce departments to remind people to eat five servings of fruits and vegetables. Local coalition members developed a sum- mer VERB program where they increased the number of places in the community for tweens to be active. They developed a card on which tweens could keep track of places they went to be physically active. Advertising space was paid for in the local newspaper, in a local family magazine, and on the radio. In addition, they got free publicity from the local media outlets and word of mouth from program partners and coalition members (Courtney, 2004). The National Bone Health Campaign used advertising including print ads and 30-second radio spots (Lefebvre, 2006). Direct marketing involves communicating directly with consumers about a product with the purpose of getting them to purchase the product or service (Belch & Belch, 2015). Common channels for direct marketing include direct mail, internet, interactive televi- sion, or telemarketing. Tobacco companies use direct mail to provide coupons and other incentives with the purpose of encouraging people to try tobacco products (Brown-Johnson, England, Glantz, & Ling, 2014). One of the more recent applications of direct marketing in public health and health care is that of direct-to-consumer genetic tests (Liang & Mackey, 2011). Health planners may use direct marketing to reach specific groups who might be at high risk and in need of the programs. For example, direct marketing has been identified as a way to get people connected with treatment for mental health and substance abuse interven- tions (Becker, 2015). Other direct marketing approaches could include emailing recent heart attack patients about a program on the need to eat in a heart healthy manner, or distributing inserts about upcoming wellness program events with employee paychecks. Chapter 11 Marketing 307 Personal selling refers to person-to-person interaction intended to persuade the cus- tomer to buy the product. Personal selling is used regularly in health care marketing. Pharmaceutical companies have representatives who meet one-on-one with health care providers for the purpose of convincing them to use a certain prescription drug. Another example of personal selling is the use of lay health workers, or promotoras. In rural South Carolina, promotoras were used to give information, assistance, and referrals to services (Sherrill et al., 2005). One way these lay health workers could engage in personal selling is by going to individual homes and encouraging people with diabetes to attend the health clinic screening and have their blood glucose tested. Sales promotions are incentives that entice consumers to try the product. Types of sales promotion include coupons, premiums (e.g., prizes with purchase), contests and sweep- stakes, rebates, or samples (Clow & Baack, 2014). In Japan, coupons for free cervical cancer screenings were sent to women between the ages of 20–40 as a way to increase screening rates. (Ueda, et al., 2015). Other examples include providing a coupon for a free bike helmet or a reduced fee at the local fitness center. Public relations, also called publicity, represents both internal and external marketing communications. The news media coverage that external public relations activities gener- ate is typically not paid for by the organization (as compared with advertising). Typical public relations tools include the use of ongoing news media outreach and sponsorship of large events that draw attention and exposure such as a special kickoff, countdown, ribbon- cutting, or health party to get a program started. Public relations activities can also be used to increase awareness about new products. The health care organization Kaiser Permanente uses social media as a public relations tool to disseminate information and engage with their stakeholders (Hether, 2014). These social media public relations activities help them to com- municate with customers about the services they provide and to clear up any misunderstand- ings that may have resulted from media coverage. Finally, there is digital communication. In recent years, the availability of the Internet has increased the options available for planners to use these traditional tools across a spectrum of channels. This form of promotion can generate a great deal of interest in the product for a rel- ative low cost and in a short period of time. The availability of electronic media in addition to the Internet, including cell phones, has expanded promotional alternatives. For example, social marketers can use podcasts and other downloads to promote their products. Websites are probably the most common channel for Internet promotion. For example, advertising can now be part of a home page or social networking site, or included as a banner ad in an online newspaper. The National Bone Health Campaign developed a Website specifically for teen girls (Lefebvre, 2006), and they placed banner ads on other Websites that the priority population often visited. There are several factors to consider when deciding which of the promotional tools and channels to use. Two of the most critical are the communication objectives and the commu- nication preferences for the priority population. If the objective is to increase awareness of a product, the tools and channels are different than if the purpose is to demonstrate how to use the product, or to illustrate key attributes, or provide in-depth details about the product features. The priority populations’ communication preferences are also critical. For example, formative research for a disaster preparedness campaign in Vietnam found that the major- ity of respondents owned a radio, fewer people owned a television, and almost nobody had 308 Part 2 Implementing a Health Promotion Program subscriptions to the newspaper or magazines (Ramaprasad, 2005). Therefore, in selecting a promotional strategy and materials, planners probably would not place an advertisement in the newspaper, but might consider a radio spot. The National Bone Health Campaign found that the most common ways for girls grades 6–12 to stay in touch with their friends was through text messages, instant messaging, and cell phones. In addition, the most popular magazines were Seventeen and Teen People (Lefebvre, 2006). For the Hispanic segments men- tioned earlier, one segment (bi-cultural) preferred marketing materials to be in English, while the other two segments (retainers and non-identifiers) preferred Spanish language materials (Alvarez, Dickson, & Hunter, 2014). Additional questions that planners may want to ask when selecting a promotional tool and channel include: 1. What are the costs of each tool or channel versus the benefits? 2. Can the tool’s or channel’s capability build on or multiply the effects of another tool or channel? 3. Will the message reach a significant portion of the priority population? 4. Can the message be sent through several different channels? 5. Through how many intermediaries must the message travel to reach the priority population? 6. Can a tool be overused to the point that it will “turn off” the priority population to the message? Messages include the words and graphics that are used to convey information about the product, where to obtain it and the benefits it will provide. The process for develop- ing appropriate messages is both an art and a science. Many communication theories and models can be used to develop effective messages. A good place to start is with consumer-based health communications as described in the National Cancer Institute’s (NCI) book Making Health Communication Programs Work (NCI, n.d.), otherwise known as the “Pink Book” (See http://www.cancer.gov/publications/health-communication /pink-book ) In order to develop effective messages, planners must know what is mo- tivating the priority population. This is learned while conducting formative research. They must know how to frame the message so that it will cut through the clutter, cap- ture the priority population’s attention, and motivate them to action. Key parts of the message should be that the product will offer a benefit that the priority population de- sires, that the product costs less than the benefits it provides, and how they can obtain the product. For example, after performing formative research related to diet and physical activity among a group of public employees, planners learned that preferences for message content included “helping employees understand that the desired changes could be inexpensive, fun and easy, and that changes would require only a minimal amount of time.” Based on these preferences, messages through email, public announcements, posters, and direct supervisor contacts (all preferred channels) were successfully used to recruit a large group of participants in a successful intervention (Neiger et al., 2001). Another example of this concept was the segmentation process that resulted from focus groups conducted with teenage girls as part of a physical activity project (Staten, Birnbaum, Jobe, & Elder, 2006). The process resulted in seven main segments that described the girls: http://www.cancer.gov/publications/health-communication/pink-book http://www.cancer.gov/publications/health-communication/pink-book Chapter 11 Marketing 309 athletic, preppy, quiet, rebel, smart, tough, and other. In addition, they discovered prefer- ences for the types of images that would be best for communication materials. Respondents provided the following suggestions: (a) for athletic girls, pictures should show girls participating in organized, competitive activities; (b) for preppy girls, pictures might show girls cheerleading, well-dressed individuals, groups of friends being active, girls being active with boys watching (with positive affect, not leering or jeering), and organized sports with “cute” uniforms; (c) for quiet girls, pictures should show girls alone or in small groups doing activities (don’t focus on competitive sports); (d) for rebel girls, pictures might include girls on skateboards, perhaps with some visible body piercing, girls wearing dark clothes, images implying dancing to punk rock music; and (e) for smart girls, pictures should show girls who are not too muscular or strong being active in small groups, and positive attitudes and neat but not trendy dress may be appealing. Small group images that show some smart girls and some preppy girls being active together may be appealing. And (f) for tough girls, pictures might show girls doing stepping or hip-hop dance or girls playing basketball (not necessarily in uniform; show street games, pick-up games). Images of girls should not be conservative. Groups of friends would be appealing. (p. 76) WoRkinG WitH CREAtiVE tEAmS to HElp ExECutE tHE pRomotionAl StRAtEGy Depending on the agency and the available budget, planners may be responsible for develop- ing and executing the promotional strategy or they may hire a marketing or public relations firm to do some of the creative work including creating messages, materials, or brand logos and tag lines. If planners are working with a creative agency, the following suggestions will help ensure that the process is successful. Keep in mind that the actual process may vary depending on the creative team and their agency policies. At all phases of the process, plan- ners should make sure to have open and honest communication with the creative team. It is important to trust their creative skills and abilities, but planners need to make sure that they are on track with the program objectives. The first step is to identify a public relations or marketing agency. The organization that a planner works for may require all outside work to be solicited through a specific procurement or bid process. In other instances, planners may be able to work directly with an agency of choice. In either circumstance, the first step is to identify a list of possible agencies. Consider getting recommendations from other health promotion programs or health-related organi- zations that have hired creative agencies. Ask the agency for samples of their previous health- related campaigns. Once an agency has been selected, hold a meeting with members of the program plan- ning team and the creative team. This is sometimes referred to as a discovery meeting. At this meeting the creative team will assess what needs to be accomplished. Planners should bring to this meeting all the research about the priority population and the program goals and objectives. A concise way to convey this information is by using a creative brief, which is a synopsis that describes the priority population, the benefits they seek, the barriers they face, the purpose of the communication, and potential communication channels. (See Box 11.8 for an outline of a creative brief.) After the discovery meeting, the creative team will come back to the agency with recom- mendations for how to proceed, including the type of appeal (e.g., humor, slice of life) and the type of communication materials. They should also provide a cost estimate for how many person-hours it will take to develop the materials and the cost of material production. 310 Part 2 Implementing a Health Promotion Program The next step is to sign an estimate agreement. Before doing so, planners need to make sure that they agree with the creative team’s recommendations. That is, does the recom- mended approach on strategy correspond to program goals and communication objectives? At this point planners want to clarify what work and deliverables are included in the fees. Once the agreement is signed, the creative team will begin their work. Based on the budget, they will flesh out a limited number of concepts, also known as draft ideas. After reviewing the concepts, planners can choose which one(s) they want to be part of their campaign. A limited number of modifications (sometimes just one) is included in the original cost estimate. Other major changes beyond that may require another fee. Knowing that several modifications can increase the cost of a promotional campaign is one reason that the discovery meeting is so important and why planners want to be prepared with formative research about the priority population. Planners should also make sure to build in time and money for pretesting materi- als and messages with the priority population, as discussed in the next section. pretesting Though planners conduct formative research and learn as much about consumers as they can prior to developing the marketing strategy, planners need to make sure that they are still on track with consumer preferences before offering products or launching the promotional campaign. The process of getting this feedback is called pretesting. Pretesting ensures that planners have developed program components in response to, and are reflective of the prior- ity population’s needs, wants, and expectations. Ideally, planners should test all components of the marketing strategy including prod- ucts, messages, materials, and selected promotional tools. However, the breadth and depth of pretesting is usually determined by the budget. It is important to include in the project time line, as well the budget, adequate time and financial resources to complete pretesting. Pretesting can be completed in two phases, both of which occur during the development process when products and promotional materials are in draft form, before ideas are finalized or any promotional materials are produced. Phase one involves testing the product concepts. Think of concepts as a prototype or draft form of products and services. For example, you are considering offering a service where people can take a photo of a mole or other mark on their skin and send it to the dermatologist for analysis. You want to know what people think about this service and if they would use it. Pretesting concepts gives planners the opportunity to get outline of the Creative Brief for a promotional Strategy 1. Background (overview about the topic and project): 2. Priority Population/Segment (concise description of the priority population): 3. Purpose of Promotion (increase awareness of product, remind them product exists, or encourage them to act): 4. Core Benefit to Highlight: 5. Place (where the people will access the product): 6. Price (both tangible and intangible): 7. Communication Preferences (tools and channels): 11.8 Box A pp lic at io n Chapter 11 Marketing 311 feedback on the design of the product as well as the product-related benefits. The topics plan- ners would want to receive feedback on when pretesting the product or service may include: ⦁ How likely they would be to use the product ⦁ What they see as benefits to using the product ⦁ What they see as the barriers; what factors would keep them from using it ⦁ What products features they like ⦁ What product features they would change, and why ⦁ If the places selected to offer the product are convenient ⦁ If the product price is reasonable ⦁ If the benefits associated with product use are believable ⦁ If the product functions as designed ⦁ If instructions for how to use the product are clear The second pretesting phase is testing the promotional strategy messages and materials. It is best to test messages and materials separately because planners will not know if the prior- ity population is responding to the message or the material. For instance, you test a message and brochure together and find that the message is not very motivating. Is this because of the content of the message? Or is it because the brochure design influenced how they un- derstood the message? Box 11.9 outlines aspects of the promotional messages and materials about which planners may want to get feedback during the pretesting process. Pretesting allows planners to identify red flags or, in other words, parts of the strategy that may reduce the chances of success. However, positive feedback from the priority population during the pretesting phase cannot indicate the degree to which the consumers will like the product or service, or how successful the promotional messages and materials will be at influ- encing people to use the product or service. The inability to generalize pretesting results to a larger population is due to a small sample size and selection methods (see Chapter 5). The methods planners can use for pretesting depend on what aspect of the marketing strategy is being tested, the topics being explored, the amount of money available for pretest- ing, and the timeline. In general, focus groups (see Chapter 4) and central location intercept interviews are common pretesting methods. Focus groups have the advantage of group discus- sion and brainstorming from several people at once. But sometimes group discussion can sway people’s opinions so you may want to use individual interviews. Central location intercept interviews requires going to a place where the priority population can be easily found (e.g., young mothers at pediatrician offices) and then asking if people would be willing to spend 10-15 minute answering some questions. These qualitative methods are preferred because they allow the planners to interact with the priority population, get in-depth reactions to products, messages and materials, and follow up with clarifying questions or probes. You can also use surveys, administered in-person, through the internet, or the mail (see Chapters 4 and 5 for more information about survey questionnaires). A survey will allow you to get feedback from more respondents but it limits the planner’s ability to probe for additional feedback. Factors to consider when using each of these methods for pretesting are presented in table 11.3. Pretesting should always be completed with members of the priority population. Planners can use probability or nonprobability (also called purposive) samples (see Chapter 5) to select the participants. In addition, planners may want to obtain reviews from subject matter experts 312 Part 2 Implementing a Health Promotion Program or gatekeepers. Subject matter experts are people who have advanced knowledge about the health topic. Having subject matter expert review ensures that the promotional messages are factually and technically correct, thereby reducing the chance of conveying false informa- tion. Gatekeepers are people who control whether messages, materials, or products reach the priority population. Gatekeeper review enables the planners to get buy-in from individu- als who are influential in distributing the product or disseminating promotional materials. Examples of gatekeepers are nurses at doctors’ offices, radio station owners, newspaper edi- tors, or individuals whom the priority population identifies as community leaders. Continuous monitoring Continuous monitoring conducted as part of a marketing strategy is somewhat analogous to aspects of both formative and process evaluations (see Chapter 14). What makes con- tinuous monitoring unique is its focus on getting reaction and comment from the priority population about all aspects of the program during the implementation phase. The moni- toring function determines if things are going as planned, if the program is operating below expectations, and whether changes noted indicate that the program is moving in the right topics for message and material pretesting Show a copy of draft messages and ask: What is the main idea that you get from this message? What do you think they want you to know? What do you think they want you to believe? What action do you think they want you to take? What image comes to mind when you hear this message? What emotions do you feel as you hear this message? Where is the best place to reach you with this message? Where would you most likely notice it and pay attention to it? What words are confusing or hard to understand? Describe what type of person this message is trying to reach. The main purpose of this message is to persuade you and people like you to [describe action related to the product]. How likely is it that you would take action based on this message? (Note: Use a Likert scale here to measure response.) What about this message is motivating? What about this message is not motivating? Show a draft of a promotional material and ask: What do you like about this [material]? What don’t you like about this [material]? What stands out to you? How attention-getting is this [material]? (Note: Use a Likert scale here to measure response.) Source: Adapted from Lee & Kotler (2016); National Cancer Institute (n.d.). 11.9 Box A pp lic at io n Chapter 11 Marketing 313 Table 11.3 Factors to Consider When Choosing Pretesting Methods Factor Potential Options Example Preferred Pretesting Method 1. What part of the social marketing strategy is being tested? Promotional messages Postcard to be received in the mail Survey; intercept interview; focus group Promotional materials based on messages Brochure, flyer, Website banner, Intercept interview; focus group A product prototype or sample Text message service Intercept interview; focus group 2. What type of responses do you want from the priority population Ratings “Rate on a scale of 1-5 how likely would you be to take action after seeing this message.” Survey; intercept interview A long list of ideas from group brainstorming “Tell me about the places you might see messages like this in your neighborhood.” Focus group In-depth reactions. You want to be able to ask follow-up questions based on their responses “Tell me about the type of person this message is talking to.” “Tell me about how they spend their time.” “Tell me about what makes you think it is for women only.” Intercept interview; focus group 3. What do you want the priority population to do? See a message, material, or product in-person Show them a poster with the message and then ask questions. Intercept interview; focus group Read a message Provide a copy of the message in writing Survey; intercept interview; focus group Hear a message Ask them to listen to a radio spot Survey; intercept interview; focus group Touch a product or material Hold the product in their hands Intercept interview; focus group Try out a product Ask them to use the Website to contact their health care provider Intercept interview; focus group 4. Would the priority population talk about this product or message in a group setting? Behaviors that are considered socially undesirable or sensitive may not be discussed as openly in a group setting Drinking and driving; intravenous drug use; sexually transmitted infections Survey; intercept interview direction (Andreasen, 1995). This continuous monitoring provides program planners with data regarding level of program acceptance by the priority population, reach of messages, product distribution sites, and in general, what is working and what is not working. Overall, continuous monitoring improves the effectiveness of the program by continually integrat- ing feedback from the priority population. 314 Part 2 Implementing a Health Promotion Program Summary An important aspect of any health promotion program is being able to design a product that will attract the priority population initially and keep them involved once they have begun a new behavior. All products must provide a benefit or outcome that the priority popula- tion values. Using marketing principles can help planners develop successful programs. Understanding the priority population, including their wants and needs, is at the heart of the marketing process. An important step in the process is identifying segments that share similar characteristics. The marketing mix should take into account the four Ps of market- ing: product, price, place, and promotion. These elements together become the basis for the marketing strategy that will facilitate the exchange between the program planner as the mar- keter and the priority population as the customer. Before launching the program, products, messages, and materials should be pretested with the priority population. After the program starts, continuous monitoring and getting feedback from the priority population will help keep the program on track. Box 11.10 is a template that planners can use to write a one-page summary of their social marketing strategy. Review Questions 1. Define the following terms: market, marketing, and social marketing. 2. What is the relationship between formative research and needs assessment? 3. How does segmenting your priority population help you in planning? 4. What are some factors to use when segmenting your priority population? Which ones are most important? one page Social marketing Summary In order to help ______________ [priority population segment] ______________ To do ______________ [behavior] ______________ We will offer ______________ [product] ______________ Which will help overcome ______________ [barriers] ______________ And provide ______________ [benefits] ______________ For this ______________ [price] ______________ At ______________ [location] ______________ We will let the priority population know about this product by using ______________ [promotional strategies] ______________ We will pretest our strategy by ______________ [pretesting methods] ______________ We will measure our success by ______________ [continuous monitoring] ______________ 11.10 Box A pp lic at io n Chapter 11 Marketing 315 5. What has to happen in order for an exchange to take place between a planner and the priority population? 6. Describe the six elements that make a social marketing approach unique from other planning approaches? 7. What are the four Ps of marketing? Explain each one. 8. Describe how to best work with a creative team to execute a promotional strategy. 9. What are the purposes of pretesting? 10. What are factors to consider when choosing pretesting methods? Activities 1. Respond to the following statements/questions with regard to a program you are planning. Make sure to explain the rationale on which you based your decision. a. Describe your product (i.e., tangible item or service). a1. How will the product make it easy and convenient for the priority population to do the behavior and receive the associated benefits? a2. How will the product help to reduce barriers to, and/or the cost of the behavior you want the priority population to engage in. a3. What is the core product (or bundle of benefits) that they will receive if they purchase and use the product? b. Describe your segmented priority population. What segmentation factors did you use to identify segments? c. What will the priority population have to “give-up,” or “pay” to receive the augmented product and the bundle of benefits? Consider both financial and non-financial costs. d. Describe where priority population will access the augmented product. In other words, where will the product be available or distributed to the priority population. What is your reason for placing it this way? If you have a service product, when will it be offered (location, days, and time)? e. What promotional tools will you use to promote your program? How, when, and where will you let the priority population know about the item or service? 2. Detail a pretesting plan for your marketing strategy. a. Identify which components of the marketing strategy you will test (product, mes- sages, materials). Include rationale for the choice of those components for pretest- ing. That is, why is it important to pretest those aspects? b. Describe what specific components of the product, message or materials will be tested. For example, are you going to test the color of the print for the materials? The appeal of the message? If people understand the main message? c. Write out the questions that you would ask during pretesting, d. Describe when (dates) and where (geographic locations) the data will be collected and who will participate (the sample) in the pretesting. 3. Using Box 11.10, create a one-page summary of your social marketing strategy. 316 Part 2 Implementing a Health Promotion Program 4. Create a promotional piece that could be used to promote your product through advertising, direct marketing, personal selling, or sales promotions. This promotional piece should include both text and graphics and highlight the core benefit being offered. 5. Survey members of the priority population to find out what would motivate them to begin a specific health behavior. Make sure to ask about products and services that would help them make that change. See Chapter 5 about survey layout and design. Weblinks 1. http://www.marketingpower.com American Marketing Association The American Marketing Association is one of the largest professional associations for marketers. This Website provides best practices related to marketing strategies, including marketing tools and templates and marketing services directories. 2. http://www.cbsm.com/public/world.lasso Fostering Sustainable Behavior and Community-Based Social Marketing This Website highlights how social marketing is used in the areas of energy, water, transportation, and the environment. On this Website there are articles, case studies, discussion forums, and other resources. 3. http://www.europeansocialmarketing.org/ European Social Marketing Association The European Social Marketing Association is primarily for connecting social marketers in Europe. On their Website you will find news, job announcements, events, and networking opportunities. 4. http://www.i-socialmarketing.org/ International Social Marketing Association The International Social Marketing Association’s mission is to “advance social marketing practice, research, and teaching through collaborative networks of professionals, supporters and enthusiasts.” On the Website you will find jobs, events, networking opportunities, webinars, social marketing news, and other resources. Some content is available for member’s only. 5. http://www.toolsofchange.com/en/programs/social-marketers/ Tools of Change This Website is based on social marketing work in Canada. Here you will find case studies, planning guides, and list of webinars and workshops available through Tools of Change. 6. http://ctb.ku.edu/en/sustain/social-marketing/overview/main Community Tool Box This Website provides excellent resources on promoting participation and social marketing. Topic sections include step-by-step instruction, examples, checklists, and related resources. http://www.marketingpower.com http://www.cbsm.com/public/world.lasso http://www.europeansocialmarketing.org/ http://www.i-socialmarketing.org/ http://www.toolsofchange.com/en/programs/social-marketers/ http://ctb.ku.edu/en/sustain/social-marketing/overview/main Chapter 11 Marketing 317 7. http://www.social-marketing.com Weinreich Communications This Website contains social marketing-related articles, resources, conference calendar, and extensive lists of links to pertinent sources of information. 8. http://www.thensmc.com/ National Social Marketing Centre (NSMC) The NSMC is a center for excellence in behavior change and social marketing located in the United Kingdom. This Website provides tools and resources for designing social marketing programs as well as case studies from around the world. 9. liStpRoC@liStpRoC.GEoRGEtoWn.EDu Georgetown Social Marketing Listserv This is an active social marketing listserv with discussions centering on a variety of social marketing topics. Subscribers can elect to receive a daily digest of emails or receive each one as it is posted. To subscribe, send an email message to the URL listed above. In the body of the message write “SUBSCRIBE SOC-MKTG [insert your own name].” http://www.social-marketing.com http://www.thensmc.com/ mailto:liStpRoC@liStpRoC.GEoRGEtoWn.EDu This page intentionally left blank 319 Earlier (in Chapters 1–10) we discussed the steps necessary to plan a solid health promotion program, and presented information (in Chapter 11) that would assist planners in marketing the program they planned. With the planning and marketing processes com- plete, planners need to focus on implementation. There are many things that need attention in the implementation process that are critical to a successful program. The eventual impact of a program will be judged not only by the effectiveness of the interventions but also by the quality of the implementation (Parcel, 1995). In fact, Timmreck (2003) has stated “imple- mentation is the most critical part of the planning process; a plan that is not implemented is 12 Chapter Implementation Strategies and Associated Concerns Chapter Objectives After reading this chapter and answering the questions at the end, you should be able to: ⦁⦁ Define and explain a logic model. ⦁⦁ Define implementation. ⦁⦁ Identify the different phases for implementing health promotion programs. ⦁⦁ Define management. ⦁⦁ Identify and briefly explain the major resources that must be managed during implementation. ⦁⦁ Identify major pieces of federal legislation that impact human resource management. ⦁⦁ List and briefly describe the concerns that need to be addressed before implementation can take place. Key Terms accounting act of commission act of omission anonymity audit beneficence confidentiality critical path method disability ethical issues external audit financial management fiscal accountability fiscal year Gantt chart HIPAA implementation implementation science informed consent inputs internal audit logic model management negligence news hook nonmaleficence outcomes outputs PERT phased in pilot testing program kick off program launch program monitoring program rollout prudent task development time line technical resources Type III errors 320 Part 2 Implementing a Health Promotion Program no plan at all” (p. 171). In this chapter, we present the key phases in implementing a program and identify the many concerns that must be addressed as implementation unfolds. Box 12.1 identifies the responsibilities and competencies for health education specialists that pertain to the material presented in this chapter. 12.1 Responsibilities and Competencies for Health Education Specialists This chapter focuses on program implementation. Because implementation is a culmination of all the preparation and planning that has come before it, several of the responsibilities and competencies for health education specialists apply. The responsibilities and competencies related to these tasks that are associated with implementation include: RESponSiBility ii: Plan Health Education/Promotion Competency 2.4: Develop a plan for the delivery of health education/ promotion Competency 2.5: Address factors that influence implementation of health education/promotion RESponSiBility iii: Implement Health Education/Promotion Competency 3.1: Coordinate logistics necessary to implement a plan Competency 3.2: Train staff members and volunteers involved in implementation of health education/promotion Competency 3.3: Implement health education/promotion plan Competency 3.4: Monitor implementation of health education/ promotion RESponSiBility V: Administer and Manage Health Education/Promotion Competency 5.1: Manage financial resources for health education/ promotion programs Competency 5.2: Manage technology resources Competency 5.3: Manage relationships with partners and other stakeholders Competency 5.6: Manage human resources for health education/ promotion programs RESponSiBility Vi: Serve as a Health Education/Promotion Resource Person Competency 6.2: Train others to use health education/promotion skills Competency 6.3: Provide advice and consultation on health education/ promotion issues RESponSiBility Vii: Communicate, Promote and Advocate for Health, Health Education/ Promotion, and the Profession Competency 7.1: Identify, develop, and deliver messages using a variety of communication strategies, methods, and techniques Competency 7.2: Engage in advocacy for health and health education/ promotion Competency 7.3 Influence policy and/or systems change to promote health and health education Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Box Chapter 12 Implementation 321 Logic Models Before discussing the various phases of implementation and the issues related to them, we feel it is important to present information on logic models because of their usefulness in the imple- mentation process. While logic models can be created and used at various times during the plan- ning, implementing, and evaluating processes, they are especially useful at this stage of program development because they can help identify the steps that must be taken to implement and manage successful programs. A logic model is a systematic and visual way for planners to share and present their understanding of the relationship among the resources they have to operate a program, the activities they plan to implement, and the outputs and outcomes they hope to achieve (CDC, 2008b; WKKF, 2004); “that is the logic of the program” (Lando, Williams, Sturgis, & Williams, 2006, p. 2). Simply put, a logic model is a road map (Goldman & Schmalz, 2006) showing the connections among the key components of a program. Logic models can take many different shapes (linear, circular, lists) and be presented in various levels of detail (simple, complex) but all depict the relationship and linkages of various components in a graphic display of boxes and arrows. “Program-level logic models are often meta-summaries of complex processes; as a result, additional logic models may be needed to ‘unpack’ each component in the original model so that more details can be articu- lated” (Helitzer et al., 2009, p. 64). In its most basic form a logic model includes four com- ponents: inputs (or resources), activities (or interventions or strategies), outputs (or evidence of activities), and outcomes (or results or effects). (See Figure 12.1 for the basic logic model.) The inputs in a logic model are the resources (or infrastructure) that are used to plan, imple- ment, and evaluate a program. They often include human resources (and related items like training, technical assistance, volunteers), partnerships, funding sources, equipment, sup- plies, materials, and community resources (e.g., space, gifts). The activities in a logic model are the interventions or strategies used in a program to bring about change. The outputs are the direct results of the activities and include things such as products (e.g., curricula, educa- tional DVDs, new software, data collection tools), services (e.g., in-service trainings, screen- ings, counseling, events), and new components of infrastructure (e.g., structure, capacity, process, and relationships). What is invested? What is done? What are the results? Intended resultsPlanned work Inputs Activities Outputs Mid-term outcomes Long-term outcomes Short-term outcomes ⦁▲ Figure 12.1 Basic Logic Model 322 Part 2 Implementing a Health Promotion Program The outcomes in a logic model are the intended results and are broken into short-term (or immediate) (e.g., changes in awareness, attitudes, knowledge, skills), mid-term (or medium) (e.g., changes in behavior or the environment), and long-term (e.g., risk reduction, change in health status, or quality of life). Some logic model experts have a step after outcomes called impact, which they define as the fundamental intended or unintended change occurring in organizations, communities, or systems as a result of program. While, others (CDC, 2010b; Goldman & Schmaltz, 2006; The Pell Institute, 2015; University of Kansas, 2015; WKKF, 2004) have suggested that logic models can also include (1) the purpose or mission of the program; (2) the context, conditions, or situations under which the program will be offered; (3) assumptions associated with the planned program; (4) external factors that could influ- ence the success of the program; and (5) a description of the evaluation of the proposed pro- gram. There is no one right way to create a logic Model (CDC, 2010b). “Ideally a logic model is contained within a single page with enough detail that it can be explained fairly easily and understood by other people” (Schmidtz & Parsons, 1999, para. 6). Although most logic mod- els are created and read from right to left, they do not have to be configured that way. Part of the usefulness of a logic model is that it is created with a series of “if . . . then” statements. So starting from the left hand side of the schematic the first statement may read—“If we have these resources then we will be able to create and deliver these activities.” The second state- ment might then read—“If we conduct these activities then we should expect these outputs.” A third statement might read—“If the planned activities deliverer the outputs that were expected, then the health of the program participants will be improved.” Good “if . . . then” statements create the “links in the chain of reasoning” (Schmidtz & Parsons, 1999, para. 11) that take planners from the program resources to the expected program outcomes. “If at any point, as you read through the logic model and the reasoning does not follow, it could mean one or more elements of the planned work in the program design does not strategically lead to an element or elements in the intended program results” (The Pell Institute, 2015, para. 2) Box 12.2 provides an example of a logic model that was used as part of the planning process for a program aimed at reducing the incidence of colon cancer. Defining Implementation In the simplest terms, implementation means to carry out. Timmreck (1997) defined imple- mentation as “the act of converting planning, goals, and objectives into action through administrative structure, management activities, policies, procedures, regulations, and organi- zational actions of new programs” (p. 328). Whereas Bartholomew and colleagues (2011) indi- cated that implementation is one of the three stages of program diffusion, with the other two being adoption and sustainability. Let’s look now at the phases in the implementation process. Phases of Program Implementation The phases of implementation that we present here are a combination of some of our own ideas with those of Parkinson and Associates (1982), Bartholomew and colleagues (2011), and Johnson and Breckon (2007). It should be noted that the resulting generic phases pre- sented are flexible in nature and can be modified to meet the many different situations and circumstances faced by planners. Chapter 12 Implementation 323 logic Model for a Colon Cancer prevention program Short-term Outcomes Mid-term Outcomes Long-term OutcomesActivities OutputsInputs Personnel Funding Equipment Supplies Space Educational materials Educate health care providers about program Change in knowledge, attitudes, beliefs, and motivation Change in awareness and knowl- edge of program Increase in referral behavior of health care providers Increase in number of people screened Increase in returned screening kits Partners identi�ed and activated Educate public about colon cancer Partnership guidelines established 100 healthcare providers attended seminar 400 members of the public participated in colon cancer classes 300 screening kits distributed Active recruitment of partners Colon cancer pre- vention Colon cancer control Quality of life of individuals improves Free colon cancer screenings procedures established 12.2 Box A pp lic at io n phase 1: Adoption of the program Because the adoption process was presented at length earlier (in Chapter 11), we will not repeat it here. However, we do want to remind planners that great care must go into the marketing process to ensure that a relevant product (i.e., the health promotion program) is planned so that those in the priority population will want to participate in it. phase 2: identifying and prioritizing the tasks to Be Completed In order for a program to be implemented, planners will need to identify and prioritize a number of smaller tasks. Even though many of these tasks are small in nature, they cannot be overlooked if planners want a smooth implementation. Reserving space where the program is to be held, making sure audiovisual equipment is available when requested, ordering the correct number of participant education packets or manuals, and arranging for interpreters when working with a diverse population are examples of tasks that are important to the suc- cess of a program. Other implementation tasks are presented later in this chapter in the sec- tion titled “Concerns Associated with Implementation.” 324 Part 2 Implementing a Health Promotion Program To assist with identifying and prioritizing these tasks, it is recommended that planners use some form of a planning timetable or time line. Planning timetables and time lines can graphically represent the dates, time span, and sequence of events involved in a program (Issel, 2014). They can also aid in monitoring program progress “so that midcourse cor- rections can be made, if needed” (McDermott & Sarvela, 1999, p. 72). Planning timetables that are commonly used include basic time lines, task development time lines (TDTLs) (Anspaugh, Dignan, & Anspaugh, 2000), Gantt charts, PERT charts, and the critical path method (CPM). A basic time line is the simplest of the tools. It places the key activities or tasks on a line in the order that they will be completed. It may or may not include an esti- mate of the dates when the activities or tasks will take place, and the time allocated to com- plete them (see Figure 12.2). Task development time lines and Gantt charts are very similar. They are both composed of rows and columns. The rows on the left-hand side of the chart represent the tasks or ac- tivities to be completed, while the columns represent periods of time. In the examples pre- sented in Figures 12.3 and 12.4, the columns represent months, but they could just as easily represent weeks or for that matter days if the chart were being used for a short-term project. The major difference between a TDTL and a Gantt chart is in the detail presented. A task development time line identifies the tasks that need to be completed and the time frame in which the tasks will be completed (Anspaugh et al., 2000). A Gantt chart, developed in 1917 by Henry Gantt as a production control tool (TechTarget, 2007–2015a), does the same plus provides an indication of the progress made toward completing the task by using dif- ferent size lines to distinguish between the projected time frame for a task and the progress toward completing the task. In addition, a Gantt chart uses a marker above the columns to indicate the current date (Timmreck, 2003). (See the check mark above the month of August in Figure 12.4.) Thus, when using a Gantt chart, planners would update their progress regu- larly on the chart. PERT is an acronym for program evaluation and review technique. PERT charts are more complex than Gantt charts and have not been used as much with health promotion programs (Timmreck, 2003). PERT charts are composed of two components, a diagram and a timetable (Minelli & Breckon, 2009). The diagram presents a visual representation of the relationship between and among the tasks to be completed. The diagram also indicates the order of completion by sequentially numbering the tasks. This means that tasks identified with lower numbers must be completed prior to taking on tasks identified with higher num- bers (TechTarget, 2007–2015b). The timetable of a PERT chart is similar to the key activity chart but also includes three estimates of time for each task. Included in the estimates are an optimistic, pessimistic, and a probabilistic time frame. The complexity of PERT puts a detailed explanation beyond the scope of this textbook. If readers are interested in learning more about it, we recommend referring to business management textbooks. Appoint committee Determine the purpose and scope Identify risk factors linked to health problem Identify problem focus Validate the need Gather data Analyze data ⦁▲ Figure 12.2 Sample Basic Time Line for a Needs Assessment Chapter 12 Implementation 325 Tasks Year 1 Months J Develop program rationale Conduct needs assessment Develop goals and objectives Create intervention Conduct formative evaluation Assemble necessary resources Market program Pilot test program Refine program Phase in intervention #1 Phase in intervention #2 Phase in intervention #3 F M A M J J A S O N D Tasks Year 2 Months J Phase in intervention #4 Total implementation Collect and analyze data for evaluation Prepare evaluation report Distribute report Continue with follow-up for long-term evaluation F M A M J J A S O N D ⦁▲ Figure 12.3 Sample Task Development Time Line for Program Planning, Implementation, and Evaluation 326 Part 2 Implementing a Health Promotion Program The last planning timetable to be presented is the critical path method (CPM). CPM charts are similar to PERT charts and are sometimes referred to as PERT/CPM. Like all the other planning timetables presented here, the CPM provides a graphical view of the project and predicts the time required to complete the project. But what is unique to CPM is that it focuses on time by showing which tasks are critical to maintaining the planning schedule and which are not (NetMBA, 2002–2010). Thus, the critical path is indicated and consists of the set of dependent tasks (each dependent on the preceding one) that together take the lon- gest time to complete. The tasks on the path are critical because any delay in their comple- tion will lengthen program implementation unless appropriate action is taken (NetMBA, 2002–2010). phase 3: Establishing a System of Management Once all the tasks have been identified and the timetable for completing them has been devel- oped, planners can turn their attention to how the program will be managed. Management has been defined as “the process of working with and through others to achieve organiza- tional or program objectives in an efficient and ethical manner” (Shi & Johnson, 2014, p. 658). Typically, the sets of resources include human, financial, and technical resources (Johnson & Breckon, 2007). Management is an important part of the program implementation process. “The efficient, satisfactory management of a health promotion program is vital to its long- term success” (Anspaugh et al., 2000, p. 124). Yet, management is both challenging and necessary (Hitt et al., 2012). It is challenging because the large number of responsibilities (e.g., planning, organization, coordination, and control) associated with the task of managing and because of change, both expected and unexpected, throughout the life of a program. Thus, good management is needed to ensure that programs are both effective and efficient (Gomez- Mejia & Balkin, 2012). Effective programs are ones that meet stated goals and objectives. Hire and train program facilitators Mar. April May June July Aug. Sept. Oct. Nov. Dec. Pilot test program Revise program based on pilot Promote the program Prepare for program “kick off” Phase in program Full implementation Evaluate program Write final report 5 planned time frame 5 completed Date ⦁▲ Figure 12.4 Sample Gantt Chart for Program Implementation and Evaluation Chapter 12 Implementation 327 They are efficient when the best possible use is made of program resources. Good managers can go a long way in making this happen. Hitt and colleagues (2012) have identified three types of skills needed by managers—technical, interpersonal, and conceptual. “Technical skills involve having specialized knowledge about procedures, processes, and equipment, and include knowing how and when to use that knowledge” (p. 19). Interpersonal skills include such qualities as sensitivity, persuasiveness, and empathy, while conceptual skills, sometimes called cognitive ability or cognitive complexity, include such skills as logical reasoning, judg- ment, and analytical abilities. Depending on the type of program being planned, the management process could range from consuming a small portion of a single planner’s time and resources, such as when a smoking cessation program is being planned for 10 people, to needing several people work- ing full-time to manage a large community-wide program. Many of the tasks associated with the management phase of implementation are presented later in this chapter. In the space below we will provide an overview of the management of the three major resources. HuMAn RESouRCES MAnAgEMEnt (HRM) There are four fundamental functions associated with HRM. “These functions, designated by the acronym PADS, are planning, acquisition, development, and sanction” (Klingner et al., 2010, p. 4). Personnel planning (the P of PADS) refers to the work that must be completed in order to be able to determine what positions are needed to carry out a program and how to fill them (Dessler, 2012), whether they are filled with employees or volunteers. (See Chapter 10 for more information on volunteers.) Thus knowing: (1) what tasks that must be completed by the personnel of a program, (2) what knowledge and skills the personnel need to complete the tasks, (3) how many people will be needed to complete the tasks, (4) how to describe the jobs (see Box 10.4 for a sample job description), and (5) how much compensation (pay and benefits) is appropriate for the jobs are all part of planning. Once the planning for personnel is complete and job descriptions are in place, program managers can then focus on acquisition (the A of PADS) of personnel; that is, the recruitment and selection of the personnel. The process used in the acquisition of personnel in organiza- tions is usually governed by specific procedures, rules, and laws (Shi & Johnson, 2014). This process begins by generating a pool of candidates for the jobs through recruitment. This is typically handled through advertising via the job posting at various sites (e.g., newspapers; online on Webpages or recruiting job boards; professional organization job lines or newslet- ters; at job fairs, employment agencies or career centers) where viable candidates will find the information (Dessler, 2012). Job postings not only describe the positions that need to be filled, needed qualifications, and salary range, but also include information about the application process. It is not unusual to have applicants provide a letter of application, complete an application form, submit a résumé, and provide either letters of recommenda- tion or the names of references to be contacted later. With the formal applications in hand, candidates must be screened (which in addition to looking for the appropriate qualifications may include testing for knowledge and skills, background checks, physical exams, and drug testing), decisions must be made on how and when to interview them, and finally the best candidates must be selected, and their services secured. The D in PADS stands for development. Development includes the orientation, training, performance appraisal, and professional growth or development opportunities to increase the personnel’s willingness and competencies to perform well (Dessler, 2012; Klingner 328 Part 2 Implementing a Health Promotion Program et al., 2010). Orientation (often called onboarding) has two major purposes: (1) to provide background information to perform the job satisfactorily, and (2) to socialize new personnel to the work environment (i.e., culture of the organization) by instilling the attitudes, stan- dards, values, and patterns of behavior that are expected (Dessler, 2012). Training involves providing personnel with the knowledge and skills needed to be successful in the position. Much training today revolves around building capacity and teamwork. (See Chapter 10 for more on these topics.) Performance appraisal and professional development opportunities frequently go hand in hand. Performance appraisal often includes some informal appraisal in which feedback is provided as needed and a more formal evaluation that is conducted on either a semi-annual or annual basis. The results of these appraisals can be used to plan ad- ditional training to deal with deficiencies or plan professional development opportunities to expand staff abilities and competencies. Such development opportunities are important for two reasons. One, employee growth/development leads to greater job satisfaction, improved morale, reduced turnover and enhanced performance. And two, organizations benefit from a staff with enhanced skills, knowledge, and attitudes (Shi & Johnson, 2014). Because of the ever-changing work environment (e.g., new technology, economic condi- tions, and increased accountability), every organization needs a line item in its budget for professional development and each employee needs a professional development plan that includes specific skills and personal growth components (Shi & Johnson, 2014). Professional growth opportunities can come in many different forms (i.e., training, education, mentoring) but they need to be planned and updated regularly. (See Box 12.3 for a sample professional development plan.) Sample template for a professional Development plan Employee Name: Year: Current position: Directions: Parts A, B, C, and D of this form should be completed and returned to your supervisor after your annual review meeting. Parts E and F should be completed at the end of the year and are your report of your professional development. Bring the completed form to your next annual review meeting with your supervisor. (Note: SMART objectives are specific, measurable, achievable, realistic, and time phased.) Part A: Assessment 1. Self-assessment (Knowledge and skills you believe you need to learn more about; consider strengths, weaknesses, opportunities, and threats [SWOT]) 2. Supervisor assessment (Knowledge and skills your supervisor believes you need) Part B: Learning objectives (Using SMART objectives, state what you plan to accomplish next year.) Part C: Proposed learning activities (State what you will do to meet your learning objectives; consider education, training, mentoring.) Part D: Budget (Identify the cost of items to meet the objectives.) Part E: Completed learning activities (State what you did during the year to meet your learning objectives.) Part F: Evaluation (Indicate what has changed as a result of your professional development experiences during the past year.) 12.3 Box A pp lic at io n Chapter 12 Implementation 329 The final fundamental function in HRM is sanction. Sanction (the S of PADS) deals with maintaining the expectations and obligations program personnel and their program manager have to one another through appropriate compensation, promotion, discipline/ grievances, health and safety, and personnel rights (Klingner et al., 2010). Much of the work of program managers as related to HRM is guided by laws and legal deci- sions. Box 12.4 includes a list of a number of the important pieces of federal legislation that impact the management of human resources. Note that most of the legislation presented in Box 12.4 applies to all employees and most employers but not all. In certain situations specific requirements must be met for the legislation to apply. For example, the Family and Medical Leave Act (FMLA) only applies in work settings with 50 or more employees. Also note that in addition to the federal legislation individual states may also have laws that im- pact human resources. An example is the “state-by-state laws that establish insurance plans to compensate employees injured on the job” (Gomez-Mejia & Balkin, 2012, p. 286). FinAnCiAl MAnAgEMEnt Financial management “is the process of developing and using systems to ensure that funds are spent for the purposes for which they have been appropriated” (Klingner et al., 2010, p. 88). Financial management begins after funds have been obtained and the program budget has been created. (See Chapter 10 for more information on sources of funding and budgets.) Thus, it is the program manager who is responsible for ensuring that program funds are spent on the things for which they were appropriated. This process begins with a system to record the transactions that take place over the life of a program. These transactions include funds coming into, the income (e.g., grant money, gifts, participant fees), and going out, the expenditures (e.g., paying for salaries and wages, and the purchase of materials, supplies, and equipment) of the program. The process of recording and summarizing these transactions and interpreting their effects on the program budget is referred to as accounting (Fallon & Zgodzinski, 2012). Each organization has an accounting process and depending on the size of the organization, responsibility for the accounting process may fall on the program manager or if the organization is large enough it may fall to an accounting department. The accounting process generates financial statements. “Financial statements can be prepared at any point in time and can cover any period of time” (Fallon & Zgodzinski, 2012, p. 60). Most organizations work on a fiscal year (or funding year) (i.e., FY) running from either January 1st to December 31st or July 1st to June 30th. The United Stated federal gov- ernment uses a FY that begins October 1 and ends September 30. However, it is common for financial statements to be created at regular intervals (i.e., weekly, monthly, quarterly, semi- annually, or annually) during the fiscal year. (See Figure 10.3.) Each “organization selects a reporting period and prepares financial statements at the end of the designated reporting period” (Fallon & Zgodzinski, 2012, p. 61). The statements usually include “actual revenue and expenses for the period, year-to-date actual, and year-to-date variance” (Johnson & Breckon, 2007, p. 180). It is then the responsibility of the person in charge of program finance to determine the status of the budget and compare the financial statement to the program budget. Armed with such information, the program manager can make the neces- sary financial decisions. Fiscal accountability “refers to the need for sound accounting, careful documentation of expenses, and tracking or revenues” (Issel, 2014, p. 340). Audits are conducted to ensure that the accounting process within an organization is being handled properly. An audit is a “review and confirmation that financial reports 330 Part 2 Implementing a Health Promotion Program important pieces of Federal legislation impacting Human Resources *Amended numerous times **Amended in 1991 ***Amended in 2008 Source: Created from Dessler (2012); Fallon & Zgodzinski (2012); Gomez-Mejia & Balkin (2012); Grudzien (2009); Johnson & Breckon (2007); Klingner et al., (2010); and USDOL (n.d.). 12.4 Box Fo cu s O n year legislation topic 1935* Social Security Act Retirement system for workers 1938 Fair Labor Standards Act Prescribes standards for wages and overtime pay 1959 Labor-Management Reporting and Disclosure Act (LMRDA) Deals with the relationship between a union and its members 1963 Equal Pay Act Prohibits discrimination in pay based on gender 1964** Civil Rights Act Prohibits discrimination based on race, color, religion, gender, or national origin 1967 Age Discrimination Employment Act Prohibits discrimination against a person 40 or older because of age 1970 Occupational Safety and Health (OSH) Act Workplace Safety 1973 Vocational Rehabilitation Act Prohibits discrimination against qualified individuals with handicaps 1974 Vietnam Era Veterans’ Readjustment Assistance Act Requires affirmative action in employment for veterans of the Vietnam War era 1974 Employee Retirement Income Security Act Regulates employers who offer pension or welfare benefit programs for their employees 1978 Pregnancy Discrimination Act Prohibits discrimination in employment against pregnant women, or related conditions 1985 Consolidated Omnibus Budget Reconciliation Act (COBRA) Provides opportunity to allow employee pay for continued health insurance coverage after termination 1988 Drug-Free Workplace Act Employers must implement certain policies to restrict employee drug use 1990*** Americans with Disability Act (ADA) Prohibits employment discrimination based on ability 1993*** Family and Medical Leave Act (FMLA) Time off for medical issues for self and family 1996 Health Insurance Portability and Accountability Act (HIPAA) Health insurance and privacy 2008 2010 Genetic Information Nondiscrimination Act (GINA) Affordable Care Act (ACA) Prohibits discrimination in health coverage and employment based on genetic information Identifies the responsibilities of both employers to provide and employees to have health insurance Chapter 12 Implementation 331 are accurate and that standard accounting procedures were used to prepare the reports” (Johnson & Breckon, 2007, p. 288). The main purpose of an audit “is to determine if fraud or other undesirable practices are occurring” (Johnson & Breckon, 2007, p. 292). Further, audits can be either external or internal. An external audit is one that is conducted by a qualified independent accountant usually just once a year, whereas an internal audit is a frequent and ongoing audit conducted by an employee of the organization not responsible for the ac- counting practices (BusinessDictionary.com, 2015a). tECHniCAl RESouRCES MAnAgEMEnt Technical resources (also referred to as other resources) include all other resources besides human or financial. Included in this category of resources are communication (both internal and external to the organization), equipment (e.g., computers), expertise, information, materi- als, partnerships, relationships, space, and supplies. (See Chapter 10 for discussion on technical assistance.) This may be the most difficult category of resources to manage because sometimes it is difficult to quantify the amount of a technical resource like personnel and funding needed for a program. For example, how are external communication and relationships quantified? phase 4: putting the plans into Action Parkinson and Associates (1982) suggested three major ways of putting plans into action: by using a piloting process; by phasing them in, in small segments; and by initiating the total program all at once. These three strategies are best explained by using an inverted triangle, as shown in Figure 12.5. The triangle represents the number of people from the priority popula- tion who would be involved in the program based on the implementation strategy chosen. The wider portion of the triangle at the top would indicate offering the program to a larger number of people than is represented by the point of the triangle at the bottom. These three different implementation strategies exist in a hierarchy. It is recommended that all programs go through all three of the strategies, starting with piloting, then phasing More people involved Evaluation more meaningful with larger group • • Easier to cope with workload Gradual investment • • Opportunity to test program Close control of program • • Advantages Big commitment No chance to test program • • Fewer people involved • Very few involved Not meeting all needs Hard to generalize about results • • • Disadvantages Phased in Total program Pilot ⦁▲ Figure 12.5 Putting Plans Into Action 332 Part 2 Implementing a Health Promotion Program in, and finally implementing the total program. However, keep in mind that limited time and resources may not always allow planners to work through all three strategies. In addi- tion, if the priority population is relatively small it may not make sense to use all three strate- gies. In such cases the phasing in strategy would probably not be used. pilot tESting Pilot testing (or piloting or field testing) a program is a crucial step. Even though planners work hard to bring a program to the point of putting it into action, it is important to try to identify any problems with the program that might exist. Pilot testing allows planners to work out any bugs before the program is offered to a larger segment of the priority population, and also to validate the work that has been completed up to this point. For the most meaningful results, a newly developed program should be piloted in a similar setting and with people as much like those who will eventually use the program as possible. Use of any other group may fail to iden- tify problems or concerns that would be specific to the priority population. As an example of the piloting process, take the case of a hospital developing a worksite health promotion program that will be marketed to outside companies. It would be best if the program were piloted on a worksite group before it was marketed to worksites in the community. The hospital could look for a company that might want to serve as a pilot group, or it might use its own employees. As part of piloting the program, planners should check on the following four areas: 1. The intervention strategies were implemented as planned. This is known as fidelity. 2. The intervention strategies worked as planned. 3. Adequate resources were available to carry out the program. 4. Participants in the pilot group had an opportunity to provide feedback about the program. It is important to have the program participants critique such aspects of the program as content, approaches used, facilitator’s effectiveness, space, accommodations, and other re- sources used. Such feedback will help planners determine if they need to revise the program, and if so how to revise it. If many changes are made in the program as a result of piloting, planners may want to pilot it again before moving ahead. (This evaluation process during the piloting phase is part of formative evaluation and will be discussed further in Chapter 13.) pHASing in Once a program has been piloted and revised, the program should, if applicable, be phased in rather than implemented in its entirety. This is especially true when there is a very large priority population. Phasing in allows the planners to have more control over the program and helps to protect planners and facilitators from getting in over their heads. There are four ways in which to phase in a program by: (1) different program offerings; (2) limiting the number of participants; (3) choice of location; or (4) participant ability Say a comprehensive health promotion program was being planned for Blue Earth County, Minnesota. To phase in the program by different offerings, planners might offer stress-management classes the first six months. During the next six-month period, they could again offer stress management but also add smoking cessation programs. This process would continue until all offerings are included. If the program were to be phased in by limiting the number of participants, planners might limit the first month’s enrollment to 25 participants, expand it to 35 the second month, to 45 the third month, and so on, until all who wanted to participate were included. Chapter 12 Implementation 333 To phase in the program by location, it might initially be offered only to those living in the southwest portion of the county. The second year, it might expand to include those in the southeast, and continue in the same manner until all were included. A program planned for a college town might be offered first on campus, then off campus to the general public. A pro- gram phased in by participant ability might start with a beginning group of exercisers, then add an intermediate group, and finally include an advanced group. totAl iMplEMEntAtion Implementing the total program all at once, in most situations, would be a mistake. Rather, planners should work toward total implementation through the piloting and phasing in pro- cesses. The only exceptions to this might be “one-shot” programs, such as programs designed around a single lecture, possibly screening programs, or programs that have been offered before to the same population, but even then piloting would probably help. FiRSt DAy oF iMplEMEntAtion No matter what program is being planned, there will be a “first day” for the program. The first day of the program, also referred to as the program launch, program rollout, or program kickoff, is just an extension of the fourth P of marketing: promotion (see Chapter 11). The focus of promotion is on creating and sustaining demand for a product. The creation of the demand for the product leads to the initiation of the program. As such, some special planning needs to take place for the first day of implementation. First, decide on a day when the program is to be rolled out. Consider launching the program to coincide with other already-occurring events or special days that can help promote the program. Examples include starting a weight loss program at the beginning of the calendar year to coincide with New Year’s resolutions, beginning a smoking cessation program on the third Thursday of November (the day each year for the American Cancer Society’s Great American Smokeout), having immunization programs and physical examinations for children prior to the begin- ning of a new school year, launching a skin cancer prevention program on a college campus prior to the annual spring break, or rolling out the community-wide exercise program at the beginning of February, Heart Health month. Second, kick off the program in style. This is important to bring attention to the program, and to create momentum and enthusiasm for the program (Chapman, 2006). Planners should consider having a first day that includes some special event such as a ribbon cutting, health screening, health fair, contest, appearance by a celebrity, or some other event that starts the program on a positive note. Celebrities need not be individuals with national or international recognition, but may be individuals such as an executive or supervisor of the organization for which the program is being planned (e.g., chief executive officer [CEO] or executive director), a visible or well-known person from the community (e.g., the mayor or a coach), or a common person who has been affected by the health problem on which the program will focus. Third, consideration should be given to obtaining news coverage (print and/or broadcast) for the first day to further publicize the program. If it is decided to seek such coverage, you should (CDC, 2003): ⦁⦁ Inform appropriate media representatives of your plans ⦁⦁ Make arrangements to meet the media representatives at the designated time and place 334 Part 2 Implementing a Health Promotion Program ⦁⦁ Prepare the following and have them ready for the day: ▪⦁⦁ Press releases ▪⦁⦁ Video news releases ▪⦁⦁ Spokespersons trained to respond to inquires from media representatives To get news coverage it might be useful to use a news hook to interest the media in the program being launched. By news hook, we mean something that will make the media want to cover the launch. The planners’ organization may have newsworthy data or information related to the health problem being targeted by the program, or there may be a related news event that is receiving media attention that would help bring attention to the new program (CDC, 2003). For example, if a new program is aimed at reducing teen pregnancy and new state legislation has been proposed to assist in such efforts or an event related to teen preg- nancy is currently an important news item, then linking the new program with those timely events can make it more newsworthy (CDC, 2003). Human-interest stories also make for good news hooks. For example, if you are starting a smoking cessation program, getting for- mer quitters to talk about how quitting changed their lives can be of interest to others. Or, if your program is aimed at teaching children what to do in an emergency situation, and you know of a child who has completed a similar program and was able to put the education to use in helping someone, many people would like to know about that. Planners should even consider linking the launch of the program with some important date in history to make it newsworthy. Linking the influenza epidemic of 1918–19 to launch the countywide flu shot program may make it more newsworthy. MonitoRing iMplEMEntAtion Once a program is up and running it must be monitored. Program monitoring “is an essential function in program implementation” (Schiavo, 2014, p. 401) and it involves the ongoing collection and analysis of data and other information to determine if the program is operating as planned. It is a form of process evaluation (see Chapter 13). One way to ap- proach program monitoring is to ask the question “Who is doing what, when, where, and how often and with what resources” (USDJ, n.d., para 1). Basic monitoring data and informa- tion for a program has the following utilities (USDJ, n.d.): ⦁⦁ It provides operating and descriptive data and information for funders and overseers of the program, other stakeholders, and most importantly for program staff and administrators. ⦁⦁ It provides the basic information for comparing outcomes to the program objectives. Such a process may lead to the refinement of an objective or changes to an intervention. ⦁⦁ It provides educational information about many aspects of the program for all involved in the program even if unexpected surprises result. ⦁⦁ Monitoring data serve as a preventive maintenance function by tracking indicators of critical elements which, if they deviate too much from the expected, may signal a program problem. Typically, the responsibility for monitoring a program falls to the administrator or manager of a program. However, if it is a large program with many different components, certain aspects of monitoring may be assigned to individuals other that the administrator Chapter 12 Implementation 335 or manager. For example, in a large program the personnel in the accounting office may handle the financial monitoring. Although primary monitoring functions include the collecting and analyzing the data, successful monitoring is not complete unless the find- ings of such efforts are integrated into the decision-making processes about the program (USDJ, n.d.). phase 5: Ending or Sustaining a program The final phase of the implementation process is to determine how long to run a program. For some programs the answer will be simple: If the program met its goals and objectives and the priority population has been served to the fullest extent necessary, then the program can be ended. For example, a worksite health promotion program may have a goal to certify 50% of the workforce in CPR. If that goal is reached, then the program’s resources could be used on other health promotion programming. However, a greater concern facing most planners is how to sustain a needed program for a longer period of time when the goals and objectives have not been met (e.g., only half of those who were expected to get flu shots got them), or goals and objectives of the program are long-term in nature (e.g., providing food and shelter for the homeless). This is especially difficult when original program funding and other types of resources and support may end or be withdrawn. Financial sustainability is a real concern with grant-funded programs. Today many funders want potential grantees to include a sustainability plan as part of the initial grant proposal. Earlier (in Chapter 11), we presented information on how to maintain interest in program participants, but here we are referring to the maintenance and institutionalization of a program or its outcomes. Techniques that have been used by planners to sustain programs include: (1) working to institutionalize the program (see Chapter 2; Goodman & Steckler, 1989; and Goodman et al., 1993); (2) seeking feedback from program participants and evaluating the program in order to generate evi- dence to show its worth (Sleet & Cole, 2010); (3) advocating for the program (see Chapter 8 for a discussion of advocacy); (4) partnering with other organizations/agencies with similar missions to share resources, expenses, and responsibilities; (5) revisiting and revising the ra- tionale used to create the program initially (see Chapter 2); and (6) establishing a resource de- velopment committee to create business and marketing plans aimed at sustainability (Doll, Bonzo, Mercy, & Sleet, 2007). Implementation of Evidence-Based Interventions While most of the concepts presented so far in this chapter apply to all health promotion programs, especially those that are being created for the first time, there are some special considerations that must be addressed when adopting or adapting an evidence-based inter- vention. With the movement toward evidence-based practice, more researchers (e.g., Jones- Webb, Nelson, McKee, & Toomey, 2014; Rosati et al., 2012; Wiecha, Hannon, & Meyer, 2013) have been engaged in implementation science. The focus of implementation sci- ence is to study how interventions, which have been shown to be effective in one setting, can be applied to sustain improvements to population health (Lobb & Colditz, 2013). Tomioka and Braun (2013) created a four-step fidelity assurance protocol that was used with the adaptation of evidence-based health promotion programs for seniors. We think that their protocol could be useful to others adopting and adapting evidence-based programs. 336 Part 2 Implementing a Health Promotion Program Step one of the protocol has planners deconstructing the program into its components (i.e., marketing, recruiting participants, identifying staff, training, implementing, and evaluat- ing) noting exactly how it was implemented in its original setting. Also as a part of step one the planners prepare a step-by-step plan for program replication in the new setting. An im- portant component to consider in this step is to ensure that the program adaptation includes adaptation to the culture of the new population (Rosati et al., 2012). In step two, planners need to identify agencies that are ready to replicate the intervention including providing the necessary training to staff who will deliver and coordinate the new program. Step three of the protocol has planners closely monitoring the fidelity of the program by using stan- dardized checklists to ensure that the primary components of the intervention are being delivered. This third step also includes a rating (i.e., above standard, meets standards, and needs improvement) of those implementing the intervention. The fourth, and final, step of the protocol has planners using the evaluation tools of the program in order to track program participants’ progress and be able to compare the collected data to the expected outcomes. The results of such analysis are then shared with staff members so that, if needed, adjust- ments can be made. Concerns Associated with Implementation Many matters of detail must be considered before and during the implementation process. Although we believe all the topics presented in this section are important, we feel that the topics of safety and medical concerns and ethical issues are the most important. That is why these topics are presented first. Safety and Medical Concerns The ultimate goal of most health promotion programs is to maintain or improve the health of its participants. As such, planners in no way want to put the health of participants in danger. Therefore, planners must give attention to the safety and medical concerns associ- ated with health promotion programs. To ensure the safety of participants, planners need to inform participants about the program they are considering joining. Only after they understand what the program is all about should they agree to participate. This concept is referred to as informed consent. More formally, informed consent means: (1) making the participants fully aware of the relevant information about the program; (2) making sure the participants comprehend the information provided; and (3) obtaining the participants vol- untary agreement, free of coercion and undue influence, to participate. As a part of the process of obtaining informed consent from participants, program facilita- tors should take seven steps: 1. Explain the nature and purpose(s) of the program. 2. Inform program participants of any inherent risks or dangers associated with participation and any possible discomfort they may experience. 3. Explain the expected benefits of participation. 4. Inform participants of alternative programs (procedures) that will accomplish the same thing. 5. Indicate to the participants that they are free to discontinue participation at any time. Chapter 12 Implementation 337 6. Allow the participants to ask questions about the program and make sure that their questions are fully answered. 7. When appropriate have participants sign informed consent forms. For example, it would be prudent to have participants of an exercise program complete an informed consent form, but not when a population-based media campaign is being conducted to improve safety belt use. Program planners must be aware that informed consent forms (sometimes called waiver of liability or release of liability) do not protect them from being sued. There is no such thing as a waiver of liability. If you are negligent, you can be found liable. However, informed consent forms do make participants aware of special concerns. Further, because people must sign the forms, they may not consider legal action even if they have a case, feeling that they were duly warned. Box 12.5 presents a sample consent form. Once participants have agreed to participate in a program, if the act of participating in the program puts anyone at medical risk (e.g., cardiovascular exercise programs), then these individuals need to obtain medical clearance before participating. Some organizations that conduct such programs on a regular basis will have a medical clearance form that will need to be completed. Typically, a physician who is familiar with the person’s health history must sign the form. If such a form is not available, then steps need to be taken to create one and have it reviewed by a lawyer to make sure it includes all the necessary information. After participants have medical clearance and are enrolled in a program, steps must be taken to ensure the safety and health of all associated with the program (i.e., participants Sample informed Consent Form Consent to Perform Cholesterol Screening I hereby grant permission to the Institute for Health Promotion personnel to perform a cholesterol screening on me. I am engaging in this screening voluntarily. I have been told this screening will provide an analysis of total blood cholesterol and that a trained employee will take my blood from a finger stick sample. This finger stick may be uncomfortable. I understand that the results of this screening are considered to be preliminary in nature and in no way conclusive. Results of a blood cholesterol screening like this can be affected by a number of factors including, but not limited to, smoking, stress level, amount of exercise, hormone levels, food eaten, heredity, and pregnancy. I also understand that my physician can perform a more complete blood lipid (fat) analysis for me, if I so desire. Further, I have been told that all the information related to this screening is considered confidential. I have read the above statement and understand what it means. I have also had an opportunity to ask questions about the screening, and all my questions have been answered to my satisfaction. ______________________ _____________ __________________________ Participant’s Signature Date Signature of Witness NOTE TO PROGRAM PLANNERS: To ensure this form meets all related organizational policies and local and state laws, this form should be submitted to legal counsel before use. 12.5 Box A pp lic at io n 338 Part 2 Implementing a Health Promotion Program and staff members). Providing a safe program includes: finding a safe program location (e.g., low-crime area), providing appropriate security at the location; ensuring that all building codes are met at the location, and ensuring that the classroom, locker rooms, laboratories, and any other facilities used are free of hazards. In addition to a safe environment, programs need qualified instructors (i.e., appropriately trained and certified), and planners need to be prepared for emergency situations by supplying the appropriate first-aid supplies and equip- ment, and developing an emergency care plan. Box 12.6 provides a checklist of items that should be considered when creating an appropriate emergency care plan. Ethical issues “Ethical issues permeate almost every decision and action undertaken in health education” (Goldsmith, 2006, p. 33), including many of the decisions associated with program plan- ning. By ethical issues we mean situations in which competing values are at play and program planners need to make a judgment about what is the most appropriate course of action. For example, planners may want to create an intervention that includes an economic incentive for a priority population that, for the most part, is composed of individuals with a low socioeconomic status. Because of the socioeconomic status of those in the priority population, the ethical issue that faces the planners is deciding at what dollar value does the incentive cross over from encouraging people to participate in a program to manipulating their participation in the program? What guides ethical decision making? Most often, these decisions are compared to a standard of practice that has been defined by other professionals in the same field. For health promotion planners, the standard of practice is outlined in the Code of Ethics for the Health Education Profession developed by the Coalition of National Health Education Organizations Checklist of items to Consider When Developing an Emergency Care plan 1. Duties of program staff in an emergency situation are defined. 2. Program staff is trained (CPR and first aid) to handle health emergencies. 3. Program participants are instructed what to do in an emergency situation (e.g., medical, natural disaster). 4. Participants with high-risk health problems are known to program staff. 5. Emergency care supplies and equipment are available. 6. Program staff has access to a telephone. 7. Standing orders are available for common emergency problems. 8. There is a plan for notifying those needed in emergency situations. 9. Responsibility for transportation of ill/injured is defined. 10. Injury (incident) report form procedures are defined. 11. Universal precautions are outlined and followed. 12. Responsibility for financial charges incurred in the emergency care process are defined. 13. The emergency care plan has been approved by the appropriate personnel. 14. The emergency care plan is reviewed and updated on a regular basis. 12.6 Box Fo cu s O n Chapter 12 Implementation 339 (CNHEO, n.d.) (see the Appendix for a copy of the Code). The preamble of the Code states: “Health Educators are responsible for upholding the integrity and ethics of the profession as they face the daily challenges of making decisions. Health Educators value diversity in society and embrace a multiplicity of approaches in their work to support the worth, dignity, potential, and uniqueness of all people” (CNHEO, n.d., para. 1). For program planners this means having integrity, and being honest, loyal, and accountable. Unethical practice leads to professional suicide; planners who act unethically damage their professional reputation and integrity (Bensley, 2009). Many of the ethical issues that program planners will face revolve around the three fun- damental principles of The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subject Research (National Commission for Protection of Human Subjects of Biomedical and Behavioral Research, 1979). These principles include: (1) respect for persons, (2) beneficence, and (3) justice. Here are some examples of the application of these principles to program planning. The principle of respect for persons acknowledges the dignity and auton- omy (i.e., freedom) of individuals, and requires that people with diminished autonomy (e.g., children, mentally disabled, and people with severe illnesses) be provided special protection (USDHHS, 2015e). It is not unusual for health education specialists to be working with pro- gram participants who have values, behavior, including health behavior, and goals that are different than their own. Even though they are different, it is important to respect them. For example, health education specialists working in a family planning clinic may see clients choose a course of action that may be different than what they personally would select, but clients have the right to choose a course of action and it must be respected. The principle of beneficence requires program planners to protect participants by maximiz- ing anticipated benefits and minimizing harms. This principle dates back to the Hippocratic Oath written by the famous Greek physician Hippocrates who lived from about 460 b.c.e. until 377 b.c.e. (Cottrell et al., 2015). The principle embodies two concepts: doing good, beneficence, and not causing harm, nonmaleficence. The Hippocratic maxim “do no harm” has long been a fundamental principle of medical ethics, but also applies to the work of health education specialists. The concepts associated with this principle seem to be com- mon sense, but well-intending health education specialists who may not be as well informed on best practices (see Chapter 8 for a discussion of best practices) could put participants at risk without knowing they are doing so. For example, much attention has been given to the public health issue of youth violence. Evidence shows that a number of well-meaning approaches to dealing with youth violence at all three levels of prevention—primary (e.g., holding youth back a grade in school), secondary (e.g., redirecting youth behavior or shifting peer group norm programs), and tertiary (e.g., “boot camps” for delinquent youths)—can bring harm to the youth (USDHHS, 2001). When dealing with the principle of beneficence, health education specialists may need to make ethical decisions revolving around the “benefit-harm ratio.” For example, should a health education specialist be barred from releasing information about a person without his or her consent, even if it will benefit that person? Consider a high school sophomore who approaches the health teacher with confidential information that she is pregnant. Should the health teacher tell anyone else, such as the girl’s parents? The principle of justice requires that program planners treat participants fairly. For ex- ample, the question of fairness may have ethical implications when it comes to charging a registration fee for a program. Because of the policies of the organization conducting the 340 Part 2 Implementing a Health Promotion Program program, the program may need to turn a profit, but those in need of the program may not be able to afford the cost of registration. Other ethical issues of justice and fairness can arise from issues of sexism, racism, and other cultural biases. The opportunities for dealing with ethical issues are many, and planners need to be pre- pared to handle them. legal Concerns Legal liability is on the mind of many professionals today because of the concern over lawsuits. With this in mind, all personnel connected with the planned health promotion program, no matter how small the risk of injury to the participants (physical or mental), should make sure that they are adequately covered by liability insurance. In addition, pro- gram personnel should have an understanding of negligence and how to reduce one’s risk of liability. nEgligEnCE Negligence is failing to act in a prudent (reasonable) manner. If there is a question whether someone should or should not do something, it is generally best to err on the side of caution. Negligence can arise from two types of acts: omission and commission. An act of omission is not doing something when you should, such as failing to warn program par- ticipants of the inherent danger in participation. An act of commission is doing something you should not be doing, such as leading an exercise class when you are not trained to do so. REDuCing tHE RiSk oF liABility When professional service (i.e., a health promotion program) is provided there is always the chance that disputes may arise between those offering the service (program planners) and those (program participants) receiving it or other (third) parties, such as a vendor. Such disputes may lead to the professionals being held legally liable for their actions. Although this is not a common occurrence as a result of health promotion activities, program planners should nonetheless take the appropriate steps to reduce their risk of liability. At the heart of reducing the risk of legal liability is to perform quality work with professional competence. In addition, program planners should: 1. Be aware of anything for which you are legally responsible, for example, protecting private health information. 2. Be aware of any professional standards associated with the services you are providing, for example, Exercise During Pregnancy and the Postpartum Period (ACOG, 2009). 3. Keep your professional knowledge and skills up-to-date. 4. Maintain any professional certification (e.g., CHES, MCHES, CPH) and make sure others associated with the program are appropriately certified for the service they are providing and for emergency care procedures. 5. Require participants to have the appropriate “clearances” prior to participation, such as a medical clearance for participation in an exercise class. 6. Provide a safe environment for all program activities. 7. Purchase adequate liability insurance for all (i.e., staff members and volunteers) who have responsibilities associated with the program. Chapter 12 Implementation 341 With regard to item 7 in the preceding list, planners should check on the availability of li- ability insurance through their employer or special coverage from a professional organization. Liability insurance may also be available through one’s homeowner’s or renter’s insurance. program Registration and Fee Collection If the program you are planning requires people to sign up and/or pay fees, you will need to establish registration procedures. Program registration and fee collection may take place before the program (preregistration), by mail, online, in person, via an indirect method like payroll deduction, or at the first session. Planners should also give thought to the type of payment that will be accepted (cash, credit card, or check) and plan accordingly. Though it may seem obvious, some thought also must be given to the security of the money received. That is, how it will be handled, transported, and deposited or otherwise secured. procedures for Record keeping Almost every program requires that some records be kept. Items such as information col- lected at registration, medical information, data on participant progress, and evaluations must be accounted for. The importance of privacy for those planners working in health care settings was further emphasized in 2003 with the enactment of the Standards for Privacy of Individually Identifiable Health Information section (the Privacy Rule) of the Health Insurance Portability and Accountability Act of 1996, officially known as Public Law 104–191 and referred to as HIPAA. The Rule sets national standards that health plans, health care clear- inghouses, and health care providers who conduct certain health care transactions electroni- cally must implement to protect and guard against the misuse of individually identifiable health information. Failure to implement the standards can lead to civil and criminal penal- ties (USDHHS, OCR, n.d.). The two terms associated with protecting the privacy of participants are anonymity and confidentiality. Anonymity exists when no one, including the planners, can relate a par- ticipant’s identity to any information pertaining to the program. Thus information associ- ated with a participant may be considered anonymous when such information cannot be linked to the participant who provided it. In applying this concept, planners need to ensure that collected data had no identifying information attached, such as the participant’s name, social security number, or any other less common information. Confidentiality exists when planners are aware of the participants’ identities and have promised not to reveal those identities to others. When handling confidential data, planners need to take every precaution to protect the participants’ information. Often this means keeping the information “under lock and key” while participants are active in a program, then destroying (e.g., shredding) the information when it is no longer needed. procedural Manual and/or participants’ Manual Depending on the type and complexity of a program, there may be a need to develop a pro- gram procedural manual and/or participants’ manual. If a program is very involved (e.g., has several interventions or a very detailed curriculum) and/or may have a number of different people facilitating the program (i.e., one that will be used in a number of locations like an ed- ucational program of a voluntary health agency), there is probably a need to create a program 342 Part 2 Implementing a Health Promotion Program procedural manual. The purposes of a program procedural manual (also sometimes referred to as a training manual) are to: (1) ensure that all who are associated with the program under- stand the program and its parameters, (2) standardize the intervention so it can be replicated and to avoid what Basch and colleagues (1985) referred to as Type III errors—failure to implement the health education intervention properly (see Chapter 15 for a discussion of Type I and II errors), (3) provide ideas for facilitation, (4) provide additional background in- formation on the topic, and (5) provide citations for additional resources. Participants’ manuals may also be needed and/or useful for several reasons. First, they may be a good way of getting all program information into participants’ hands at one time, including the educational materials and program procedures and guidelines. Second, they can help participants organize information they receive and keep it all in one place, espe- cially if they are set up as loose-leaf notebooks or folders. Third, they can serve as a reference or resource for the participants. And fourth, if participants frequently use their manual as part of the program and become familiar with it, they may be more inclined to refer to it out- side of the program sessions. If a program is being developed in-house and manuals are needed, they will more than likely need to be developed in-house as well. Developing either type of manual—procedural or participant—in-house is a major task; therefore, adequate resources and time need to be given to developing the manuals. If a canned program is obtained from another organization (e.g., a voluntary health agency) or is being purchased from a vendor, it should more than likely include manuals. program participants with Disabilities A special situation for program planners during not only the implementation phase, but in all phases of program planning is ensuring that the programs being planned meet the needs of program participants with disabilities. From legal, benefit, and social program perspec- tives, disability is “often defined on the basis of specific activities of daily living, work and other functions essential to full participation in community-based living” (USDHHS, 2005, p. 4). Disability can range from sensory problems (e.g., seeing and hearing) to problems re- sulting from cognitive impairment, neuromuscular disorders, serious injury, and intellectual and developmental disabilities. However, “disability is not an illness. The concept of health means the same for persons with or without disabilities: achieving and sustaining an optimal level of wellness—both physical and mental—that promotes a fullness of life” (Krahn, 2003, as stated in USDHHS, 2005, p. 3). The number of people with disabilities in the United States are estimated to be about 12.6% (~38+ million) (Erickson, Lee, & von Schrader, 2015). As such, program planners must be prepared to work with individuals who have disabilities. Because most program planners have not received training developing programs for people with disabilities, Drum and colleagues (2009) have put forth useful guidelines and criteria. We have presented a list of their guidelines, criteria, and key questions (see Box 12.7) that need to be answered to ensure programs meet the needs of these individuals. training for Facilitators An important part of the implementation process is to make sure that the program inter- vention is implemented as planned, as noted earlier this is referred to as fidelity. There are a couple reasons for this. First, as you are now aware, a great deal of effort goes into adoption, Chapter 12 Implementation 343 guidelines, Criteria, and issues to Consider When implementing programs for individuals with Disabilities operational guidelines for Health promotion programs for people with Disabilities Criterion 1. Health promotion programs for people with disabilities should have an underlying conceptual or theoretical framework. issues: 1. Does the program use theories and concepts drawn from a wide variety of disciplines such as health promotion, disability studies, and/or education? 2. Does the program integrate appropriate theories and concepts into all aspects of the health promotion program (i.e., in planning, implementation, and evaluation)? Criterion 2. Health promotion programs should implement process evaluation. issues: 1. Does the program include process evaluation measures for people with disabilities and their families or caregivers, including rating their satisfaction with the program? 2. Does the program make changes based on participant feedback? 3. Does the program have mechanisms for obtaining process feedback using appropriate methods such as the use of readers or interpreters? 4. Does the program record intervention-related expenses such as cost of materials, recruitment, equipment, space, and personnel? Criterion 3. Health promotion programs should collect outcomes data using disability- appropriate outcomes measures. issues: 1. Does the program collect data on outcomes of health promotion activities? 2. Are the outcomes measures appropriate for people with disabilities (e.g., not penalizing for functional limitations)? participation guidelines for Health promotion programs for people with Disabilities Criterion 4. People with disabilities and their families or caregivers should be involved in the development and implementation of health promotion programs for people with disabilities. issues: 1. Did people with disabilities and their families or caregivers participate in the development of the program by identifying program outcomes or reviewing program content before implementation? 2. Are people with disabilities and their families or caregivers involved in implementing the program? Criterion 5. Health promotion programs for people with disabilities should consider the beliefs, practices, and values of its target groups, including support for personal choice. 12.7 Box Fo cu s O n 344 Part 2 Implementing a Health Promotion Program adapting, or creating an intervention for the specific priority population, possibly even tailor- ing the intervention; that effort should not be wasted. And second, appropriate implementa- tion is necessary to be able to evaluate and document the effectiveness of an intervention. To ensure that a program is implemented as planned, the program facilitators need to be familiar with the intervention. This familiarity may come about by participating in the planning of the intervention or through a training session. If those who implement the intervention are also the ones who planned the intervention, then a brief review of the steps in the interven- tion may be all that is needed. If those who will be facilitating the intervention are brought in specifically for that task and are not familiar with the intervention more in-depth training will be needed. Also, regardless of how familiar the intended facilitators are with an interven- tion, if multiple facilitators are going to be used for implementation (e.g., the same program being implemented at different sites at the same time) then implementation training would 12.7 Box continued issues: 1. Are the beliefs, practices, and values of people with disabilities reflected in the program’s mode of delivery, training materials, and written materials? 2. Does the program support participants in identifying and achieving personal health goals? Accessibility guidelines for Health promotion programs for people with Disabilities Criterion 6. Health promotion programs should be socially, behaviorally, programmatically, and environmentally accessible. issues: 1. Does the program consider social and behavioral and programmatic barriers that reduce participation among people with disabilities? 2. Does the program consider environmental barriers that reduce participation among people with disabilities, including environmental accessibility of the program site (e.g., physical and signage)? 3. Is the program site available via accessible public transportation? 4. Do the program materials (training materials and handouts) lend themselves to being translated into alternative formats? 5. Are process and outcomes measures produced in a variety of other formats, including but not limited to Braille, large print, and computer disk? 6. Are such accommodations provided when requested? Criterion 7. Health promotion programs should be affordable to people with disabilities and their families or caregivers. issues: 1. Does the program maintain reasonable participant fees? 2. Does the program ensure low-cost transportation for participants? Source: “Guidelines and Criteria for the Implementation of Community-Based Health Promotion Programs for Individuals With Disabilities” by C. E. Drum, J. J. Peterson, C. Culley, G. Krahn, T. Heller, T. Kimptron, J. McCubbin, J. Rimmer, T. Seekins, R. Suzuki, and G. W. White from American Journal of Health Promotion. Copyright © 2009 by the American Journal of Health Promotion. Reprinted with permission. Chapter 12 Implementation 345 be useful to ensure there is a standardized delivery of the program. Without standardization of the intervention through training, the actual intervention delivered can deviate from what was intended depending on the personal preferences of those facilitating the intervention (Issel, 2014). “This has serious implications for achieving the desired outcomes and, subse- quently, for ensuring the long-term sustainability of the program” (Issel, 2014, p. 255). A qualified instructor should conduct the actual training sessions. That instructor may be internal to the organization offering the program or it may be necessary to hire a vendor or consultant to conduct the training. It may also mean sending the people to be trained to other training classes outside the organization to become qualified facilitators. Finally, if the intervention being implemented needs a specially qualified person (e.g., certified or licensed) to facilitate it, such a person must be used. Do not assume some knowledgeable person who is not formally qualified to facilitate a program can do it because that places those who appoint/hire the facilitators in a high-liability situation. For example, if you are planning an exercise program for a group of people and someone comes to you and indicates he wants to lead the classes because he has been a participant in such a program for two years and knows just as much as past instructors but is not certified or licensed to facilitate the pro- gram, he should not be permitted to do so. Dealing with problems With the program up and running, the task of the planners is to anticipate and deal with problems that might arise and to do so in a constructive manner. Even if a program has been piloted and phased in prior to total implementation problems can still arise. Astute and effective planners must anticipate the possibility of things going wrong (Timmreck, 2003). “If problems are anticipated, they can be resolved more easily should they occur in the implementation process” (Timmreck, 2003, pp. 182–183). The problems that could be encountered can range from petty concerns to matters of life and death. Problems might in- volve logistics (room size, meeting time, or room temperature), participant dissatisfaction, or a personal or medical emergency. Whatever the problem, it should be worked out as much as possible to the satisfaction of all concerned. If there is a question of whether to accommodate a program participant or the program personnel, 99% of the time the participants should be satisfied. They are the lifeblood of all programs. As a part of this implementation concern, it might be a good idea to conduct an early evaluation, say after one month, asking questions similar to the ones asked in the piloting evaluation. Documenting and Reporting Throughout the implementation process there are various times when program planners may need to collect data or information to document program activities and ongoing prog- ress. Planners need to decide what types of data and information need to be collected to best serve and protect their program. Documentation can range from keeping track of program registration and attendance to the use of program resources (e.g., personnel and financial records) to the collection of data for an evaluation. Good documentation can: (1) assist plan- ners in monitoring program implementation; (2) provide feedback on whether things are working properly (Shi & Johnson, 2014); (3) help identify where changes need to be made in a program; (4) provide feedback on participant satisfaction with a program; and (5) if ever needed, provide evidence if there is a legal challenge to any aspect of implementation. 346 Part 2 Implementing a Health Promotion Program In addition to appropriate documentation, planners should keep the stakeholders in- formed about the progress of the program for several different reasons, including: (1) ac- countability associated with the delivery of the product and the use of program resources, (2) public relations for the program and organization, and (3) participant motivation, satisfaction, and recruitment. The procedures for documenting and reporting will vary by organization, but “can be integrated in to daily routines and may require coordination among various units and sites in order to provide meaningful data for future planning” (Shi & Johnson, 2014, p. 492). And finally, depending on the sensitivity of the data and informa- tion collected, organizations need to identify a secure location for their storage (Fallon & Zgodzinski, 2012) Summary A great deal of work goes into developing a program before it is ready for implementation. The process used to implement a program may have much to say about its success. This chap- ter presents five phases planners can follow in implementing a program: (1) adoption of the program, (2) identifying and prioritizing the tasks to be completed, (3) establishing a system of management, (4) putting the plans into action, and (5) ending or sustaining a program. Also presented in this chapter are matters that need to be considered and planned for prior to and during implementation. Review Questions 1. What are logic models? Why are they used? What are the major components of logic models? 2. What is meant by the term implementation? 3. Name and briefly describe the five phases of implementation presented in this chapter. 4. Briefly describe how each of the following planning timetables can be used: a. Basic time line b. Task development time line c. Gantt chart d. PERT chart e. Critical path method 5. What is meant by the term management? 6. What are the three major categories of resources that need to be managed during implementation? 7. Why is professional development so important to human resource management? 8. What are three strategies from the modified model of Parkinson and Associates (1982) for implementing health promotion programs? Chapter 12 Implementation 347 9. What are some techniques planners can use to enhance the first day of implementation? What does it mean to kick off a program? What is included in monitoring a program? 10. What is meant by the term informed consent? 11. What is meant by implementation science? What is its relationship to evidence-based interventions? 12. What can program planners do to ensure the health and safety of program participants? 13. What is an ethical issue? What are the three ethical principles associated with the Belmont Report? 14. Where can you find the Code of Ethics for the Health Education Profession? 15. What is negligence? What is the difference between an act of omission and an act of commission? 16. How can program planners reduce their risk of liability? 17. What implications does HIPAA have for planners? 18. What is the difference between anonymity and confidentiality? 19. What are procedural and participant manuals? When should they be used? 20. Why is it important that those who implement planned interventions be trained well to do so? Activities 1. Using the guidelines presented in this chapter, create a logic model for a program you are planning. 2. Create two different types of planning timetables for the program you are planning. 3. Explain how you would implement a program you are planning using a pilot study, phasing in, and total implementation. Also explain what you plan to do to kick off the program. 4. Using the template presented in Box 12.3, create a professional development plan for yourself that covers the next 12 months. 5. In a one-page paper, identify what you see as the biggest ethical concern of health promotion programming, and explain your choice. 6. Select one of the pieces of legislation listed in Box 12.4 to learn more about. Once selected, locate a U.S. government Website that includes information about the legislation and then write a one-page paper that describes why the legislation is important to human resources management. 7. Visit the Community Tool Box Website (http://ctb.ku.edu/en/tablecontents /sub_tools_1165.aspx) and review the information presented in the sample informed consent forms. After reviewing the information, create a consent form that could be used with the collection of primary data via a written questionnaire for a program you are planning. http://ctb.ku.edu/en/tablecontents/sub_tools_1165.aspx http://ctb.ku.edu/en/tablecontents/sub_tools_1165.aspx 348 Part 2 Implementing a Health Promotion Program Weblinks 1. http://www.hhs.gov/ocr/privacy U.S. Department of Health and Human Services (USDHHS) At this page of the USDHHS Website you can get more information about the National Standards to Protect the Privacy of Personal Health Information. 2. http://www.history.com/this-day-in-history This Day in History This commercial Webpage allows you to input a specific date to find out what historical events took place that day. It can be of use to planners when trying to make the kick off of the program newsworthy by linking it to a historical event. 3. http://www.cnheo.org Coalition for National Health Education Organizations (CNHEO) You can find both the short and long versions of the Code of Ethics for the Health Education Profession at the CNHEO Website. 4. http://asq.org/learn-about-quality/project-planning-tools/overview/gantt-chart.html American Society for Quality (ASQ) The ASQ Webpage provides information on how to create a Gantt chart. 5. http://www2a.cdc.gov/phlp/?source=govdelivery Centers for Disease Control and Prevention (CDC) This page at the CDC Website presents the Public Health Law Program. The site was created in 2000 and has as its goals to: (1) improve the understanding and use of law as a public health tool, (2) develop CDC’s capacity to apply law to achievement of its Health Protection Goals, and (3) develop the legal preparedness of the public health system to address all public health priorities. 6. http://www.dol.gov/opa/aboutdol/lawsprog.htm United States Department of Labor (USDOL) The USDOL Website presents a summary of the major laws associated with labor. You’ll find brief descriptions of many of the principal statutes most commonly applicable to businesses, job seekers, workers, retirees, contractors, and grantees. http://www.hhs.gov/ocr/privacy http://www.history.com/this-day-in-history http://www.cnheo.org http://asq.org/learn-about-quality/project-planning-tools/overview/gantt-chart.html http://www2a.cdc.gov/phlp/?source=govdelivery http://www.dol.gov/opa/aboutdol/lawsprog.htm Chapter 13 351 Evaluation: An Overview Chapter 14 365 Evaluation Approaches and Designs Chapter 15 387 Data Analysis and Reporting The chapters in this section present an overview of the evaluation process, including how to plan an evaluation, how to analyze and interpret data, and how to report evaluation results. PARt III Evaluating a HEaltH Promotion Program This page intentionally left blank 351 Performing adequate and appropriate evaluation is necessary for any program regardless of size, type, or duration. While it is true that program resources, namely the proportion of the budget that can be devoted to evaluation, as well as the evaluation expertise of program staff and partners, will influence the type and quality of the evaluation performed, every effort should be made to address the two most critical and basic purposes of program evalua- tion: (1) assessing and improving quality, and (2) determining effectiveness. As displayed in Box 13.1, conducting evaluation and research is a major area of respon- sibility for health education specialists who must demonstrate both knowledge of and the capacity to develop evaluation plans and collect and analyze related data (NCHEC & SOPHE, 2015). Your credibility as a planner and evaluator will often be directly linked to your ability to perform these important tasks. Those who neglect evaluation also risk losing all or part of their program funding. This chapter presents an overview of evaluation and introduces evaluation terminol- ogy; the basic purposes of evaluation, including distinctions between formative and process internal evaluation outcome evaluation process evaluation quality standards of evaluation summative evaluation Key Terms baseline data effectiveness evaluation evaluation consultant external evaluation formative evaluation impact evaluation institutional review boards Chapter Objectives After reading this chapter and answering the questions at the end, you should be able to: ⦁⦁ Define evaluation in general. ⦁⦁ Explain the two basic purposes of evaluation. ⦁⦁ Distinguish between formative and summative evaluation as well as between formative and process evaluation. ⦁⦁ Describe the process of conducting an evaluation. ⦁⦁ Identify some of the problems that may prevent an effective evaluation. ⦁⦁ Explain the difference between internal and external evaluations. ⦁⦁ Describe key considerations in planning and conducting an evaluation. Evaluation An Overview13 Chapter 352 Part 3 Evaluating a Health Promotion Program evaluation, as well as summative, impact, and outcome evaluation; the process of conduct- ing an evaluation; problems or barriers in conducting program evaluation; and other issues to consider when conducting an evaluation. Basic Terminology In general, evaluation can be defined as the process of determining the value or worth of a health promotion program or any of its components based on predetermined criteria or stan- dards of success identified by stakeholders. Two broad categories of evaluation correspond to the two basic purposes of evaluation—improving quality and determining effectiveness. Formative evaluation relates to quality assessment and program improvement, whereas summative evaluation pertains to determining effectiveness. Formative evaluation begins when programs are conceived and developed (or are forming). Though it continues through the implementation phase and usually ends when the program is concluded, it is particularly important and most relevant during the early stages of program de- velopment and implementation. The purpose of formative evaluation is to improve the quality of a program or any of its components before the program concludes (Fink, 2015). Another type of evaluation closely associated with formative evaluation is process evaluation, which assesses the implementation process in general, and tracks and mea- sures what went well and what went poorly and how these factors contributed to the suc- cess or failure of a particular program. It also measures fidelity, or how closely program implementation followed existing standards or protocol. Process evaluation is not focused on improving the quality of a program while it is in process. Rather, it measures how well program implementation occurred. While this represents a process of looking backward after the program concludes, data are collected throughout the implementation process. Process evaluation also measures how many products were distributed or how many services were of- fered as well as how many people participated in the program (i.e., the extent of a program’s reach). An occasional criticism leveled at health promotion is that programs sometimes limit their assessment to process evaluation (e.g., the number of program participants, etc.) and do not adequately address summative evaluation (the degree to which actual changes occurred 13.1 Responsibilities and Competencies for Health Education Specialists Responsibilities and competencies that are connected with the content in this chapter include: RESponSiBility iV: Conduct Evaluation and Research Related to Health Education Competency 4.1: Develop an evaluation plan for health education/ promotion Competency 4.4: Collect and manage data Competency 4.5: Analyze data Competency 4.6: Interpret results Competency 4.7: Apply findings Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Box Chapter 13 Evaluation 353 as a result of the program). While process evaluation is important, it should not be performed in lieu of formative or summative evaluation. In professional practice, formative and process evaluations are often used interchange- ably and have become somewhat synonymous. However, commonly accepted features serve to distinguish the two, at least in theory. For example, formative evaluation attempts to enhance program components before and during implementation so the very best products and services are offered to the priority population. Formative evaluation includes pretesting program components (e.g., curriculum, video clips, public service announcements, language for potential policy change, etc.) as well as pilot testing (testing the complete program with a small segment of the priority population before broad implementation). Though both formative and process evaluations are related to implementation, formative evaluation focuses on improving the quality of the program and its components while they are being implemented, whereas process evaluation measures the degree to which the program was successfully implemented and generally applies lessons learned in subsequent versions or implementations of the program. (Specific components of both formative and process evalu- ation, which will more clearly distinguish the two, are presented in Chapter 14.) The purpose of summative evaluation on the other hand, is to assess the effectiveness of the intervention and the extent to which awareness, attitudes, knowledge, behavior, the environment, or health status changed as a result of a particular program. Summative evalu- ation requires the measurement and establishment of a baseline value (the starting point or status of a health indicator prior to the implementation of an intervention) as well as measurement of the same health indicator after the program is concluded (i.e., a posttest). Accordingly, summative evaluation occurs after a program is finished. Closely associated with summative evaluation are both impact and outcome evalu- ations. While summative evaluation is more generally an umbrella term associated with effectiveness, impact evaluation tends to focus on intermediate measures such as behavior change or changes in attitudes, knowledge, and awareness, whereas outcome evaluation tends to measure the degree to which end points such as diseases or injuries actually de- creased. Collectively speaking, at least in health promotion practice, impact and outcome evaluations together constitute summative evaluation. To summarize, in formative evaluation the quality of program components is measured and improved prior to or during program implementation. In process evaluation the me- chanics and results of program implementation are assessed. In summative evaluation, program outcomes are measured including impact evaluation (e.g., behavior change) and outcome evaluation (e.g., disease). Without evaluation, claims related to program quality and effectiveness can rarely, if ever, be made. Both historical and more contemporary supporting definitions for formative, summative, process, impact, and outcome evaluation are presented below. ⦁⦁ Formative evaluation: “Any combination of measurements obtained and judgments made before or during the implementation of materials, methods, activities or programs to control, assure or improve the quality of performance or delivery” (Green & Lewis, 1986, p. 362). Data derived from formative evaluation help assess the feasibility of program implementation and interventions, the acceptability of program methods and materials, and the potential to produce short-term results (Windsor, 2015). Formative evaluation focuses on the current status of a program and provides regular feedback to administrators and those delivering the program (Spaulding, 2014). 354 Part 3 Evaluating a Health Promotion Program ⦁⦁ Summative evaluation: “Any combination of measurements and judgments that permit conclusions to be drawn about impact, outcome, or benefits of a program or method” (Green & Lewis, 1986, p. 366). Summative evaluation determines whether results have met stated goals (Chen, 2015) and assesses impact, outcome, and benefits (Perrin, 2015). ⦁⦁ Process evaluation: “Is used to monitor and document program implementation and can aid in understanding the relationship between specific program elements and program outcomes” (Saunders, Evans, & Joshi, 2005, p. 134). The central purposes for process evaluation are to “identify the key components of an intervention that are effective, to identify for whom the intervention is effective, and to identify under what conditions the intervention is effective” (Steckler & Linnan, 2002, p. 1). It also evaluates the “extent to which a program is being implemented as planned” (Harris, 2010, p.207). In summary, it examines all aspects of implementation including the environment surrounding the implementation (Perrin, 2015). ⦁⦁ Impact evaluation: Focuses on “the immediate observable effects of a program, leading to the intended outcomes of a program; intermediate outcomes” (Green & Lewis, 1986, p. 363). Most notably, impact evaluation is associated with intermediate or long- term changes in behavioral impact (Windsor, 2015). ⦁⦁ Outcome evaluation: Focuses on “an ultimate goal or product of a program or treatment, generally measured in the health field by mortality or morbidity data in a population, vital measures, symptoms, signs, or physiological indicators on individuals” (Green & Lewis, 1986, p. 364). Outcome evaluation is long-term in nature and generally takes more time and resources to conduct than impact evaluation. Ultimately, it makes a determination of the effect of a program or policy on its beneficiaries (Harris, 2010). Purpose of Evaluation Beyond improving the quality of programs and their components and measuring effective- ness, stakeholders will determine which factors will be measured to determine the worth or value of the program. While the outcome of any health promotion program should relate in some way to improved health, a number of factors leading to this outcome can be measured in the evaluation process. These include how broadly and successfully a program was imple- mented and the degree to which the program influenced knowledge, attitudes, confidence, abilities, and behaviors. An evaluation can also assess less tangible benefits deemed important by stakeholders. These benefits may include outcomes such as the degree of good will or organizational pres- ence produced by a program, the amount of social capital or community cohesiveness cre- ated, or the extent to which consumers are satisfied with a program for reasons other than improved health status. Ultimately, stakeholders will determine the worth of a program based on criteria unique and important to them. In the most basic sense, programs are evaluated to gain information and make decisions. The information gained through evaluation may be used by planners during the implemen- tation of a program to make immediate improvements (i.e., formative evaluation) as well as improvements to the implementation process in subsequent versions of the program (i.e., process evaluation). In other words, you do not want to continue indefinitely with a bad program. Evaluation may also be used to see if certain immediate outcomes—such as Chapter 13 Evaluation 355 knowledge, attitudes, skills, environment, and behavior change—have occurred (i.e., impact evaluation). It may also be used over time to determine whether long-term program goals and objectives associated with disease outcomes and improved health status have been met (i.e., outcome evaluation). Capwell, Butterfoss, and Francisco (2000) identified six general reasons why stakeholders may want programs evaluated: 1. To determine achievement of objectives related to improved health status. In other words, evaluation can measure the scope of a program’s effects, the duration of outcomes and the extent of its influence in improving health (Fink, 2015). Probably the most common reason for program evaluation is to determine the degree to which program objectives related to improved health conditions were met. In this sense, evaluation may also be used to determine which of several programs was most effective in achieving a given objective. You should always attempt to link and limit the scope of evaluation (and the degree to which your personal or program performance is assessed) to program goals and objectives. For this reason, it is important to ensure that goals and objectives are specific, measurable, attainable, realistic and time-phased. 2. To improve program implementation. Planners should always be interested in improving a program. Program evaluation can help planners understand why a particular intervention worked (Valente, 2002) or did not work, and thus, weak elements can be identified, removed, and replaced (Green & Lewis, 1986). This is most closely associated with process evaluation. In other words, evaluation can help ensure that implementation is completed in timely and organized ways (Perrin, 2015). With respect to implementation, evaluation can also monitor staff performance and improve staff skills (Windsor, 2015). 3. To provide accountability to funders, the community, and other stakeholders. Many stakeholders are interested in the value of a program to a community, or if the program is worth its cost. Perhaps more importantly, stakeholders will want information to improve the program and to determine if the program worked and if it should be continued (Chen, 2015). 4. To increase community support for initiatives. The results of an evaluation can increase community awareness of a program. Positive evaluation data channeled through proper communication channels can generate backing for a program, which in turn may lead to additional funding. So, data produced by appropriate evaluation can be used by funders to determine continued support, but also by consumers to assess continued interest (Fink, 2015). Evaluation can also promote positive public relations and community awareness (Windsor, 2015). 5. To contribute to the scientific base for community public health interventions. Program evaluation can provide findings that can lead to new hypotheses about human behavior and individual or community change, which in turn may lead to new and better programs. According to Spaulding (2014) and Windsor (2015), one of the key purposes of applied research is to inform practice and contribute to the science-evidence base of programs, or to help ensure that only effective or promising approaches are used. 6. To inform policy decisions. Program evaluation data can be used to impact policy within the community. For example, studies on passive or secondhand smoke have been the impetus for many states and local communities to pass laws or ordinances prohibiting indoor smoking. Evaluation can also be useful in investigating potential political ramifications and sustainability of a particular program or initiative (Perrin, 2015). 356 Part 3 Evaluating a Health Promotion Program Framework for Program Evaluation In 1999, the Centers for Disease Control and Prevention (CDC, 1999a) published an evaluation framework for public health programs. The framework was developed by a working group that included evaluation experts, public health program managers and directors, state and local public health officials, teachers, researchers, U.S. Public Health Service agency representatives, and CDC staff members. This framework has stood the test of time and is still very robust. The framework (see Figure 13.1) is composed of six steps that can be helpful in any evalu- ation, regardless of type (formative, summative, etc.) or setting. However, this framework probably has more application for what has been described earlier as impact evaluation (i.e. measuring changes in behavior as well as knowledge, attitudes, and awareness, etc.) than any other evaluation type. These steps are not a prescription; rather, they are starting points for tailoring the evaluation. The early steps provide the foundation, and all steps should be final- ized before moving to the next step: ⦁⦁ Step 1—Engaging stakeholders. This step begins the evaluation cycle. Stakeholders must be engaged to ensure that their perspectives are understood. “Stakeholders are much more likely to support the evaluation and act on results and recommendations if they are involved in the evaluation process (CDC, 2011c, p.14).” This engagement must occur STEPS Engage stakeholders Describe the program Ensure use and share lessons learned Focus the evaluation design Justify conclusions Gather credible evidence STANDARDS Utility Feasibility Propriety Accuracy ⦁▲ Figure 13.1 CDC Framework for Program Evaluation Source: CDC (1999c), p. 4. Chapter 13 Evaluation 357 early in the planning process to determine how stakeholders will gauge the success of the program and to build this information into goals and objectives. Otherwise, planners and evaluators open themselves up to criticism or resistance later when results are reported to stakeholders and are inconsistent with predetermined values. The three primary groups of stakeholders are (1) those involved in the program operations, (2) those served or affected by the program, and (3) the primary users of the evaluation results. While the scope and level of stakeholder involvement will vary with each program being evaluated, it is important to focus on stakeholders who can increase the credibility of your evaluation and program or those who will advocate for or authorize funding for your program (CDC, 2011c). ⦁⦁ Step 2—Describing the program. “A comprehensive program description clarifies all the components and intended outcomes of the program, thus helping you focus your evaluation on the most central and important questions (CDC, 2011c, p. 21).” This step sets the frame of reference for all subsequent decisions in the evaluation process. At a minimum, the program should be described in enough detail that the mission, goals, and objectives are understood. Also, the program’s capacity to affect change, its stage of development, and how it fits into the larger organization and community should be known. Usually, a logic model is used in this step to display a sequence of program events (see Chapter 12 for a discussion of logic models) and the relationship among inputs, activities, and outputs or outcomes. Logic models have been used for several years in health promotion practice to graphically display the relationship between a program’s activities and its intended outcomes and the role evaluation plays in describing these relationships (CDC, 2011c). As intended outcomes are established in this step, it is important to set targets for success that are meaningful without being unreasonable or unattainable. Stakeholders will be invaluable in helping make these decisions. ⦁⦁ Step 3—Focusing the evaluation design. Among the items to consider in this step are: stating the reason for the evaluation (e.g., improve the quality of programs as in formative evaluation or assess effects, including behavior change and changes in health status, as in impact and outcome evaluation, etc.). This step also includes formulating research questions and/or hypotheses, determining the specific type of evaluation design that will be used, selecting participants and related sample sizes, deciding on the types of statistical analyses that will be used, and recruiting evaluation participants. Again, these decisions relate back to stakeholders and are made in the context of who will use the evaluation results and how evaluation results will be used (CDC, 2011c). ⦁⦁ Step 4—Gathering credible evidence. During this step, evaluators decide on measurement indicators [i.e., specific, observable, and measurable outcomes that describe exactly what evaluators are looking for (CDC, 2011c)], sources of evidence, quality and quantity of evidence, and logistics for collecting the evidence. This step also involves organizing data including specific processes related to coding, filing, and cleaning. In this step, evaluators make arrangements to have questionnaires copied or available electronically. They make arrangements for space if paper/pencil (in-person) surveys or face-to-face surveys etc. are conducted. Program partners need to be assigned dates and times to administer evaluation methods, including how to collect and store data. ⦁⦁ Step 5—Justifying conclusions. This step includes the comparison of the evidence against the standards of success (i.e., analyzing and synthesizing data); interpreting those comparisons; judging the worth, merit, or significance of the program; and creating recommendations for actions based on the results of the evaluation. In essence, evaluators compare their data or evidence against the measures of success that were developed in previous steps to determine effectiveness, and ultimately, the value of the program. Part of this analysis will assess the fidelity of the evaluation process itself, or how carefully steps were taken to follow appropriate evaluation protocol to reduce 358 Part 3 Evaluating a Health Promotion Program bias. Evaluators must make every effort to increase objectivity and decrease subjectivity. “When agencies, communities, and other stakeholders agree that the conclusions are justified, they will be more inclined to use the evaluation results for program improvement (CDC, 2011c, p. 74).” ⦁⦁ Step 6—Ensuring use and sharing lessons learned. This step focuses on the use and dissemination of the evaluation results. This is a time when a decision can be made to modify, continue, or discontinue the intervention(s) based on data. This is sometimes referred to as the evaluation feedback loop. Stakeholders will also determine the format of the data report (e.g. PowerPoint (R) slides, a data report, an executive summary, or a paper submitted to a peer-review journal, etc.). Specific aims of sharing evaluation results include: demonstrating that allocated resources are justified and are making a difference in terms of improved health outcomes; retaining or increasing funding associated with the program; enhancing the image of the program; identifying training and technical assistance needs; and suggesting different, perhaps more reasonable, outcomes, etc. (CDC, 2011c). In addition to these six steps, the framework uses four standards of evaluation, which are displayed in the box at the center of Figure 13.1. These standards provide practical guidelines for the evaluators to follow when having to decide among evaluation options. For example, these standards help evaluators avoid evaluations that may be accurate and feasible but not useful or those that would be useful and accurate but not feasible (CDC, 1999a). The four standards are: 1. “Utility standards ensure that information needs of evaluation users are satisfied” (CDC, 1999a, p. 27). This includes determining who needs the evaluation results and ensuring that the evaluation will provide relevant information in a timely manner to appropriate audiences (CDC, 2011c). 2. “Feasibility standards ensure that the evaluation is viable and pragmatic” (CDC, 1999a, p. 27). In other words, the evaluation is realistic and affordable given the time, resources and expertise available (CDC, 2011c). 3. “Propriety standards ensure that the evaluation is ethical (i.e., conducted with regard for the rights and interests of those involved and effected)” (CDC, 1999a, p. 27). In addition to ensuring the welfare of those involved and affected by the evaluation, propriety helps ensure that the evaluation is engaging those in the community most directly affected by a particular health problem (CDC, 2011c). 4. “Accuracy standards ensure that the evaluation produces findings that are considered correct” (CDC, 1999a, p. 29). This means findings are both valid and reliable, or that what is reported is not only accurate but consistent with the data that were collected, and that similar findings can be repeated over time As used here, accuracy also requires an adequate number of community participants engaged with the program and its evaluation (CDC, 2011c). Practical Problems or Barriers in Conducting an Evaluation Several authors have identified practical problems or barriers to effective evaluation. Some of the more common problems or barriers that remain consistent over time are presented below. 1. Planners either fail to build evaluation in the program planning process or do so too late (Koelen et al., 2001; Solomon, 1987; Timmreck, 2003; Valente, 2002). Chapter 13 Evaluation 359 2. Adequate resources (e.g., personnel, time, money) may not be available to conduct an appropriate evaluation (Jacobs et al., 2010; NCI, n.d.; Robinson et al., 2006; Solomon, 1987; Valente, 2002). 3. Organizational restrictions on hiring consultants and contractors may prohibit evaluation efforts (Datta & Petticrew, 2013; Lobo et al., 2014; NCI, n.d.). 4. Effects are often hard to detect because changes are sometimes small, come slowly, or do not last (Glasgow, 2002; Koelen et al., 2001; Solomon, 1987; Valente, 2002). 5. Length of time allotted for the program and its evaluation is not realistic given the nature of behavior change or the interval that is necessary to measure mortality or morbidity (NCI, n.d.). 6. Restrictions (i.e., policies, ethics, lack of trust in the evaluators) that limit the collection of data among the priority population (NCI, n.d.). 7. It is difficult to make an association between cause and effect (Robinson et al., 2006; Solomon, 1987). 8. It is difficult to separate the effects of multiple interventions within a program (Glasgow et al., 1999), or multiple programs within a community, or to isolate program effects on the priority population since evaluators/researchers cannot control all the influences of real-world phenomena (Datta & Petticrew, 2013; NCI, n.d.). 9. Discrepancies arise between professional standards and actual practice (Lobo et al., 2014; Solomon, 1987) with regard to appropriate evaluation design, particularly among novice evaluators. 10. Sometimes evaluators’ motives to demonstrate success introduce bias (Datta & Petticrew, 2013; Lobo et al., 2014; Solomon, 1987; Valente, 2002). 11. Stakeholders’ perceptions of the evaluation’s value may vary too drastically (NCI, n.d.; Robinson et al., 2006). 12. Intervention strategies are sometimes not delivered as intended (i.e., Type III error) (Glasgow, 2002), or are not culturally specific (NCI, n.d.; Valente, 2002). Examples of these problems in health promotion programs may occur by not collecting initial information from participants because evaluation plans were not in place, failing to budget for the cost of the evaluation (e.g., printing questionnaires, additional staff, postage), or conducting the evaluation prematurely before a change can occur (e.g., changes in choles- terol level) or too long after program completion (e.g., posttest effects of a smoking cessation program). Those without evaluation expertise may conduct an evaluation without a sound design, such as not using appropriate sampling techniques or comparison groups. Lack of capacity or inability to conduct an evaluation may be one of the most significant barriers to meaningful evaluations in general (Lobo et al., 2014). Additionally, program managers who are motivated to make their programs cost-effective may minimize costs and unwittingly jeopardize the integrity of an evaluation. Awareness of these problems and development of strategies to deal with them will im- prove the value of program evaluation. The remainder of this chapter discusses strategies that can help minimize problems with evaluation, such as including evaluation in the early stages of program planning, accounting for ethical considerations, determining who will conduct the evaluation, carefully considering the evaluation design, increasing objectivity, and developing a plan to use the evaluation results. 360 Part 3 Evaluating a Health Promotion Program Evaluation in the Program Planning Stages Evaluation design must reflect the goals and objectives of the program (see Chapter 6). In turn, the results of the evaluation will determine whether the goals and objectives were met. To be most effective, the evaluation must be planned in the early stages of program develop- ment and should be in place before the program begins. Results from evaluations conducted early in the program planning process can assist in improving the program (i.e., formative evaluation). Having a plan in place to conduct an evaluation before the end of a program will make collecting data related to program outcomes much easier and more reliable. Discussion on how evaluation plans can be included in program planning will focus on examples of formative and summative evaluations. The formative evaluation should provide feedback to the program administrator, with program monitoring beginning in the early stages. Collecting information and communicating it to the administrator quickly allows for the program to be modified and improved. Data reflecting the initial status or interests of the participants—baseline data—or something like qualitative data from focus groups can be used to assess participant satisfac- tion. Additional information from the formative evaluation may indicate that the necessary number of staff members has been hired, program sites are available, materials have been printed, participants are satisfied with the times the programs are offered, and classes are of- fered with the needs of the prospective participants in mind. Initial data regarding the program should be analyzed promptly to make any necessary adjustments to the program. This type of evaluation can improve both new and existing programs. Information from the formative evaluation can also be useful in answering ques- tions such as whether the programs are provided at convenient locations for the community members, whether the necessary materials were available on time, and whether people are attending the workshops at all the various times they are offered. If the answer to any of these questions is “no,” specific program attributes needing quality improvement can be identified and addressed. By developing the summative evaluation plan at the beginning of the program, planners can ensure that the results will be less biased. Early development of the summative evalu- ation plan ensures that the questions answered relate to the original objectives and goals of the program. This type of evaluation can provide answers to many questions, such as whether the group approach or the individual approach was more effective in reducing to- bacco use among the participants in a smoking cessation program, whether the participants in a weight loss program actually lost weight and/or maintained the weight loss, and how many people in the priority population increased their knowledge, changed their attitudes, or reduced their risks. Ethical Considerations Always remember that evaluation or research should never cause mental, emotional, or physical harm to those involved. Nor should it cause a delay in products or services that could potentially improve health among those being evaluated/researched. Evaluation participants should always be informed of the purpose and potential risks of any evalu- ation and should always give their consent before participating. Generally, evaluators Chapter 13 Evaluation 361 assure the confidentiality and anonymity of evaluation responses. Although evaluation data are reported in the aggregate, no individual should ever have his or her personal in- formation revealed in any setting or circumstance. Because evaluations may have ethical considerations for the individuals involved, most colleges, universities, school systems, and large health organizations have boards to review the evaluation design and potential risk to participants. These groups are most often referred to as institutional review boards (IRBs) or human subjects committees (Cottrell & McKenzie, 2011). These boards serve to safeguard the rights, privacy, health, and well-being of those involved in the evaluation/research. Before conducting any evaluation or research involving human subjects, make sure to get IRB approval. Who Will Conduct the Evaluation? At the beginning of the program, planners must determine who will conduct the evaluation. The program evaluator must be as objective as possible and should have nothing to gain personally from the results of the evaluation. The evaluator may be someone associated with the program or someone from outside. If an individual trained in evaluation and personally involved with the program conducts the evaluation, it is called an internal evaluation. For example, a local health department may assign one of its own employees to evaluate its programs. An internal evaluator would have the advantage of: (1) being more familiar with the organization and the program his- tory, (2) knowing the decision-making style of those in the organization, (3) being present to remind others of results over time, and (4) being able to communicate technical results more frequently and clearly (Fitzpatrick, Saunders, & Worthen, 2004). Conducting an internal evaluation is also less expensive than hiring additional personnel to conduct the evalua- tion. The major drawback, however, is the possibility of evaluator bias or conflict of interest. Someone closely involved with the program has an investment in the outcome of the evalua- tion and may not be completely objective. After all, a positive evaluation of the program may result in future funding that would enhance the positions of the staff members. An external evaluation is one conducted by someone who is not connected with the program. Often an external evaluator is referred to as an evaluation consultant. Having a researcher from a university or some other type of research institute conduct evaluations for a local health department would be an example of an external evaluator. External evalu- ators are somewhat isolated, often lacking knowledge of and experience with the program that the internal evaluator possesses. Evaluation of this nature is also more expensive, since an additional person must be hired to carry out the work. However, an external evaluator: (1) can often provide a more objective review and a fresh perspective, (2) can help to ensure an unbiased evaluation outcome, (3) brings a global knowledge of evaluation having worked in a variety of settings, and (4) “typically brings more breadth and depth of technical exper- tise” (Fitzpatrick et al., 2004, p. 23). When selecting an external evaluator, planners should look for someone with formal training in evaluation methods. Whether an internal or external evaluator conducts the program evaluation, the main goal is to choose someone with credibility who values objectivity. The evaluator must have a clear role in the evaluation design and accurately report the results regardless of the findings. Box 13.2 presents characteristics of good evaluators. 362 Part 3 Evaluating a Health Promotion Program Evaluation Results The question of who will receive the evaluation results is also an important consideration. The evaluation can be conducted from several vantage points, depending on whether the results will be presented to the program administrator, the funding source, the organiza- tion, or the public. These stakeholders may all have different sets of questions they would like answered. The evaluation results must be disseminated to groups interested in the program. Different aspects of the evaluation can be stressed, depending on the group’s particular needs and interests. An administrator may be interested in which program ap- proach was more successful, the funding source may want to know if all objectives were reached, and a community member may want to know if participants felt the program was beneficial. The planning process associated with the evaluation should include a determina- tion of how the results will be used. It is especially important in formative evaluation to implement the findings rapidly to improve the program. However, a feedback loop and action plan are needed in summative, impact, and outcome evaluation to ensure that results and lessons learned are used to determine how to proceed with health promotion programs. Summary Evaluation can be thought of as a way to make sound decisions regarding the value and effec- tiveness of health promotion programs, to compare different types of programs, to eliminate weak program components, to meet requirements of funding sources, or to provide informa- tion about programs. The evaluation process takes place before, during, and after program implementation. If the evaluation is well designed and conducted appropriately, the find- ings can be very beneficial to program stakeholders. 13.2 Box Characteristics of a Good Evaluator ⦁⦁ Experience in the type of evaluation needed ⦁⦁ Comfortable with quantitative data sources and analysis ⦁⦁ Able to work with a wide variety of stakeholders, including representatives of target populations ⦁⦁ Can develop innovative approaches to evaluation while considering the realities affecting a program (e.g., a small budget) ⦁⦁ Incorporates evaluation into all program activities ⦁⦁ Understands both the potential benefits and risks of evaluation ⦁⦁ Educates program personnel in designing and conducting the evaluation ⦁⦁ Will give the staff full findings (i.e., will not gloss over or fail to report certain findings) Source: Centers for Disease Control and Prevention (2011c), p. 11. H ig hl ig ht s Chapter 13 Evaluation 363 Review Questions 1. What are the two basic purposes of program evaluation? 2. What are the two broad categories of evaluation and how do they relate to the two basic purposes of program evaluation? 3. List and describe the six steps in CDC’s framework for program evaluation. 4. List and describe the four evaluation standards in CDC’s framework for program evaluation. 5. Give an example of a question that could be answered in a process evaluation, impact evaluation, and outcome evaluation. 6. What are some of the more common problems associated with or barriers to effective evaluation? 7. What different types of information could an evaluation provide for the various stakeholders (planners, funding source, administrators, and participants)? 8. Why is it important to begin the evaluation process in the program planning stages? 9. Explain how feedback from an evaluation can be used in program planning. 10. In what type of situation would an internal evaluation be more appropriate than an external evaluation? 11. What are the desirable characteristics of an external evaluator (evaluation consultant)? Activities 1. Describe potential roles and results of formative and summative evaluations in a program related to an HIV needle-exchange program. 2. Describe how process, impact, and outcome evaluation could be used in a stress management program for college students. 3. Write a rationale to a funding source for hiring an external evaluator (evaluation consultant). 4. Review the evaluation component from a health promotion program in your community and/or discuss an evaluation plan with a planner or evaluator. Look for the planning process used, the rationale for the data collection method, and how the findings were reported. To what extent did the program follow CDC’s framework for evaluation? 5. Assume you are responsible for selecting an evaluator for a health promotion program you are planning. Would you select an internal or an external evaluator? Explain your rationale. If you select an external evaluator (evaluation consultant), where do you think you could find such a person? Weblinks 1. http://www.eval.org American Evaluation Association (AEA) The AEA is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. http://www.eval.org 364 Part 3 Evaluating a Health Promotion Program 2. http://www.evaluationcanada.ca/ Canadian Evaluation Society (CES) The CES is a professional association of evaluators dedicated to the advancement of evaluation theory and practice. Information at this Website is available in both English and French. 3. http://ctb.ku.edu/en/default.aspx Community Tool Box This Website has long provided technical assistance to health professionals on a number of tasks related to planning and evaluation in health promotion. With respect to evaluation, a general search for evaluation will present a number of specific links including introduction to evaluation, operations in evaluating community interventions, methods for evaluating comprehensive community initiatives, and using evaluation to understand and improve the initiative. 4. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4811a1.htm CDC Framework for Program Evaluation in Public Health This is CDC’s evaluation framework described earlier in this chapter published in Morbidity and Mortality Weekly Report. This document describes in detail the six steps related to the framework. 5. http://www.cdc.gov/eval/guide/cdcevalmanual Introduction to program evaluation for public health programs: A self-study guide This is an excellent evaluation resource from the CDC that provides additional information and training on CDC’s evaluation framework as well as information on evaluation in general. 6. http://www.rand.org/pubs/technical_reports/tR101.html Getting to Outcomes: Promoting Accountability through Methods and Tools for Planning, Implementation, and Evaluation An excellent evaluation resource related to establishing and measuring evidence-based program oucomes. 7. http://whqlibdoc.who.int/hq/2000/WHo_MSD_MSB_00.2e Process Evaluations This is a document on process evaluations from the World Health Organization. It is a good resource for designing and conducting process evaluations. http://www.evaluationcanada.ca/ http://ctb.ku.edu/en/default.aspx http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4811a1.htm http://www.cdc.gov/eval/guide/cdcevalmanual http://www.rand.org/pubs/technical_reports/tR101.html http://whqlibdoc.who.int/hq/2000/WHo_MSD_MSB_00.2e 365 This chapter focuses on evaluation approaches and designs. The term approaches re- fers to formative, process, and summative evaluation and suggests these types of evaluation are distinct. Designs are diagrams that display steps or associations between elements in the evaluation process, often including specific and unique notations. For the purpose of this chapter, designs relate exclusively to summative evaluation. Whereas formative and process 14 Chapter Evaluation Approaches and Designs Chapter Objectives After reading this chapter and answering the questions at the end, you should be able to: ⦁⦁ Describe the difference between formative and summative evaluations as well as their relationship to process, impact, and outcome evaluations. ⦁⦁ Identify elements and strategies related to both formative and process evaluations. ⦁⦁ List important considerations in selecting an evaluation design. ⦁⦁ Compare and contrast the major types of evaluation designs. ⦁⦁ Compare and contrast quantitative and qualitative methods of evaluation. ⦁⦁ List the various qualitative methods that can be used in evaluation and research. ⦁⦁ Differentiate between experimental, control, and comparison groups. ⦁⦁ Identify the threats to internal and external validity and explain how evaluation design can increase control. Key Terms accountability adjustment approaches blind capacity comparison group confounding variables consumer orientation context control group cost-benefit analysis cost-effectiveness analysis cost-identification analysis deductive designs dose double blind evidence experimental design experimental group external validity fidelity generalizability inclusion inductive interaction internal validity justification multiplicity nonexperimental design pilot testing posttest pretest pretesting qualitative method quantitative method quasi-experimental design reach recruitment resources response satisfaction summative evaluation support triple blind 366 Part 3 Evaluating a Health Promotion Program evaluations are typically defined with descriptions of strategies, summative evaluations are generally associated with experimental, quasi-experimental, and non-experimental designs. Box 14.1 identifies the responsibilities and competencies for health education specialists that pertain to the material presented in this chapter. Formative Evaluation At its core, formative evaluation focuses on the quality of program content and program implementation. Some elements of formative evaluation occur before the start of the imple- mentation phase and help ensure that a program and its elements have been conceptualized and developed appropriately. Formative evaluation collects data and informs stakeholders of important findings that could potentially improve a program or its delivery, and allows for appropriate changes before the program is fully implemented and completed. Although a for- mative evaluation can be used to improve a program between implementation cycles (i.e., an evaluator identifies various issues that need to be addressed before the program is implemented again), it is usually better to allow a formative evaluation to inform and guide the development and implementation of a program as it unfolds. In cases where a program’s implementation is ongoing, the distinction between formative and process evaluation is not as clear or relevant as long as programs are being improved based on feedback collected in the evaluation process. Table 14.1 displays the elements of a comprehensive formative evaluation. The degree to which these elements are used will be determined by many factors including the preferences of stakeholders. However, all 15 elements are important and have a bearing on program qual- ity, which, in turn, leads to program effectiveness as measured in summative evaluation. Formative evaluation occurs from the time of program inception through implementa- tion. By nature, certain elements of formative evaluation are more applicable at the time of program inception. This is when planners either begin developing a new program or decide to use an existing program and adapt it to their priority population. For example, addressing 14.1 Responsibilities and Competencies for Health Education Specialists This chapter describes evaluation approaches including formative, process, and summative evaluations (including impact and outcome evaluations), elements of formative and process evaluations, and evaluation designs associated with summative evaluation. Responsibilities and competencies connected with this chapter include: RESponSiBiliTy iV: Conduct Evaluation and Research Related to Health Education/ Promotion Competency 4.1: Develop an evaluation plan for health education/ promotion Competency 4.4: Collect and manage data Competency 4.5: Analyze data Competency 4.6: Interpret results Competency 4.7: Apply findings Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Box Chapter 14 Evaluation Approaches and Designs 367 TAblE 14.1 Elements of a Comprehensive Formative Evaluation *These items relate to formative evaluation as they help ensure that an adequate number of people are participating in the program. But they also relate to process evaluation as an evaluation of the implementation process itself would naturally measure not only how many people had the opportunity to participate in the program, but more importantly, how many people actually participated. Element Description Justification Degree to which a program, service, or activity is mandated or approved by relevant stakeholders and justified by needs assessment data and analysis Evidence Degree to which the program, service, or activity is evidence-based (i.e., documented evaluation results in the literature suggest the program is effective or at least promising) Capacity Extent to which professionals have adequate knowledge, skills, and abilities to design and implement a program, service, or activity or the degree to which they can access or contract with other organizations and professionals to provide the same program, service, or activity Resources Adequacy of resources (e.g., budget, community resources or assistance, assets, time, etc.) Consumer-orientation Degree to which the program, activity, or service is tailored to the priority population (i.e., culturally appropriate and based on consumer preferences) Multiplicity Degree to which multiple components (i.e., intervention strategies) are built into the program, service, or activity (e.g., education, communication, policy, environmental change, etc.) Support Degree to which a support component is built into a program, service, or activity (e.g., a hotline/quit line for a tobacco media campaign, development of walking paths for a community physical activity campaign) Inclusion Extent to which an adequate range and number of appropriate partners or organizations are involved with the program, service, or activity Accountability Extent to which internal staff and external partners are fulfilling their responsibilities as planned and are communicating needs appropriately Adjustment Degree to which programs, services, or activities are modified based on feedback received from participants, partners, or other stakeholders Recruitment* Degree to which members of the priority population are adequately recruited through appropriate communication channels and places consistent with cultural and other unique characteristics Reach* Proportion of the priority population given the opportunity to participate in the program, activity, or service Response* Proportion of the priority population actually participating in the program, activity, or service Interaction Quality of interactions (e.g., customer service; interpersonal, counseling, and presentation skills; clarity of instructions) between professionals (those providing programs, services, and activities) and participants Satisfaction Degree to which the needs of participants are being met, how satisfied they are with the program, service, or activity, and their belief that a positive impact is being made in their lives the elements termed justification and evidence provides assurance that programs are supported by key stakeholders and are evidence-based. It is easy to make assumptions about these issues during a planning process. But addressing these key elements initially will in- fluence planners to make careful assessments about other program and evaluation compo- nents. In this regard, formative evaluation can be beneficial before much, if any, time and effort are applied to the program. 368 Part 3 Evaluating a Health Promotion Program Three additional elements displayed in Table 14.1 relate to issues that should be addressed early in the formative evaluation process. Assessing capacity requires evaluators to care- fully examine the abilities and competency of those who are designing and implementing a program. This can be somewhat challenging if those performing the evaluation are the same professionals designing and implementing the program. Despite this potential chal- lenge, planners and evaluators should identify the strengths and weaknesses of the internal staff and external partners and either invest in training or contract for external providers as necessary. Resources relate to adequate internal or external funding and/or assistance from partner organizations. Although it is easy to underestimate program costs, evaluators performing a formative evaluation should match the projected costs with available resources to deter- mine whether the program can be realistically implemented. Closely related to the concept of resources are three types of cost analyses that can help guide planners in the selection of specific interventions. Cost-identification analysis (or cost-feasibility analysis) is used to compare different interventions available for a program, often to determine which intervention would be the least expensive. With this type of analysis, evaluators identify various items (e.g., personnel, facilities, materials, curriculum, etc.) associated with a given intervention, determine a cost for each item, total the costs for that intervention, and then compare total costs across interventions. For example, if a health department is interested in providing a tobacco prevention and control program for a school district, it could conduct a cost-identification analysis on three different interventions: (1) teacher led, (2) peer-to-peer, and (3) voluntary agency provided. Costs for each of these interventions—such as staff time, staff benefits, curriculum materials, and volunteer training—would be identified, compared, and analyzed. While cost-identification analysis provides good data on cost variation, it does not include the benefit of each program alternative or option as in cost-benefit analysis or cost- effectiveness analysis (Dedhia et al., 2011). Cost-benefit analysis yields the dollar benefit received from the dollars invested in the program. “Because cost-benefit analysis compares program alternatives in monetary terms, the evaluator documents whether a method has economic benefits exceeding costs” (Windsor, 2015, p. 293). Cost-effectiveness analysis relates to how much it costs to produce a certain effect. For example, based on the cost of a program, the effect of years of life saved, number of smokers who stop smoking, or morbidity or mortality rates can be determined. Cost-effectiveness analysis generally assesses program alterna- tives or options to determine which approach is more likely to provide the greatest yield per unit cost, thus providing planners with useful data to make resource allocation deci- sions (Windsor, 2015). In summary, cost-benefit analysis measures how much money you will save for every dollar spent (e.g., for every dollar spent on this program, tax- payers will save three dollars, etc.) and cost-effectiveness analysis measures how much change you will derive for every dollar spent (e.g., every dollar spent on this program will result in X pounds of weight loss per participant, etc.). As displayed in Table 14.1, evaluators must also ensure that consumer orientation, or the degree to which programs are adapted to the needs of the priority population, is adequately addressed. Professionals commonly assume that members of the priority population hold the same understanding and value for programs as those who design and implement the programs. Data from social marketing studies indicate this is not the case Chapter 14 Evaluation Approaches and Designs 369 (Neiger  &  Thackeray, 2002; Thackeray, Neiger, & Keller, 2012). Assuring that programs are tailored to the values, wants, and needs of the priority population is an important compo- nent of a formative evaluation and helps ensure that programs are more readily accepted by the priority population and that intended outcomes occur. Two elements displayed in Table 14.1 relate to the development and content of a pro- gram. The term multiplicity relates to a concept in health promotion where, compared with single-component programs (i.e.,one intervention strategy), multiple-component programs cater more effectively to the varied needs of consumers and tend to be accepted more readily. For example, the Truth Campaign in Utah offered a multidimensional approach to preventing and controlling tobacco use among both youth and adults. Program components involved educational materials including a comprehensive guide for schools, media resources, models for policy and legislation, materials for health care professionals, and a quit line to assist smokers in cessation efforts (Utah Department of Health, 2011). Support, a closely related concept to multiplicity, assures that programs have appropriate built-in reinforcement components to assist participants with the ex- pected level of involvement and/or behavior change. For example, a well-baby program that promotes prenatal care through a media campaign cannot responsibly broadcast messages without an infrastructure that can actually support prenatal care. In addition, a well-baby program of this nature should also be prepared to make referrals based on a variety of demographic variables within the priority population, including the ability to pay for services. Certain elements in formative evaluation relate to key components of program imple- mentation and ensure that: the right people and organizations are participating in the deliv- ery of the program; partners are doing what they’re assigned to do; and necessary changes are being made based on feedback from both participants and partners. Inclusion ensures that the right partners are involved with the program. The natural in- clination of most professionals or organizations is to include as many partners as possible to bear the burden of a program’s cost and implementation. Care should be taken, however, to ensure that only those organizations and individuals that share similar values and commit- ment are included as program partners. This is not to suggest that organizations should not seek diverse or nontraditional partners. However, ideally, all partners should bring a similar level of vision and energy to the program development and implementation process. While partners will be those who actively participate in the program, other agencies, programs, or individuals can be classified as sponsors or supporters. Accountability ensures that each partner organization performs its work as previ- ously arranged. For this reason, it is important for partners to meet regularly, report on progress and identify ways to improve performance. Adjustment, perhaps the most critical element of formative evaluation, is the process whereby planners make necessary changes to the program or its implementation based on feedback from participants and partners. In this regard, those who develop and implement programs must collect data (or information) on what needs to change and then ensure that appropriate changes are made. Recruitment, reach, and response pertain to promoting a program and ensuring that people in the priority population are aware of the program, have the opportunity to participate in the program, and that an adequate number actually do participate in the pro- gram. Obviously, the budget, among other factors, influences the proportion of the priority 370 Part 3 Evaluating a Health Promotion Program population that has access to the program. Evaluators must develop projections for partici- pation early and then match projections with actual participation. Furthermore, evaluators must determine whether methods for recruitment or promotion are appropriate based on communication capabilities and preferences of the priority population. For example, social media approaches will not work if members of the priority population do not use their de- vices to download information planners want to send them. Similarly, newspaper advertise- ments will do little good if word-of-mouth communication is a preferred channel within the priority population. Interaction and satisfaction address the degree to which practitioners effectively work and communicate with program participants and how satisfied participants are with the program in general or with specific components. For example, an evidence-based curric- ulum for weight loss among adults may be appealing to participants, theoretically grounded, and technically sound in every way but not resonate with participants because of an ineffec- tive instructor. A formative evaluation can identify this problem and generate necessary rec- ommendations or adjustments (e.g., a new instructor). Likewise, data regarding participant satisfaction may produce important modifications during program implementation or in future applications of the program. In contrast to formative evaluation, a process evaluation looks back on the implementa- tion process and measures what went well and what went poorly. While data from process evaluation can certainly inform subsequent versions of a program, its main objectives are to describe how closely the program implementation followed protocols; how successful it was in recruiting and reaching members of the priority population; how many people partici- pated or how many products or services were distributed; and what other factors may have competed with or confounded program results. Elements of process evaluation are displayed in Table 14.2. Fidelity ensures that pro- grams are implemented either as intended or as per protocol. Because the results of effec- tive programs may be published in scientific journals or other reporting venues, methods sections should provide a sequential order or step-by-step description of how the program was implemented. Other practitioners may then rely on this information to replicate the *Adapted from Steckler & Linnan (2002); and Saunders, Evans, & Joshi (2005). TAblE 14.2 Elements of a Process Evaluation* Element Description Fidelity Extent to which the program, activity, or service was delivered as planned or as per protocol including the use of Gantt charts (i.e., time lines) and logic models Dose Number of program units delivered (e.g., presentations, products, services, messages etc.) Recruitment* Degree to which members of the priority population are adequately recruited through appropriate communication channels and places consistent with cultural and other unique characteristics. Reach* Proportion of the priority population given the opportunity to participate in the program, activity, or service Response* Proportion of the priority population actually participating in the program, activity, or service Context External factors that may influence program results (e.g., competing programs, conflicting messages, other confounders) Chapter 14 Evaluation Approaches and Designs 371 program. In addition, programs should routinely include some type of procedures outline or protocol that guides implementation. In this regard, process evaluation can assure that appropriate procedures are followed throughout implementation. Dose is a measurement of how many products, services, or other program components were delivered to the priority population (e.g., number of educational sessions presented, number of nicotine devices distributed, number of car seats on loan, number of times a pub- lic service announcement was aired, etc.). Often, process evaluation is associated with dose. In other words, the practitioner tracks and reports how many products were distributed and equates this with the quality of a program. Although dose is an important element of process evaluation, it should not be the sole focus of the evaluation. As an independent measure- ment, dose cannot fully represent process evaluation nor should it be used as a proxy mea- sure to describe the quality, value, or effectiveness of a program. As described in formative evaluation, recruitment, reach, and response are also measured in process evaluation since an evaluation of the implementation process itself would natu- rally measure fairness and adequacy of recruiting practices, how many members of the pri- ority population had the opportunity to participate in the program, and most importantly, how many people actually participated. Finally, context assesses the presence of any confounding factors, or naturally occur- ring events in the same environment that may affect program participation and results. For example, participation in a school-based alcohol/drug-free graduation celebration may be diminished by alternative activities that appeal more directly to the intended participants. Negative aspects of the physical environment or location of a program may have a negative effect on program participation or retention. A television program documenting disabling aspects of cancer aired at the same time a cancer screening program is initiated may scare potential program participants and impact their involvement. Strategies for conducting formative evaluations, and to some extent process evaluations, are displayed and briefly described in Table 14.3. Although no single strategy is inherently superior to another, the element being evaluated (see Tables 14.1 and 14.2) will largely influ- ence the selection of the appropriate strategy. For example, a key informant interview would generally be appropriate if an evaluator is measuring capacity or resources. In this scenario, the key informant would probably be an administrator with adequate information about the skill sets of his or her staff and the type of budget that would be dedicated to the program. On the other hand, assessing fidelity in a process evaluation can be accomplished with a proto- col checklist. Certain elements can be addressed by one of many strategies or a combination of strategies. For example, assessing interaction or satisfaction can be accomplished by focus groups, in-depth interviews, or surveys. Each of the strategies listed in Table 14.3 has a specific protocol to guide its use. Evaluators must ensure that these strategies are used appropriately and that data are not extrapolated or projected beyond their natural or appropriate function. (For further explanation on specific strategies, see Chapter 4 for information on focus groups, survey methods, interviews, use of forms or existing records, and observations, etc.) Two additional strategies, pretesting and pilot testing, commonly associated with forma- tive evaluation, are presented here as ways to assess the quality of distinct components of a program and to assess the overall quality of a program before full implementation occurs. Although the two terms are often used interchangeably, certain distinctions are important to make and understand. 372 Part 3 Evaluating a Health Promotion Program TAblE 14.3 Procedures Used in Formative Evaluation *Responses are recorded, transcripted, coded, and analyzed to identify themes and draw conclusions. (Note: see Chapter 4 for types of data collection.) Procedure Description Focus Groups* Qualitative research wherein a trained moderator uses an interview or moderator’s guide to ask questions about new programs, products, services, ideas, or topics to determine the attitudes, opinions, and preferences of a group of 6–12 individuals from a subgroup of the priority population (see Chapter 4). Surveys The collection of data, generally through questionnaires, from a representative sample of the priority population that allows evaluators to draw general conclusions about the entire priority population. May involve face-to-face interviews or written questionnaires, mailed questionnaires, telephone interviews, electronic questionnaires, etc. An intercept survey attempts to approach consumers in their natural environments (e.g., grocery stores, malls, community events) for a brief face-to-face interview (see Chapter 4). In-Depth Interviews* Formal interviews with program participants generally lasting a half hour or longer with the use of an interview guide and related probes. Allows evaluators to observe body language and facial expressions as prompts for additional questions and information. Informal Interviews Brief interviews with program participants that may take the form of a conversation rather than a formal interview. Key Informant Interviews Qualitative, in-depth interviews with individuals who understand the priority population and can represent their attitudes, values, and opinions to evaluators. Key informants are often people of influence within the priority population (see Chapter 4). Direct observation A process wherein evaluators immerse themselves in the program and assess the interactions between professionals and other participants, the general reactions and behaviors of the participants, and any problems or issues associated with program content and delivery. Use of this procedure sometimes involves concealing the observer from the program participants (see Chapter 4). Expert Panel Reviews A process wherein a small group of professionals, not associated with the program but who have expertise related to the program, volunteer or are contracted to collect data, analyze the program, draw conclusions about its strengths and weaknesses, and make recommendations. Quality Circles A qualitative approach wherein internal staff from the same program or work area meet regularly to discuss the strengths and weaknesses of a product, program, service, or activity and make recommendations for improvement. As an alternative to quality circles, evaluators may choose to interview program staff directly. Protocol Checklist A linear or sequential list of tasks or procedures that allows evaluators to compare how a program is being implemented compared with how it was originally intended to be implemented, or compared with what has been done elsewhere and reported in published studies or reports. Use of logic models may be used in lieu of the protocol checklist. Gantt Chart A type of bar or line chart that displays a program’s time line or project schedule. Whereas protocol checklists or logic models are not usually time phased, Gantt charts display the start and finish dates of key program elements (e.g., program objectives or key activities and tasks) (see Chapter 12). Program and Evaluation Forms Program forms collected prior to program implementation may provide relevant information to evaluators (e.g., factors that have motivated participation, identification of goals, previous participation). Data from forms compiled during the program may reveal information helpful to program improvement (e.g., strengths, barriers, risks). Evaluation forms are generally administered at the conclusion of a program to measure the awareness, knowledge, attitudes, skills and behaviors, and general levels of satisfaction as well as feedback on specific program components. Chapter 14 Evaluation Approaches and Designs 373 pretesting Pretesting can be defined in at least two ways: (1) testing components of a program (e.g., strategies and materials), services, and products with the priority population prior to implementation (Grier & Bryan, 2005); and (2) collecting baseline data prior to program implementation that will be compared with posttest data to measure the effectiveness of programs. The type of pretesting that relates to formative evaluation pertains to the first definition—testing components of a program prior to program implementation. This type of pretesting is often associated with social marketing and health communication. When applied to health communication, pretesting has been defined as an evaluation that involves systematically collecting intended-audience reactions to messages and materials before the messages and materials are produced in final form (NCI, n.d.). Pretesting, however, can be applied to any component of a program (e.g., specific sessions of an educational curriculum, a video clip to be used in a presentation, a participant manual, draft language for a legislative bill, the visual presence and structural layout of a booth that will be used in a health fair, a planned location and structure of a community exercise path, etc.). Pretesting assumes that program components have already been reviewed for evidence. That is, the component is demonstrated to be evidence-based in the literature or through some other reporting mechanism. Pretesting also assumes that practitioners have prepared program components in nearly final form. In other words, it is not appropriate for practitio- ners to take short cuts and present materials with the mindset that members of the priority population will correct any flaws. Many of the same strategies displayed in Table 14.3 are used to pretest program compo- nents. The most common strategies involve focus groups, in-depth interviews, and surveys (NCI, n.d.). Practitioners would be well advised to receive training in these strategies before attempting to conduct them. Otherwise, it is prudent to contract for services with profes- sionals who have appropriate experience and expertise. In addition, it has been proposed that if practitioners want to reliably predict the effectiveness of interventions during a devel- opmental phase such as pretesting, experimental research methods should also be applied (Whittingham, Ruiter, Zimbile, & Kok, 2008). pilot Testing Whereas pretesting focuses on specific program components, pilot testing (also referred to as field testing or alpha testing) generally presents the entire program to a limited and manage- able number of members of the priority population so necessary modifications can be made before the program is implemented to a larger segment of the priority population. Pilot testing allows for “dry runs” to assess and measure the overall quality of a program. Occasionally, pilot testing may be associated with shorter durations of time compared with actual implementation time, but this is generally not advisable. Implementing the entire program to a limited number of people in the actual time frame is helpful for evaluators to discover important issues related to timing, spacing, and duration of interventions. (See Chapter 12 for more information on this application.) Pilot testing offers evaluators a wide angle or broad view of the program to assess how the entire program impacts participants. Conducting a pilot test generally involves collecting data from participants. It is advisable to use the same data collection instruments that will be used in the actual implementation of the program to make adjustments to the instruments (e.g. a questionnaire) and program 374 Part 3 Evaluating a Health Promotion Program components simultaneously. (The specific methodologies associated with summative evalu- ation are addressed later in this chapter and in Chapter 15. Chapter 5 also provides useful information on measurement, data collection, and sampling.) Summative Evaluation If a program accounts for the elements displayed in Table 14.1 and adequately monitors and improves quality through formative evaluation, practitioners can assume that the collective efforts of stakeholders in designing and implementing a high-quality program will result in the accomplishment of program goals and objectives related to changes in behaviors and dis- ease indicators. These expected outcomes are the focus of summative evaluation, which is any combination of measurements that permit conclusions to be drawn about impact, outcome, or benefits of a program (Green & Lewis, 1986). By way of review, summative evaluation includes both impact evaluation, which focuses on intermediate indicators such as awareness, knowledge, attitudes, skills, environment, and most importantly, behaviors, as well as outcome evaluation, which focuses on long-term program measures such as mortality, morbidity, or disability. Indicators used in summative evaluation might include years of potential life lost (or saved), prevalence of tobacco use, re- ductions in diabetes mortality, a decreased incidence of HIV/AIDS, reduced absenteeism (as often measured in worksite settings), number of pounds lost, and health care costs saved due to health promotion programs. As in formative and process evaluations, the list of potential indicators in summative evaluation can be extensive. Although many types of indicators and outcomes may be related to summative evaluation, the process itself is usually associated with the development of designs. This is particularly true of impact evaluation, which requires a thoughtful design, appropriate data collection procedures, valid and reliable questionnaires or other instruments, and proper analysis and data reporting. Outcome evaluation related to communities or large populations often involves analysis of vital statistics and trend data with the evaluator try- ing to measure the effectiveness of a program or intervention over time while accounting for confounding variables, or additional influences not part of an intervention which, nonetheless, have some type of impact on results (Sullivan, 2008). Impacts due to confound- ing variables or “confounding” can be positive or negative. In other words, community-wide programs often have great difficulty identifying, with any precision, the degree to which the programs themselves had an impact when the priority population was exposed to many other influences simultaneously. As described earlier, confounding variables relate to the ele- ment of context as measured in process evaluation. An evaluation design is used to organize a summative evaluation and to provide for planned, systematic data collection, analysis, and reporting. A well-planned evaluation design helps ensure that the conclusions drawn about the program will be as accurate as pos- sible. The design is developed during the early stages of program planning and focuses on program goals and objectives. CDC’s Framework for Program Evaluation (1999a) (discussed in Chapter 13) suggests the study design should be addressed in Step 3, only after engaging stake- holders and describing the program. As designs are developed, evaluators must consider the audience and/or stakeholders who will read the results of the evaluation. In other words, the design must produce information that will answer the evaluation questions of stakeholders. Chapter 14 Evaluation Approaches and Designs 375 Selecting an Evaluation Design There are no perfect evaluation designs, because no situation related to program design and implementation is ideal, and there are always constraining factors, such as limited resources. The challenge is to devise an optimal evaluation—as opposed to an ideal evalua- tion (CDC, 1999a). Planners should give much thought to selecting the best design for each situation. The following questions may be helpful in the selection of a design for summative evaluation: ⦁⦁ How much time do you have to conduct the evaluation? ▪⦁⦁ Do stakeholders want basic results or do they want a more sophisticated analysis? ▪⦁⦁ What indicators are stakeholders most interested in tracking (e.g. costs, attitudes, knowledge, awareness, behavior change, decreases in disease, etc.)? ⦁⦁ What financial or budgetary resources are available to conduct the evaluation? ⦁⦁ How many participants can be included in the evaluation? ⦁⦁ Are you more interested in qualitative or quantitative data? ⦁⦁ Do you have data analysis skills or access to statistical consultants? ⦁⦁ Is it important to be able to generalize your findings to other populations? ⦁⦁ Are the stakeholders concerned with validity and reliability? ⦁⦁ Do you have the ability to randomize participants into experimental and control groups? ⦁⦁ Do you have access to a comparison group? Dignan (1995) presented four steps in choosing an evaluation design. These four steps are outlined in Figure 14.1. The first step is to orient oneself to the situation. The evaluator must identify resources (time, personnel), constraints, and hidden agendas (unspoken goals). During this step, the evaluator must determine what is to be expected from the program and what can be observed. The second step involves defining the problem—determining what is to be evaluated. During this step, definitions are needed for independent variables (what the sponsors think makes the difference), dependent variables (what will indicate a difference, e.g., awareness, knowledge, attitudes, skills, environmental change, behaviors, disease prevalence), and con- founding variables (what the evaluator thinks could be impacting the results in addition to or in place of the program under investigation). The third step involves making a decision about the design—that is, whether to use quali- tative or quantitative methods of data collection or both. The quantitative method is deductive in nature (applying a generally accepted principle to an individual case), so that the evaluation produces numeric (hard) data, such as counts, ratings, scores, or classifica- tions. Examples of quantitative data include the posttest scores on a nutrition knowledge test, a decrease in percent of body weight from pretest to posttest, and reduction of mortality rates related to cancer. This method is suited to programs that are well defined and compares outcomes of programs with those of other groups or the general population. It is the method most often used in evaluation designs. The qualitative method is an inductive method (individual cases are studied to for- mulate a general principle) and produces narrative data, such as words and descriptions. This is a good method to use for programs that emphasize individual outcomes or in cases where 376 Part 3 Evaluating a Health Promotion Program other descriptive information from participants is needed. That is, qualitative data provide depth of understanding, study motivation, enable discovery, are exploratory and interpre- tive, and allow insights into behavior and trends. Conversely, quantitative data measure levels of occurrence, provide proof, and measure levels of actions and trends (NCI, n.d.). Box 14.2 provides a summary of various qualitative methods. Patton (1988) produced a checklist to determine whether qualitative data might be appro- priate in a particular program evaluation. Collecting qualitative data may be a good strategy if there is a need to describe individual outcomes, to understand the dynamics and process of the programs, to obtain in-depth information on certain clients or sites, or to gather infor- mation to improve the program during process evaluation. The fourth step in selecting an evaluation design includes choosing how to measure the dependent variable, deciding how to collect the data (these components were discussed in Chapter 4) and how the data will be analyzed, and determining how the results will be reported. (These components are discussed in Chapter 15.) Experimental, Control, and Comparison Groups As in research studies, when evaluating a health promotion program, the group of indi- viduals who receive the intervention is known as the experimental group (or treatment group). The evaluation is designed to determine what effects the program has on these participants. To ensure the effects are caused by the program and not due to some other Resources, constraints, and hidden agendas Orientation to the situation Step 1 Dependent variables Independent variables Confounding variables Combination of qualitative and quantitative Quantitative Qualitative Measurement Data collection Data analysis Reporting of results Step 4 Plans for: Defining the problem Step 2 Step 3 Basic design decision ⦁▲ Figure 14.1 Steps in Selecting an Evaluation Design Source: Measurement and Evaluation of Health Education. M. B. Dignan. Copyright © 1995 by Charles C. Thomas Publisher, Ltd. Reprinted with Permission. Chapter 14 Evaluation Approaches and Designs 377 factor, a control group should be used. The control group should be as similar to the experimental group as possible, but the members of this group do not receive the program (intervention or treatment) that is to be evaluated. Without the use of a properly selected control group, the apparent effect of the program could actually be due to a variety of confounding variables. Ideally, participants should be randomly selected, then randomly assigned to one of two groups, and finally it should be randomly determined which group becomes the experimental group and which becomes the control group. Theoretically, randomization evenly distributes the characteristics of the participants and increases the credibility of the evaluation by controlling for confounding variables. It is not always possible, practical or ethical to assign participants to a control group, especially in population-based programs, or if doing so would mean that individuals would be denied a necessary, or even critical program or service. For example, a health promotion 14.2 Box Qualitative Methods Used in Evaluation ⦁⦁ Case studies: In-depth examinations of a social unit, such as an individual, family, household, work site, community, or any type of institution as a whole. ⦁⦁ Content analysis: A systematic review identifying specific characteristics of messages. ⦁⦁ Delphi techniques: A process that generates consensus through a series of questionnaires. (See Chapter 4 for an in-depth discussion of the Delphi technique.) ⦁⦁ Ethnographic studies: A variety of techniques (participant-observer, observation, interviewing, and other interactions with people) used to study an individual or group. ⦁⦁ Films, photographs, and videotape recording (film ethnography): Includes the data collection and study of visual images. ⦁⦁ Focus group interviewing: Interviews used to obtain information about the feelings, opinions, perceptions, insights, beliefs, misconceptions, attitudes, and receptivity of a group of people concerning an idea or issue. (See Chapter 4 for an in-depth discussion of focus group interviewing.) See also Table 14.3. ⦁⦁ Historical analysis: A review of historical accounts that may include an interpretation of the impact on current events. ⦁⦁ In-depth interviewing: Formal interviews with program participants. Allows evaluators to observe body language and facial expressions as prompts for additional questions and information. See also Table 14.3. ⦁⦁ Nominal group process: A highly structured process in which a few knowledgeable representatives of the priority population are asked to qualify and quantify specific needs. (See Chapter 4 for an in-depth discussion of the nominal group process). ⦁⦁ Participant-observer studies: Those in which the observers (evaluators) also participate in what they are observing. ⦁⦁ Quality circle: A group of internal program people who meet at regular intervals to discuss problems and to identify possible solutions. See also Table 14.3. ⦁⦁ Unobtrusive techniques: Data collection techniques that do not require the direct participation or cooperation of human subjects and include such things as unobtrusive observation, review of archival data, and study of physical traces. Source: Health Education Evaluation and Measurement: A Practitioner’s Perspective. Robert McDermott and Paul Sarvela. Copyright © 1999 by McGraw-Hill. Fo cu s O n 378 Part 3 Evaluating a Health Promotion Program program could be designed for individuals with hypertension. Individuals diagnosed with hypertension could be referred by a physician into a health promotion class focused on re- ducing the risk factors associated with this disease. Denying some individuals access to the program in order to form a control group would clearly be unethical. One way to deal with this problem is to provide the control group with an alternative program or to offer the regular program to the group at a later time (if a delay is not poten- tially harmful). Another alternative is to compare two programs (e.g., offer an innovative program to some participants and continue the conventional program for others). Because the main purpose of social programs is to help individuals, the individuals’ viewpoints should be the primary concern. It is important to keep this in mind when considering ethi- cal issues in the use of control groups. When participants cannot be randomly assigned to an experimental or control group, a nonequivalent group may be selected. This is known as a comparison group. It is important to find a group that is as similar as possible to the ex- perimental group, such as two classrooms of students with similar characteristics or a group of residents in two comparable cities. Factors to consider include participants’ age, gender, education, location, socioeconomic status, and experience, as well as any other variable that might impact program results. Evaluation Designs Measurements used in evaluation designs can be collected at three different times: after the program; both before and after the program; and several times before, during, and after the program. Measurement is defined as the quantitative data or numbers that come from applying an instrument (e.g., a questionnaire) to attributes about a person or people (Windsor, 2015). Figure 14.2 presents evaluation designs commonly used in health promotion. In the figure, the letter O refers to measurement or observations involving data derived from ques- tionnaires, tests, interviews, observations, or other methods of gaining information. When multiple measurements are taken, the subscript number beside each O indicates the order in which the measurements are made. Measurement before the program begins is known as the pretest, and measurement after the completion of the program is known as the posttest. The letter X represents the program (intervention, or independent variable); the relative positions of the two letters in the table indicate when measurements are made in relation to when the program is provided. The figure also shows which groups receive the program and when participants are randomly assigned to groups [(R)]. Windsor (2015) differentiates between experimental and quasi-experimental designs. Experimental design offers the greatest control over confounding variables that may influence the results of an intervention and its evaluation. It involves random assign- ment to experimental and control groups with pretest and posttest measurement of both groups. This evaluation design produces the most reliable evidence of effectiveness. Quasi-experimental design results in interpretable and supportive evidence of program effectiveness, but usually cannot control for all factors that affect the validity of the results. There is no random assignment to the groups, and comparisons are made between ex- perimental and comparison groups. A nonexperimental design (referred to by Windsor, 2015, as a pre-experimental design) also uses pretest and posttest measurements among one Chapter 14 Evaluation Approaches and Designs 379 group of participants without a control or comparison group. This approach has little control over confounding variables and bias that affect the validity and interpretation of results. The most powerful design is the experimental design, in which participants are randomly assigned to the experimental and control groups. The difference between designs I.1 and I.2 in Figure 14.2 is the use of a pretest to measure the participants before the program begins. Use of a pretest would help ensure that the groups are similar and provide baseline measure- ment. Random assignment should equally distribute any of the variables of the participants (such as age, gender, and race) between the different groups. Potential disadvantages of the experimental design are that it requires a relatively large group of participants and the inter- vention may be delayed for those in the control group. A design more commonly found in evaluations of health promotion programs is the quasi-experimental pretest-posttest design using a comparison group (II.1 in Figure 14.2). This design is often used when a control group cannot be formed by random assignment. In such a case, a comparison group (a nonequivalent control group) is identified, and both groups are measured before and after the program. For example, a program on healthy eat- ing for two ninth-grade classrooms could be evaluated by using a food inventory instrument at pretest and posttest. Two other ninth-grade classrooms not receiving the program could I. Experimental design 1. Pretest-posttest design — Experimental group (R) O 1 X O2 — Control group (R) O 1 O2 2. Posttest-only design — Experimental group (R) X O O)R(puorg lortnoC — 3. Time series design — Experimental group (R) O 1 O2 O3 X O4 O5 O6 — Control group (R) O 1 O2 O3 O4 O5 O6 II. Quasi-experimental design 1. Pretest-posttest design — Experimental group O 1 X O2 — Comparison group O1 O2 2. Time series design — Experimental group O 1 O2 O3 X O4 O5 O6 — Comparison group O1 O2 O3 O4 O5 O6 III. Nonexperimental design 1. Pretest-posttest design — Experimental group O 1 X O2 2. Time series design — Experimental group O 1 O2 O3 X O4 O5 O6 Key: (R) = Random assignment O = Measurement/Observation X = Program/Intervention ⦁▲ Figure 14.2 Evaluation Designs 380 Part 3 Evaluating a Health Promotion Program serve as the comparison group. Similar pretest scores between the comparison and experi- mental groups would indicate that the groups were equal at the beginning of the program and comparisons of posttest scores could indicate the differences between the groups at the conclusion of the program. However, without random assignment, it would be impossible to be sure that other variables (e.g., a unit on meal preparation in a family and consumer science course, a reality television show related to weight loss, changes made by the primary meal preparer at home, etc.) did not influence the results. Sometimes participants cannot be assigned to a control group and no comparison group can be identified. In such cases, a nonexperimental pretest-posttest design (III.1 in Figure 14.2) can be used, but the results are of limited significance, because changes could be due to the program or to some other event. An example of this type of design would be the measurement of safety belt use after a community program on that topic. An increase in use might mean that the program successfully motivated individuals to use safety belts; however, it could also reveal the impact of increased enforcement of a mandatory safety belt law, a traffic fatality in the community, or a social media campaign related to safety. A time series evaluation design (I.3, II.2, III.2 in Figure 14.2) can be used to examine dif- ferences in program effects over time. Random assignment to groups (I.3) offers the most control over factors influencing the validity of the results. The use of a comparison group (II.2) offers some control; without a control group or comparison group (III.2), it is possible to determine changes in the participants over time, but one cannot be sure that the changes were due only to the program. In the time series design, several measurements are taken over time both before and after a program is implemented. This process helps to identify other factors that may account for a change between the pretest and posttest measurements and is especially appropriate for measuring delayed effects of a program. A time series design could be used in a weight loss program to indicate the amount of participants’ weight loss over time and their ability to maintain a desired weight. This is especially important since most change will generally be more prominent at the immediate conclusion of a program. But stakeholders may want to investigate results over time (e.g. three months and six months) to ensure change is lasting. Another design that may be used is the staggered treatment design (see Figure 14.3), which is used to determine the effects of a program over time by including several measure- ments after the end of the program. It also indicates the effects of testing, since not all groups in this design receive a pretest. The staggered treatment design can also be used in quasi- experimental and nonexperimental designs, although with the limitations of not using a control group or comparison group. Experimental group 1 (R) X O1 O2 O3 O4 Experimental group 2 (R) O1 X O2 O3 O4 O)R(3 puorg latnemirepxE 1 X O2 O3 OX)R(4 puorg latnemirepxE 1 Key: (R) = Random assignment O = Measurement/Observation X = Program/Intervention ⦁▲ Figure 14.3 Staggered Treatment Design Chapter 14 Evaluation Approaches and Designs 381 Internal Validity The internal validity of evaluation is the degree to which change that was measured can be attributed to the program and allows evaluators to speak with more confidence that the program itself actually made a difference (Issel, 2014). Many factors can threaten internal validity, either singly or in combination, making it difficult to determine if the outcome was brought about by the program or some other cause(s). Cook and Campbell (1979) identified common threats to internal validity which have come to be known as the Campbellian valid- ity typology (Chen, 2015). Campbell’s typology is still supported today (Chen, 2015; Fink, 2015; Sharma & Petosa, 2014) and is summarized as follows: ⦁⦁ History occurs when unanticipated events happen between the pretest and posttest that are not part of the health promotion program being evaluated. An example of history as a threat to internal validity is having a national antismoking campaign coincide with a local smoking cessation program. ⦁⦁ Maturation occurs when the participants in the program show pretest-to-posttest differences due to growing older, wiser, or stronger as a function of time. For example, in tests of muscle strength in an exercise program for junior high students, an increase in strength could be the result of muscular development and not the effect of the program. ⦁⦁ Testing occurs when the participants become familiar with the test format due to repeated testing. For example, participants in a job training program may perform better in job interviews as a result of past interviews compared with the effect of the program itself (Chen, 2015). Pretest measurements may also change the perceptions or knowledge of participants thus making their responses on posttests less accurate (Sharma & Petosa, 2014). ⦁⦁ Instrumentation occurs when there is a change in measurement between pretest and posttest, such as the observers becoming more familiar with or skilled in the use of the testing format over time. Instrumentation bias can also occur when evaluators themselves change or when there is inconsistency between evaluators (e.g., evaluators making direct observations of people practicing relaxation techniques and measuring outcomes differently). ⦁⦁ Statistical regression is when extremely high or low scores (which are not necessarily accurate) on the pretest naturally move closer to the mean or average on the posttest. This might be relevant if an evaluator is trying to assess a certain risk factor and those surveyed in the pretest include a disproportionately large number of high risk individuals (i.e. people who score high on the risk factor). Results from the posttest may reflect statistical regression compared with the effect of the program itself. ⦁⦁ Selection reflects differences in the experimental and comparison groups, generally due to lack of randomization. For example, people who are very motivated to change in a particular way may self-select to the experimental group whereas people who have more neutral feelings may self-select to the comparison group. Selection can also interact with other threats to validity, such as history, maturation, or instrumentation, which may appear to be program effects. ⦁⦁ Attrition (originally referred to as mortality by Cook and Campbell, 1979) refers to participants who drop out of the program between the pretest and posttest. For example, if most of the participants who drop out of a weight loss program are those with the least (or the most) weight to lose, the group composition is different at the posttest. Attrition occurs for various reasons (e.g. sickness, loss of interest, relocation to a different city or state, etc.). 382 Part 3 Evaluating a Health Promotion Program ⦁⦁ Interaction (originally referred to as diffusion or imitation of treatments by Cook and Campbell, 1979) results when participants in the control or comparison group interact and learn from the experimental group. Students randomly assigned to an innovative drug prevention program in their school (experimental group) may discuss the program with students who are not in the program (control or comparison group), biasing the results. ⦁⦁ Compensatory equalization of treatments occurs when the program or services are not available to the control or comparison group and there is an unwillingness to tolerate the inequality. For instance, the control or comparison group from the previous example (students not enrolled in the innovative drug prevention program) may complain, since they are not able to participate. ⦁⦁ Compensatory rivalry is when the control or comparison group is seen as the underdog and is motivated to work harder. ⦁⦁ Resentful demoralization of respondents receiving less desirable treatments occurs among participants receiving the less desirable treatments compared to other groups, and the resentment may affect the outcome. For example, an evaluation to compare two different smoking cessation programs may assign one group (control) to the regular smoking cessation program and another group (experimental) to the regular program plus an exercise class. If the participants in the control group become aware that they are not receiving the additional exercise class, they may resent the omission, and this may be reflected in their smoking behavior and attitude toward the regular program. The most significant way in which threats to internal validity can be controlled is through randomization. By random selection of participants, random assignment to groups, and ran- dom assignment of types of intervention or no intervention to groups, any differences between pretest and posttest can be interpreted as a result of the program. When random assignment to groups is not possible and quasi-experimental or nonexperimental designs are used, the evalu- ator must make all threats to internal validity explicit and then rule them out one by one. External Validity The other type of validity that should be considered is external validity, or the extent to which the program can be expected to produce similar effects in other populations. This is also known as generalizability which is most closely associated with program evaluations that involve large sample sizes and are found to be internally valid (Harris, 2010). However, the more a program is tailored to a particular population, the greater the threat to external validity, and the less likely it is that the program can be generalized to another group. As with internal validity, several factors can threaten external validity. They are some- times known as reactive effects, since they cause individuals to react in a certain way. The fol- lowing are several types of threats to external validity: ⦁⦁ Social desirability occurs when individuals give a particular response to try to impress or satisfy the wants of the evaluator (Sharma & Petosa, 2014). An example would be children who tell their teacher they brush their teeth every day, regardless of their actual behavior. ⦁⦁ Expectancy effect or Pygmalion effect (Sharma & Petosa, 2014) is when attitudes projected onto individuals cause them to act in a certain way. For example, in a drug abuse treatment program, the facilitator may feel that a certain individual will not benefit from the treatment; projecting this attitude may cause the individual to behave in self- defeating manners. Chapter 14 Evaluation Approaches and Designs 383 ⦁⦁ Hawthorne effect refers to a behavior change because of the special status of those being tested (Sharma & Petosa, 2014) or when behavior changes as participants become more aware they are being studied (Fink, 2015). ⦁⦁ Placebo effect causes a change in behavior due to the participants’ belief in the treatment. Cook and Campbell (1979) discussed the threats to external validity in terms of statistical interaction effects. These include interaction of selection and treatment (the findings from a program requiring a large time commitment may not be generalizable to individuals who do not have much free time); interaction of setting and treatment (evaluation results from a program conducted on campus may not be generalizable to the worksite); and interaction of history and treatment (results from a program conducted on a historically significant day may not be generalizable to other days). Conducting the program several times in a variety of settings, with a variety of par- ticipants can reduce the threats to external validity. Threats to external validity can also be counteracted by making a greater effort to treat all subjects identically. In a blind study, the participants do not know whether they have been assigned to the experimental group or the control group. In a double blind study, the type of group participants are in is not known by either the participants or the planners. In a triple blind study, this information is not available to the participants, planners, or evaluators. It is important to select an evaluation design that provides both internal and external va- lidity. This may be difficult, because lowering the threat to one type of validity may increase the threat to the other. For example, tighter evaluation controls make it more difficult to generalize the results to other situations. There must be enough control over the evaluation to allow evaluators to interpret the findings while sufficient flexibility in the program is maintained to permit the results to be generalized to similar settings. Summary This chapter focused on evaluation approaches, design elements, and strategies for conduct- ing a comprehensive evaluation. Distinctions between formative and process evaluation were made and key issues related to summative evaluation were outlined. The steps for selecting an evaluation design were also presented with a discussion about quantitative and qualitative methods. Evaluation design should be considered early in the planning process. Evaluators need to identify what measurements will be taken as well as when and how. In doing so, a design should be selected that controls for both internal and external validity. Review Questions 1. List the elements of a comprehensive formative evaluation and describe when in the design and implementation process they are most appropriately applied. 2. What are the fundamental differences between formative and process evaluations? 384 Part 3 Evaluating a Health Promotion Program 3. What is the difference between cost-benefit analysis and cost-effectiveness analysis? Which is more appropriate for use in health promotion programs? 4. What is the difference between quantitative and qualitative evaluations? When would one method be more appropriate than the other? How could they be combined in an evaluation design? 5. Name at least five different qualitative methods of evaluation and describe each. 6. What are the advantages of using a control group? What types of evaluation design do not use control groups? What is the difference between a control group and a comparison group? 7. What is the difference between experimental, quasi-experimental, and nonexperimental designs? 8. What is the difference between internal validity and external validity? 9. What are some considerations in the selection of an evaluation design presented in this chapter? What considerations can you add to this list? Activities 1. Interview the manager of a health promotion program of your choice about how he or she measures quality. How many elements of formative evaluation can you detect? 2. Look at an evaluation of a health promotion program that has been conducted in your community. Identify the evaluation approach that it most closely follows. Discuss your view with the program evaluator. 3. Develop an evaluation design for a program you are planning. Explain why you chose this design, and list the strengths and weaknesses of the design. 4. If you were hired to evaluate a weight loss program in a community, what evaluation design would you use and why? Assume you have all the resources you need to conduct the evaluation. 5. Explain what evaluation design you would use in evaluating the difference between two social media approaches. Why would you choose this design? Weblinks 1. https://www.wmich.edu/evaluation/checklists Evaluation Center at Western Michigan University (WMU) The Evaluation Center at WMU Website provides evaluation specialists and users with refereed checklists to improve the quality and consistency of evaluations. The site’s purpose is to improve evaluation capacity through the promotion and use of high- quality checklists targeted to specific evaluation tasks and approaches. Visitors to this site can download a number of checklists and information on how to create them. https://www.wmich.edu/evaluation/checklists Chapter 14 Evaluation Approaches and Designs 385 2. http://oerl.sri.com/ Online Evaluation Resource Library (OERL) Funded by the National Science Foundation (NSF), OERL was developed for professionals seeking to design, conduct, document, or review project evaluations. OERL’s resources include instruments, plans, and reports from evaluations that have proven to be sound and representative of current evaluation practices. 3. http://www.eric.ed.gov/ Educational Resources Information Center (ERIC) The ERIC Clearinghouse on Assessment and Evaluation Website offers a variety of resources and seeks to provide balanced information concerning educational assessment, and resources to encourage responsible test use. 4. http://www.socialresearchmethods.net/kb/destypes.php Web Center for Social Research Methods This site addresses the basic types of evaluation designs and reinforces the material covered in this chapter including information on experimental, quasi-experimental, and nonexperimental designs as well as random selection and threats to validity. 5. http://whqlibdoc.who.int/hq/2000/WHo_MSD_MSB_00.2e World Health Organization This is a link to WHO’s document on process evaluation that supplements material in this chapter. It describes why a process evaluation should be performed and how to do a process evaluation. 6. http://www.rand.org/pubs/technical_reports/TR101/ Rand Organization—Getting to Outcomes This document, which focuses on substance abuse, provides an excellent explanation of promoting accountability through methods and tools for planning, implementation, and evaluation. One focus of the document is how to get to outcomes that justify prevention programs in general. http://oerl.sri.com/ http://www.eric.ed.gov/ http://www.socialresearchmethods.net/kb/destypes.php http://whqlibdoc.who.int/hq/2000/WHo_MSD_MSB_00.2e http://www.rand.org/pubs/technical_reports/TR101/ This page intentionally left blank 387 Like other aspects of evaluation, the type of data analysis used in an evaluation should be determined in the pre-planning stage. Basically, the analysis will help determine what, if any, impact was made by the program. The evaluator then draws conclusions and prepares reports and/or presentations. The types of analyses used and how the information is pre- sented are determined by the evaluation questions as well as the needs of the stakeholders. This chapter describes different types of analyses commonly used in evaluating health promotion programs. To present them in detail or to include all possible techniques is 15 Chapter Data Analysis and Reporting Chapter Objectives After reading this chapter and answering the questions at the end, you should be able to: ⦁⦁ Define data management. ⦁⦁ List examples of univariate, bivariate, and multivariate analyses and explain how they can be used in evaluation. ⦁⦁ Differentiate between descriptive and inferential statistics. ⦁⦁ Differentiate between parametric and non- parametric data. ⦁⦁ Explain the difference between the null hypothesis and the alternative hypothesis in significance testing. ⦁⦁ Define level of significance, Type I error, and Type II error. ⦁⦁ Define independent variable and dependent variable. ⦁⦁ Describe guidelines for presenting data, and ways to enhance an evaluation report. ⦁⦁ Discuss ways to increase the use of evaluation findings. Key Terms alpha level alternative hypothesis analysis of variance (ANOVA) bivariate data analysis chi-square correlations data management dependent variables descriptive statistics independent variables inferential statistics level of significance mean measures of central tendency measures of spread or variation median mode multiple regression multivariate data analysis non-parametric tests null hypothesis parametric tests program significance range statistical significance t-tests Type I error Type II error univariate data analysis variable 388 Part 3 Evaluating a Health Promotion Program beyond the scope of this text. If you need more information, refer to statistics textbooks, research methods and statistics courses, or statistical consultants. Box 15.1 identifies the re- sponsibilities and competencies for health education specialists that pertain to the material presented in this chapter. Evaluations affected by methodological problems are not likely to inspire confidence. A common problem in this regard is inadequate documentation of methods, results, and data analysis. The evaluation should be well designed and implemented and the data report itself should contain a complete background and description of the program, a thorough explana- tion of methodology including information about the instrumentation, the program par- ticipants and their selection, evaluation design and statistical analysis, as well as an objective interpretation of facts, and a discussion of features of the study that may have influenced the findings. Attention to these details will help ensure a more accurate assessment of program effectiveness as well as enhance the credibility of planners/evaluators among stakeholders. In addition, this level of professionalism will also increase the likelihood that evaluation reports can be translated to peer reviewed publications and contribute to the research and knowledge base of health promotion in general. Data Management Once data have been collected (see Chapter 4 for data collection methods), they must be or- ganized in such a manner that they can be analyzed in order to interpret related findings. To do this, the data, whether quantitative or qualitative, must be coded, cleaned, and organized into a usable format. These steps are collectively referred to as data management. By coded, we mean that the data are assigned labels so they can be read and processed by a computer. Evaluators often create codebooks that include descriptions of all the questions, codes, and vari- ables associated with a survey or any other method used to collect data (Fink, 2015). For example, if the answer to a question on an instrument is yes, yes answers may be coded as the number 1 when entered into the computer, whereas no answers may be coded as a number 2. In addition to creating the coding scheme for raw data, a coding system also establishes rules for dealing with coding problems such as when respondents circle both yes and no for their answer to a question, or when neither yes nor no is circled but rather the space between the yes and no is circled. 15.1 Responsibilities and Competencies for Health Education Specialists This chapter describes managing data collected in evaluations or other research; types of data analyses; applications of data analyses; interpreting data; reporting the results of evaluation, including designing written reports and how and when to present evaluation reports; and increasing the use of evaluation results. Responsibilities and competencies related to the content in this chapter include: RESponSiBility iV: Conduct Evaluation and Research Related to Health Education/Promotion Competency 4.5: Analyze data Competency 4.6: Interpret results Competency 4.7: Apply findings Source: A Competency-Based Framework for Health Education Specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Box Chapter 15 Data Analysis and Reporting 389 Once the data have been coded, they must be cleaned before being entered into a computer system. Data cleaning entails checking for errors associated with data entry and may involve searching for missing values or discarding certain data that are indecipherable or incomplete (Sharma & Petosa, 2014; Fink, 2015). For example, if the possible range of answers for a particular question is 1 to 3 and the frequency distribution identifies some 4s, those response forms with the 4s must be identified and checked to determine if the person completing the instrument made an error or if there was an error made by the person coding the data. If it was a data coding error, it should be corrected. If the person completing the data collection instrument made an error, it would be treated as no response to that question or as missing data (Cottrell & McKenzie, 2011). Once data have been cleaned, the appropriate data analysis can begin. Data Analysis Once data have been cleaned, the goal of data analysis is to apply the correct statistical tests or procedures to the data to answer evaluation or research questions or to test hypotheses. Regardless of the type of data analysis to be used, the process begins with the identification of the variables of interest. A variable is a characteristic or attribute that can be measured or observed (Creswell, 2002). In program evaluation, variables are generally classified as independent or dependent variables. Independent variables are those that are either controlled by the evaluator or cause or exert some influence, whereas the dependent variables are the outcome variables being studied. In other words “independent variables influence dependent variables” (Valente, 2002, p. 165). Examples of independent variables include exposure to an intervention, gender, race, age, education, income, and so on, while dependent variables may include awareness, knowledge, attitudes, skills, and behaviors. Statistics are used to analyze variables. Descriptive statistics are used to organize, sum- marize, and describe characteristics of a group. Descriptive statistics are generally displayed as frequency distributions (e.g. tables and graphs) or presented as measures of central ten- dency (e.g. a mean score or mathematical average) (Sharma & Petosa, 2015) and answer basic questions related to: who; what; where; when; and how much. Inferential statistics test relationships between variables and attempt to explain causality in order to make generaliza- tions (or inferences) about a larger population based upon findings from a sample. When one variable is analyzed, it is called univariate data analysis. Analysis of two variables is called bivariate data analysis and analysis of more than two variables is referred to as multivariate data analysis. Box 15.2 contains examples of the types of evaluation ques- tions that can be answered by using different types of data analyses. The type of analysis selected is based on the evaluation questions, the type of data col- lected, and the audience that will receive the results (Newcomer & Wirtz, 2004). For some types of analysis in evaluation, descriptive data are all that stakeholders want and need, and techniques might be selected to create simple frequencies only. Other evaluation questions are designed to test a hypothesis about relationships between variables; in such cases, more elaborate statistical techniques are needed. The level of measurement (i.e., nominal, ordinal, interval, or ratio) (discussed in Chapter 5) is also an important factor in selecting the type of analysis to be used. For example, after you have identified the level of measurement related to the data you have collected, you apply either parametric or non-parametric tests. Parametric tests assume a normal distribution curve 390 Part 3 Evaluating a Health Promotion Program while non-parametric tests assume the distribution curve is skewed (i.e. not normal as in negatively or positively skewed). A more basic distinction between parametric and non-parametric tests is that if your measurement scale is nominal or ordinal then you use non-parametric statistics. If you are using interval or ratio scales, then use parametric statistics. Parametric data are considered to be more powerful since they use more information in their calculations (though there is at least one non-parametric test that is equivalent to each parametric test). Examples of in- ferential statistical tests associated with parametric data include: t-tests; analysis of variance (ANOVA); and Pearson’s correlation. Examples of inferential statistical tests associated with nonparametric data include: chi-square; Mann-Whitney U test; Wilcoxon Signed-Ranks test; and Spearman’s Rank-Order Correlation. The issue of who will receive the final evaluation report should also be considered when selecting the type of analysis. Evaluators want to be able to present the evaluation results in a form that can be understood by stakeholders. With regard to this issue, it is probably best to err on the side of too simple an analysis rather than one that is too complex. Finally, regard- less of the type of analysis selected for an evaluation, the method should be identified early in the evaluation process and put in place before the data are collected. Univariate Data Analyses Univariate data analyses examine one variable at a time. It is common for univariate analyses to be descriptive in nature. As noted earlier, descriptive statistics are used to describe, clas- sify, and summarize data. Summary counts (frequencies) are totals, and they are the easiest type of data to collect and report. Summary counts can be used in process evaluation—for 15.2 Box Examples of Evaluation Questions Answered Using Univariate, Bivariate, and Multivariate Data Analysis Univariate Analysis ⦁⦁ What was the average score on the cholesterol knowledge test? ⦁⦁ How many participants at the worksite attended the healthy lifestyle presentation? ⦁⦁ What percentage of the participants in the corporate fitness program met their target goal? Bivariate Analysis ⦁⦁ Is there a difference in smoking behavior between the individuals in the experimental and control groups after the healthy lifestyle program? ⦁⦁ Is peer education or classroom instruction more effective in increasing knowledge about the effects of drug abuse? ⦁⦁ Do students’ attitudes about bicycle helmets differ in rural and urban settings? Multivariate Analysis ⦁⦁ Can the risk of heart disease be predicted using smoking, exercise, diet, and heredity? ⦁⦁ Can mortality risk among motorcycle riders be predicted from helmet use, time of day, weather conditions, and speed? ⦁⦁ Which of the following most accurately predict successful management of stress among program participants: physical activity, diet, meditation, anger management, yoga, or deep breathing? A pp lic at io n Chapter 15 Data Analysis and Reporting 391 example, to count the number of participants in blood pressure screening programs at vari- ous sites. The information would assist the planners in publicizing sites with low attendance or adding additional personnel to busy sites. Other examples of frequencies, or summary counts, are the number of participants in a workshop, those who scored above 80% on a knowledge posttest, or the number of individuals wearing a safety belt. Measures of central tendency are other forms of univariate data analyses. The mean is the arithmetic average of all the scores. The median is the midpoint of all the scores, dividing scores ranked by size into equal halves. The mode is the score that occurs most frequently. These are all useful in describing the results, and reporting all three measures of central tendency will be especially helpful if extreme scores are found. Measures of spread or variation refer to how spread out the scores are in the data set. Range is the difference between the highest and lowest scores. For example, if the high score is 100 and the low score is 60, the range is 40. Measures of spread or variation—such as range, standard deviation, or variance—can be used to determine whether scores from groups are similar or spread apart. Bivariate Data Analyses Bivariate data analyses are used to study two variables simultaneously and determine how they relate to one another. When using bivariate analyses, it is common to state evaluation questions in the form of hypotheses. The null hypothesis holds that there is no observed difference between groups. The alternative hypothesis states there is a difference be- tween groups. For example, a null hypothesis might state there is no difference between two groups, for example men and women, in knowledge about cancer risk factors, while the alter- native hypothesis states there is a difference in their knowledge. Statistical tests are used to determine if the relationships or differences between groups are statistically significant. Statistical significance “is a statement regarding the likelihood that observed variable values happened by chance” (Sharma & Petosa, 2014, p. 281). In other words, statistical tests are used to determine whether the null hypothesis is rejected (mean- ing a relationship between the groups probably does exist) or whether it fails to be rejected (indicating that any apparent relationship between groups is due to chance). There is the possibility that the null hypothesis can be rejected when it is, in fact, true; this is known as Type I error. There is also the possibility of failing to reject the null hypothesis when it is, in fact, not true; this is a Type II error. The probability of making a Type I error is reflected in the alpha level. The alpha level, or level of significance, is established before the statistical tests are run and is generally set at 0.05 or 0.01. This indicates that the decision to reject the null hypothesis is incorrect 5% (or 1%) of the time; that is, there is a 5% prob- ability (or 1% probability) that the outcome occurred by chance alone. When a smaller alpha level is used (0.01 or 0.001), the possibility of making a Type I error is reduced; at the same time, however, the possibility of a Type II error increases. An example of a Type I error is the adoption of a new program due to higher scores on a knowledge test, when, in reality, increases in knowledge occurred by chance and the new program is not more effective than the existing program. An example of a Type II error is not adopting the new program when it is, in reality, more effective. Bivariate analyses that are commonly used in program evaluation include chi-square, t-tests, analysis of variance, and correlations. Chi-square is a statistical test “that measures the association between two nominal and/or ordinal variables” (Valente, 2002, p. 170). 392 Part 3 Evaluating a Health Promotion Program An example of this type of analysis would be measuring the association of grade levels (e.g., third and fifth grades) with the attitudes of children toward the use of bicycle helmets (i.e., strongly agree, agree, disagree, and strongly disagree). While chi-square is used to study nominal and/or ordinal variables (as with non-parametric tests described earlier), t-tests and analysis of variance (ANOVA) are statistical tests used to study group differences when the dependent variables involve interval or ratio data (e.g., as with parametric tests described earlier). There are several situations in which a t-test could be used. The most common use of a t-test is to determine whether a variable changed significantly in one group at two different points in time, such as between baseline before the intervention (pretest) and at follow-up after the intervention (posttest). This type of t-test is called a depen- dent t-test. A second common use of a t-test is to study the differences between two groups at a single point in time. An example of such a situation is the comparison of scores on nutrition practices after two groups have been exposed to different nutrition education interventions. This type of t-test is called an independent t-test. ANOVA is a statistical test that can be used to study differences between two groups just like a t-test, but is more commonly used to study differences between more than two groups. For example, an ANOVA could be used to determine if there was a difference in the test scores of three groups (i.e., different age groups like 15–24, 25–45, and 46–65 year olds) on a physi- cal activity assessment following exposure to a single health promotion intervention. While the bivariate analyses discussed so far are used to determine if differences exist be- tween groups, correlations are used to study the extent to which two variables are related to each other such that the changes in one variable are accompanied by changes in another variable (Furlong, Lovelace, & Lovelace, 2000). Correlations are expressed as values between +1 (a positive correlation) and -1 (a negative correlation), with a 0 indicating no relationship between the variables. Larger absolute values that are either positive or negative indicate stronger relationships (Furlong et al., 2000). Correlation between variables indicates only a relationship; this technique does not establish cause and effect. An example of the use of correlation would be to determine the relationship between safety belt use and age of the driver. If older people were found to wear their safety belts more often than younger people, that would constitute a positive correla- tion between age and safety belt use. If younger people wore their safety belts more often, it would be a negative correlation. If age made no difference in what population wore safety belts more frequently, the correlation would be 0. Multivariate Data Analyses Multivariate data analyses are used to study three or more variables simultaneously. Examples of multivariate analyses include multiple regression, discriminant analysis, and factor analysis. Of these, the one that tends to be used most commonly in health promotion evaluation is multiple regression. Though the procedures and applications for various types of regression differ (e.g. stepwise regression, logistic regression, and general linear regression), they are “useful in exploring relationships among variables or in exploring the independent effects of many variables on one dependent variable” (Fitzpatrick et al., 2004, p. 359). An example of the latter would be trying to predict the risk of heart disease (the de- pendent variable) using the independent variables of smoking, cholesterol, lack of exercise, high stress, etc. Chapter 15 Data Analysis and Reporting 393 Applications of Data Analyses Many evaluation concepts have been presented. Therefore, a few examples here will help you see how to move from a program goal to an intervention to an evaluation design to data analysis. To illustrate these concepts, a few statistics have been selected that are commonly used with health promotion programs: chi-square and t-tests. Case #1 Program goal: Reduce the prevalence of smoking in the priority population Priority population: The 140 employees of Company X who smoke Intervention (independent variable): Two different smoking cessation programs Variable of interest (dependent variable): Smoking cessation after six months Evaluation design: R A X1 O1 R B X2 O1 where: R = random assignment A = group A B = group B X1 = method 1 X2 = method 2 O1 = self-reported smoking behavior Data collected: Nominal data; quit yes or no Smoking Employees Group A Method 1 Group B Method 2 Quit 24% 33% Did not quit 76% 67% Data analysis: A chi-square test of statistical significance can be used to test the null- hypothesis that there is no difference in the success of the two groups. Case #2 Program goal: Increase knowledge of HIV/AIDS within the priority population Priority population: The 3,200 incoming freshmen at University X Intervention (independent variable): A two-hour lecture-discussion program presented during the freshmen orientation program Variable of interest (dependent variable): Knowledge of HIV/AIDS Evaluation design: O1 X O2 where: O1 = pretest scores X = two-hour program at freshman orientation O2 = posttest scores 394 Part 3 Evaluating a Health Promotion Program Data collection: Ratio data; scores on 100-point-scale test Test Results Pretest Posttest Number of students 3,200 3,200 Mean score 69.0 78.5 Data analysis: A dependent t-test of statistical significance can be used to test the null hypothesis that there is no difference between the pre- and posttest means on the knowledge test. Case #3 Program goal: To improve the testicular self-examination skills of the priority population Priority population: All boys enrolled in the eighth grade at Junior High School X Intervention (independent variable): Two-week unit on testicular cancer Variable of interest (dependent variable): Score on testicular self-exam skills test Evaluation design: A O1 X O2 B O1 O2 where: A = eighth-grade boys at Junior High School X B = eighth-grade boys at Junior High School Y O1 = pretest scores X = two-week unit on testicular cancer O2 = posttest scores Data collected: Ratio data; scores on 100-point skills test Test Results Junior High X (n = 142) Junior High Y (n = 131) Pre 62 63 Post 79 65 Data analysis: An independent t-test of statistical significance can be used to (1) test the null hypothesis that there is no difference in the pretest scores of the two groups be cause the groups were not randomly assigned, and (2) test the null hypothesis that there is no difference in the posttest scores of the two groups. Interpreting the Data With the data analyses completed, attention turns to interpreting the data. By interpretation we mean attaching meaning to the analyzed data and drawing conclusions. “Interpretation should be characterized by careful, fair, open methods of inquiry.” (Fitzpatrick et al., 2004, p. 364.) Chapter 15 Data Analysis and Reporting 395 To ensure that the interpretation is fair and as objective as possible, it is recommended that the interpretation not be the sole responsibility of the evaluator or, for that matter, any other single person. Earlier, when we began our discussion of evaluation, we spoke of the im- portance of making sure that the evaluation process is a collaborative process that includes representation from all of the stakeholders (see Chapter 13). That principle applies not only to the planning of the evaluation but also to the interpretation of the data. It is advisable to bring stakeholders and evaluators together in one or more meetings to systematically review evaluation findings. Such meetings take advantage of the diverse perspectives of the stakeholders, as well as allowing for a discussion of the implications of various interpretative conclusions. There is no single method used to interpret data. In fact, a number of different methods could be used. Fitzpatrick and colleagues (2004) have identified eight methods: 1. “Determining whether objectives have been achieved; 2. Determining whether laws, democratic ideals, regulations, or ethical principles have been violated; 3. Determining whether assessed needs have been reduced; 4. Determining the value of accomplishments; 5. Asking critical reference groups to review the data and to provide their judgments of successes and failures, strengths, and weaknesses; 6. Comparing results with those reported by similar entities or endeavors; 7. Comparing assessed performance levels on critical variables to expectations of performance or standards; 8. Interpreting results in light of evaluation procedures that generated them” (p. 364). Given this list, it becomes clear that there is a difference between what is termed sta- tistical significance and program significance. Program significance measures the meaningfulness of a program (based on stakeholder preferences) compared with statisti- cal significance determined by statistical testing. It is possible—especially when a large number of people are included in the data collection—to have statistically significant results that indicate gains in performance that are not meaningful in terms of program goals. For example, if the mean scores on a knowledge test of two groups are 70 and 69 (out of 100 points) and the groups are large enough, it would be possible that the differ- ence in the scores (i.e., 1 point) could be statistically significant. But in practical terms, the group with a mean score of 70 compared with 69 will likely not have more knowl- edge  that will translate to anything meaningful. Thus, spending extra dollars on the program that generated the mean score of 70 versus the less expensive program that gen- erated a mean score of 69 would not be cost-effective. Statistical significance is similar to reliability in that they are both measures of precision. In addition, while program results may not be considered statistically significant, stakeholders may feel the program should be continued for various reasons (e.g., goodwill is being developed in the community or the organization is receiving a lot of positive attention that is drawing more clients to other programs, etc.). 396 Part 3 Evaluating a Health Promotion Program Evaluation Reporting The results and interpretation of the data analyses, as well as a description of the evaluation process, are incorporated into a final report that is presented to stakeholders. The report itself generally follows the format of a research report, including an introduction, methodology, results, and discussion, including conclusions and recommendations. Some may see the creation of an evaluation report as a nonessential step in the larger pro- cess of evaluation; however, an evaluation report is essential for several reasons (Wurzbach, 2002). An evaluation report can provide: ⦁⦁ The impetus “to help you critically analyze the results of the evaluation and think about any changes you should make as a result ⦁⦁ A tangible product for your agency ⦁⦁ Evidence that your program or materials have been carefully developed—to be used as a sales tool with gatekeepers (e.g., television station public service directors) ⦁⦁ A record of your activities for use in planning future programs ⦁⦁ Assistance to others who may be interested in developing similar programs or materials ⦁⦁ A foundation for evaluation activities in the future (e.g., it is easier to design a new questionnaire based on one you have previously used than to start anew)” (p. 590) The number and type of reports required are determined at the beginning of the evalua- tion based on the needs of the stakeholders. For a formative evaluation, reports are needed early and may be provided on a weekly or monthly basis. Related feedback may be formal or informal, ranging from scheduled presentations to informal telephone calls but must be submitted in a timely manner in order to provide immediate feedback so that program modi- fications can be made before program implementation has progressed too far. For a summa- tive evaluation, the report is generally more formal and may resemble a scientific paper that can be submitted to a journal for publication. In fact, it is advisable in many circumstances to recommend to stakeholders that the evaluation report take the form of such a paper so that publication is an option. In this regard, successful programs can be shared with the larger profession of health promotion. Ultimately, stakeholders will determine the format of the report (technical report, journal article, news release, meeting, presentation, press confer- ence, letter, or workshop, etc.) as well as the criteria that will define program success. Often, an oral presentation will accompany the submission of a final evaluation report and at times, more than one method is selected in order to meet the needs of all stakeholders. For example, following an innovative worksite health promotion program, the evaluator might prepare a story for the worksite newsletter, a letter of findings to all staff who participated, a technical report for the funding source, and an executive summary for the administrators. Evaluators must be able to communicate to all audiences when presenting the results of the evaluation. The reaction of each audience—participants, media, administrators, funding sources—must be anticipated in order to prepare the necessary information. In some cases, technical information must be included; in other cases, anecdotal information may be ap- propriate. The evaluator must fit the report to the audience as well as prepare for a negative response if the results of the evaluation are not favorable. This involves looking critically at the results and developing responses to anticipated reactions. Chapter 15 Data Analysis and Reporting 397 Designing the Written Report As previously mentioned, the evaluation report follows a similar format to that used in a scientific or research report. The evaluation report generally includes the following sections: ⦁⦁ Abstract or executive summary: This is a summary of the total evaluation including goals and objectives, methods, results, and discussion, including conclusions and recommendations. It is a concise presentation of the evaluation because it may be the only portion of the report that some of the stakeholders read. Most abstracts/executive summaries range in length from 200 to 500 words. ⦁⦁ Introduction: This section of the report contains a complete description of the program including background information as well as rationale or justification for the program and its evaluation. Goals and objectives of the program are listed, as well as the evaluation questions to be answered. ⦁⦁ Methods/procedures: This section includes information on the evaluation design, priority populations, instruments used, and how the data were collected and analyzed. ⦁⦁ Results: This section is the most critical component of the report. It includes the findings from the evaluation, summarizing and simplifying the data and presenting them in a clear, concise format. Data are presented for each evaluation or research question. If null and alternative hypotheses were developed as part of the evaluation or research, they are also explained and answered as part of this section. ⦁⦁ Discussion: This section interprets the results (presented in the previous section) to determine significance and provide explanations for what was found. Conclusions and recommendations are included in this section and may be based on findings from other studies, other literature previously published, or related theories. Box 15.3 summarizes what is included in the evaluation report. presenting Data The data that have been collected and analyzed are presented in the evaluation report. Data presen- tation should be simple and straightforward. Graphic displays and tables may be used to illustrate certain findings; in fact, they are often a central part of the report. They also often make it easier for the readers of a written report or the audience of an oral report to understand the findings of the evaluation. Graphic displays should be self-explanatory. In fact, it is usually ill-advised to describe in the text too much of what is already displayed in a table or figure. When presenting the data in graphic form it is often helpful to include a frame of reference—such as a comparison with national, state, local, or other data—and explain any limitations of the data. If graphic displays are used in a report, it is recommended (USDHHS, CDC, n.d.) that such displays are appropriate for the results: ⦁⦁ Use horizontal bar charts to focus attention on how one category differs from another. ⦁⦁ Use vertical bar charts to focus attention on a change in a variable over time. ⦁⦁ Use cluster bar charts to contrast one variable among multiple subgroups. ⦁⦁ Use line graphs to plot data for several periods and show a trend over time. ⦁⦁ Use pie charts to show the distribution of a set of events or a total quantity. ⦁⦁ Use brownie pans (i.e. colored charts in rectangular or square form that display proportional amounts of data, similar to a pie chart) to show proportions of data (i.e. large versus medium versus small data amounts). ⦁⦁ Use pictographs (or pictograms) to show pictorial representations of data. 398 Part 3 Evaluating a Health Promotion Program If many tables or graphs are included, only the most relevant should be inserted in the text of the report with the remainder placed in an appendix. In addition, it should not be necessary to describe or explain elements of tables or graphs in detail in an evaluation report. In other words, these displays should be self-explanatory. How and When to present the Report Evaluators must carefully consider the logistics of presenting the evaluation findings and should discuss this with the stakeholders involved in the evaluation. An evaluator may be in the position of presenting negative results, encountering distrust among staff members, or 15.3 Box What to include in the Evaluation Report Abstract/executive summary Overview of the program and evaluation General discussion of results, conclusions, and recommendations Introduction Purpose of the evaluation Rationale or justification for the evaluation Program and participant description (including staff, materials, activities, procedures, etc.) Goals and objectives Evaluation questions Methods/procedures Design of the evaluation Priority population Instrumentation, including information on validity and reliability Sampling procedures Data collection procedures Pilot study results Data analyses procedures Results Description of findings from data analyses Answers to evaluation questions Explanation of findings Charts and graphs of findings Discussion Interpretation of results Conclusions about program effectiveness Limitations Program recommendations Determining if additional information is needed Fo cu s O n Chapter 15 Data Analysis and Reporting 399 submitting a report that will never be read. Following are several suggestions for enhancing the evaluation report: ⦁⦁ Give key stakeholders advance information on the findings; this increases the likelihood that the information will be processed most appropriately. Avoid releasing any information to media outlets until all stakeholders have had an opportunity to read and discuss findings. ⦁⦁ Maintain anonymity (i.e. responses cannot be linked to a specific individual) and confidentiality (i.e. personal information of respondents is not released). Be sensitive to cultural norms in reporting data and ensure that individuals and populations involved in the evaluation study are not portrayed unfairly or unreasonably. ⦁⦁ Choose ways to report the evaluation findings so as to meet the needs of diverse stakeholders, and include information that is relevant to each group. Increasing Utilization of the Results Far too often an evaluation will be conducted and a report submitted to the stakeholders without the recommendations being implemented. This occurs for a variety of reasons. Evaluators may not use findings because they are conducting the evaluation only to fulfill the requirements of the funding source, to serve their own self-interest, or to gain recogni- tion for a successful program. If decision makers do not press those responsible for the pro- gram to make improvements, those implementing the program may not feel inclined to go to the trouble of making the necessary changes. Those who are given the evaluation results for their program may find that they are unable to make sense of the report due to language and concepts that are unfamiliar to them. Weiss (1984) developed the following guidelines to increase the chances that evaluation results will actually be used: 1. Plan the study with program stakeholders in mind and involve them in the planning process. 2. Continue to gather information about the program after the planning stage; a change in the program should result in a change in the evaluation. 3. Focus the evaluation on conditions about the program that the decision makers can change. 4. Write reports in a clear, simple manner and submit them on time. Use graphs and charts within the text and include complicated statistical information in an appendix. 5. Base the decision on whether to make recommendations on how specific and clear the data are, how much is known about the program, and whether differences between programs are obvious. A joint interpretation between evaluator and stakeholders may be best. 6. Disseminate the results to all stakeholders, using a variety of methods. 7. Integrate evaluation findings with other research and evaluation as they relate to the program focus. 8. Provide high-quality research. 400 Part 3 Evaluating a Health Promotion Program Summary Evaluation questions developed in the early program planning stages can be answered once the data have been analyzed. Descriptive statistics can be used to summarize or describe the data, and inferential statistics can be used to generate or test hypotheses and infer and trans- fer findings to the broader population. These statistics are generated by applying the appro- priate univariate, bivariate, and/or multivariate analyses. Evaluators then interpret the data and present the results to the stakeholders via a formal or informal report. Review Questions 1. What issues should be addressed to ensure an accurate evaluation? 2. What is meant by the term data management? 3. What is the difference between descriptive statistics and inferential statistics? 4. What is the difference between parametric data and non-parametric data? 5. What are some types of univariate data analyses used in evaluation? When would these be used? 6. How are bivariate and multivariate data analyses used in evaluation? 7. Explain the concepts of hypothesis testing, level of significance, Type I error, and Type II error. 8. What are the roles of evaluators and stakeholders in interpreting program results and making recommendations? 9. What is the difference between statistical significance and program significance? 10. What information is included in the written evaluation report? How is the information modified for various audiences? 11. What are some guidelines for presenting data in an evaluation report? 12. How can the evaluation report be enhanced? 13. How can the evaluator increase the likelihood of utilization of the evaluation findings? Activities 1. Obtain an actual report from a program evaluation (perhaps in a data-based article in a scientific journal pertaining to health promotion). Look for the type of statistical tests used, level of significance, independent and dependent variables, interpretation of the findings, recommendations, and format for the report. 2. Discuss evaluation with a decision maker from a health agency. Find out what types of evaluation the agency conducted, who conducted them, what the findings were, whether the findings were implemented, and how the information was reported. 3. Compare an evaluation report with a research report (e.g., perhaps a peer-reviewed journal article). What are the similarities and differences? How could you improve the report? 4. Using data that you have generated or data presented by your instructor, create one table and one graph. Chapter 15 Data Analysis and Reporting 401 Weblinks 1. http://www.astho.org/ Association of State and Territorial Health Officials (ASTHO) ASTHO is the national nonprofit organization representing the state and territorial public health agencies of the United States, the U.S. territories, and the District of Columbia. ASTHO’s members are the chief health officials of these jurisdictions. At this site you can link to all the state and territorial public health agencies where you can find various examples of the presentation of health data using charts, graphs, and tables. 2. http://www.cancercontrol.cancer.gov/index.html National Cancer Institute (NCI) NCI’s Website provides information on cancer control and population sciences, including evaluation/research reports on a number of cancer-related programs. 3. https://developers.google.com/chart/?hl=en Google Charts Google charts provides users with interactive charts and other data tools to represent evaluation elements described in this chapter. 4. http://www.cdc.gov/learning/ Centers for Disease Control and Prevention (CDC Learning Connection) This is a CDC Webpage where you can access information related to concepts described in this chapter. 5. http://www.cdc.gov/nchs/ National Center for Health Statistics (NCHS) This Website is a rich source of information about America’s health and provides many examples of the presentation of health data. 6. http://www.nhtsa.gov/ State Traffic Safety Information (STSI) This is NHTSA’s National Center for Statistical Analysis Website. STSI presents a state- by-state profile of traffic safety data and information including crash statistics, economic costs, legislation status, funding programs, and more. Here you will find examples of the presentation of health data using charts, graphs, and tables. http://www.astho.org/ http://www.cancercontrol.cancer.gov/index.html https://developers.google.com/chart/?hl=en http://www.cdc.gov/learning/ http://www.cdc.gov/nchs/ http://www.nhtsa.gov/ This page intentionally left blank 403 Preamble The Health Education profession is dedicated to excellence in the practice of promoting individual, family, group, organizational, and community health. Guided by common goals to improve the human condition, Health Educators are responsible for upholding the integrity and ethics of the profession as they face the daily challenges of making decisions. Health Educators value diversity in society and embrace a multiplicity of approaches in their work to support the worth, dignity, potential, and uniqueness of all people. The Code of Ethics provides a framework of shared values within the professions in which Health Education is practiced. The Code of Ethics is grounded in fundamental ethical principles including: promoting justice, doing good, and avoidance of harm. The responsibility of each health educator is to aspire to the highest possible standards of con- duct and to encourage the ethical behavior of all those with whom they work. Regardless of job title, professional affiliation, work setting, or population served, Health Educators should promote and abide by these guidelines when making professional decisions. Article I: Responsibility to the Public A Health Educator’s responsibilities are to educate, promote, maintain, and improve the health of individuals, families, groups and communities. When a conflict of issues arises among in- dividuals, groups, organizations, agencies, or institutions, health educators must consider all issues and give priority to those that promote the health and well-being of individuals and the public while respecting both the principles of individual autonomy, human rights, and equality. Section 1 Health Educators support the right of individuals to make informed decisions regarding their health, as long as such decisions pose no risk to the health of others. Section 2 Health Educators encourage actions and social policies that promote maximizing health benefits and eliminating or minimizing preventable risks and disparities for all affected parties. Code of ethiCs for the health eduCation Profession Source: The Coalition of National Health Education Organizations, Ethics Task Force, September 30, 2015. www.cnheo.org /ethics.html. Reprinted by permission. Appendix A http://www.cnheo.org/ethics.html http://www.cnheo.org/ethics.html 404 Appendix A Code of ethics for the health education Profession Section 3 Health Educators accurately communicate the potential benefits, risks, and/or consequences associated with the services and programs that they provide. Section 4 Health Educators accept the responsibility to act on issues that can affect the health of individuals, families, groups, and communities. Section 5 Health Educators are truthful about their qualifications and the limitations of their educa- tion, expertise, and experience in providing services consistent with their respective level of professional competence. Section 6 Health Educators are ethically bound to respect, assure, and protect the privacy, confidenti- ality, and dignity of individuals. Section 7 Health Educators actively involve individuals, groups, and communities in the entire edu- cational process in an effort to maximize the understanding and personal responsibilities of those who may be affected. Section 8 Health Educators respect and acknowledge the rights of others to hold diverse values, attitudes, and opinions. Article II: Responsibility to the Profession Health Educators are responsible for their professional behavior, for the reputation of their profession, and for promoting ethical conduct among their colleagues. Section 1 Health Educators maintain, improve, and expand their professional competence through continued study and education; membership, participation, and leadership in professional organizations; and involvement in issues related to the health of the public. Section 2 Health Educators model and encourage nondiscriminatory standards of behavior in their interactions with others. Section 3 Health Educators encourage and accept responsible critical discourse to protect and enhance the profession. Section 4 Health Educators contribute to the profession by refining existing and developing new prac- tices, and by sharing the outcomes of their work. Appendix A Code of ethics for the health education Profession 405 Section 5 Health Educators are aware of real and perceived professional conflicts of interest, and pro- mote transparency of conflicts. Section 6 Health Educators give appropriate recognition to others for their professional contributions and achievements. Section 7 Health educators openly communicate to colleagues, employers and professional organiza- tions when they suspect unethical practice that violates the profession’s Code of Ethics. Article III: Responsibility to Employers Health Educators recognize the boundaries of their professional competence and are account- able for their professional activities and actions. Section 1 Health Educators accurately represent their qualifications and the qualifications of others whom they recommend. Section 2 Health Educators use and apply current evidence-based standards, theories, and guidelines as criteria when carrying out their professional responsibilities. Section 3 Health Educators accurately represent potential and actual service and program outcomes to employers. Section 4 Health Educators anticipate and disclose competing commitments, conflicts of interest, and endorsement of products. Section 5 Health Educators acknowledge and openly communicate to employers, expectations of job-related assignments that conflict with their professional ethics. Section 6 Health Educators maintain competence in their areas of professional practice. Section 7 Health Educators exercise fiduciary responsibility and transparency in allocating resources associated with their work. Article IV: Responsibility in the Delivery of Health Education Health Educators deliver health education with integrity. They respect the rights, dignity, confidentiality, and worth of all people by adapting strategies and methods to the needs of diverse populations and communities. 406 Appendix A Code of ethics for the health education Profession Section 1 Health Educators are sensitive to social and cultural diversity and are in accord with the law when planning and implementing programs. Section 2 Health Educators remain informed of the latest advances in health education theory, research, and practice. Section 3 Health educators use strategies and methods that are grounded in and contribute to the development of professional standards, theories, guidelines, data, and experience. Section 4 Health Educators are committed to rigorous evaluation of both program effectiveness and the methods used to achieve results. Section 5 Health Educators promote the adoption of healthy lifestyles through informed choice rather than by coercion or intimidation. Section 6 Health Educators communicate the potential outcomes of proposed services, strategies, and pending decisions to all individuals who will be affected. Section 7 Health educators actively collaborate and communicate with professionals of various educational backgrounds and acknowledge and respect the skills and contributions of such groups. Article V: Responsibility in Research and Evaluation Health Educators contribute to the health of the population and to the profession through research and evaluation activities. When planning and conducting research or evaluation, health educators do so in accordance with federal and state laws and regulations, organiza- tional and institutional policies, and professional standards. Section 1 Health Educators adhere to principles and practices of research and evaluation that do no harm to individuals, groups, society, or the environment. Section 2 Health Educators ensure that participation in research is voluntary and is based upon the informed consent of the participants. Appendix A Code of ethics for the health education Profession 407 Section 3 Health Educators respect and protect the privacy, rights, and dignity of research participants, and honor commitments made to those participants. Section 4 Health Educators treat all information obtained from participants as confidential unless otherwise required by law. Participants are fully informed of the disclosure procedures. Section 5 Health Educators take credit, including authorship, only for work they have actually performed and give appropriate credit to the contributions of others. Section 6 Health Educators who serve as research or evaluation consultants maintain confidentiality of results unless permission is granted or in order to protect the health and safety of others. Section 7 Health Educators report the results of their research and evaluation objectively, accurately, and in a timely fashion to effectively foster the translation of research into practice. Section 8 Health Educators openly share conflicts of interest in the research, evaluation, and dissemi- nation process. Article VI: Responsibility in Professional Preparation Those involved in the preparation and training of Health Educators have an obligation to accord learners the same respect and treatment given other groups by providing quality education that benefits the profession and the public. Section 1 Health Educators select students for professional preparation programs based upon equal opportunity for all, and the individual’s academic performance, abilities, and potential con- tribution to the profession and the public’s health. Section 2 Health Educators strive to make the educational environment and culture conducive to the health of all involved, and free from all forms of discrimination and harassment. Section 3 Health Educators involved in professional preparation and development engage in careful planning; present material that is accurate, developmentally and culturally appropriate; provide reasonable and prompt feedback; state clear and reasonable expectations; and con- duct fair assessments and prompt evaluations of learners. 408 Appendix A Code of ethics for the health education Profession Section 4 Health Educators provide objective, comprehensive, and accurate counseling to learners about career opportunities, development, and advancement, and assist learners in securing professional employment or further educational opportunities. Section 5 Health Educators provide adequate supervision and meaningful opportunities for the profes- sional development of learners. Approved by the Coalition of National Health Education Organizations February 8, 2011 Task Force Members: Michael Ballard Brian Colwell Suzanne Crouch Stephen Gambescia Mal Goldsmith, Chairperson Marc Hiller Adrian Lyde Lori Phillips Catherine Rasberry Raymond Rodriquez Terry Wessel 409 The Seven Areas of Responsibility contain a comprehensive set of Competencies and Sub- competencies defining the role of the health education specialist. These Responsibilities, Competencies, and Sub-competencies were verified by the 2015 Health Education Specialist Practice Analysis (HESPA) project. Coding: No asterisk = Entry-level Sub-competency * = Advanced–1 level Sub-competency ** = Advanced–2 level Sub-competency Area I: Assess Needs, Resources, and Capacity for Health Education/Promotion 1.1 Plan assessment process for health education/promotion 1.1.1 Define the priority population to be assessed 1.1.2 Identify existing and necessary resources to conduct assessments 1.1.3 Engage priority populations, partners, and stakeholders to participate in the assessment process 1.1.4* Apply theories and/or models to assessment process 1.1.5 Apply ethical principles to the assessment process 1.2 Access existing information and data related to health 1.2.1 Identify sources of secondary data related to health 1.2.2* Establish collaborative relationships and agreements that facilitate access to data 1.2.3 Review related literature 1.2.4 Identify gaps in the secondary data 1.2.5 Extract data from existing databases 1.2.6 Determine the validity of existing data 1.3 Collect primary data to determine needs 1.3.1 Identify data collection instruments 1.3.2 Select data collection methods for use in assessment Appendix B HealtH education SpecialiSt practice analySiS (HeSpa 2015)—reSponSibilitieS, competencieS and Sub-competencieS 410 Appendix B Health education Specialist practice analysis (HeSpa 2015) 1.3.3 Develop data collection procedures 1.3.4 Train personnel assisting with data collection 1.3.5 Implement quantitative and/or qualitative data collection 1.4 Analyze relationships among behavioral, environmental, and other factors that influence health 1.4.1 Identify and analyze factors that influence health behaviors 1.4.2 Identify and analyze factors that impact health 1.4.3 Identify the impact of emerging social, economic, and other trends on health 1.5 Examine factors that influence the process by which people learn 1.5.1 Identify and analyze factors that foster or hinder the learning process 1.5.2 Identify and analyze factors that foster or hinder knowledge acquisition 1.5.3 Identify and analyze factors that influence attitudes and beliefs 1.5.4 Identify and analyze factors that foster or hinder acquisition of skills 1.6 Examine factors that enhance or impede the process of health education/promotion 1.6.1 Determine the extent of available health education/promotion programs and interventions 1.6.2 Identify policies related to health education/promotion 1.6.3 Assess the effectiveness of existing health education/promotion programs and interventions 1.6.4 Assess social, environmental, political, and other factors that may impact health education/promotion 1.6.5 Analyze the capacity for providing necessary health education/promotion 1.7 Determine needs for health education/promotion based on assessment findings 1.7.1* Synthesize assessment findings 1.7.2 Identify current needs, resources, and capacity 1.7.3 Prioritize health education/promotion needs 1.7.4 Develop recommendations for health education/promotion based on assessment findings 1.7.5 Report assessment findings Area II: Plan Health Education/Promotion 2.1 Involve priority populations, partners, and other stakeholders in the planning process 2.1.1 Identify priority populations, partners, and other stakeholders 2.1.2 Use strategies to convene priority populations, partners, and other stakeholders 2.1.3 Facilitate collaborative efforts among priority populations, partners, and other stakeholders 2.1.4 Elicit input about the plan 2.1.5 Obtain commitments to participate in health education/promotion 2.2 Develop goals and objectives 2.2.1 Identify desired outcomes using the needs assessment results 2.2.2 Develop vision statement 2.2.3 Develop mission statement 2.2.4 Develop goal statements 2.2.5 Develop specific, measurable, attainable, realistic, and time-sensitive objectives 2.3 Select or design strategies/interventions 2.3.1* Select planning model(s) for health education/promotion 2.3.2* Assess efficacy of various strategies/interventions to ensure consistency with objectives 2.3.3* Apply principles of evidence-based practice in selecting and/or designing strategies/ interventions 2.3.4 Apply principles of cultural competence in selecting and/or designing strategies/ interventions 2.3.5 Address diversity within priority populations in selecting and/or designing strategies/ interventions 2.3.6 Identify delivery methods and settings to facilitate learning 2.3.7 Tailor strategies/interventions for priority populations 2.3.8 Adapt existing strategies/interventions as needed 2.3.9* Conduct pilot test of strategies/interventions 2.3.10* Refine strategies/interventions based on pilot feedback 2.3.11 Apply ethical principles in selecting strategies and designing interventions 2.3.12 Comply with legal standards in selecting strategies and designing interventions 2.4 Develop a plan for the delivery of health education/promotion 2.4.1 Use theories and/or models to guide the delivery plan 2.4.2 Identify the resources involved in the delivery of health education/promotion 2.4.3 Organize health education/promotion into a logical sequence 2.4.4 Develop a timeline for the delivery of health education/promotion 2.4.5 Develop marketing plan to deliver health program 2.4.6 Select methods and/or channels for reaching priority populations 2.4.7 Analyze the opportunity for integrating health education/promotion into other programs 2.4.8* Develop a process for integrating health education/promotion into other programs when needed 2.4.9 Assess the sustainability of the delivery plan 2.4.10 Design and conduct pilot study of health education/promotion plan 2.5 Address factors that influence implementation of health education/promotion 2.5.1 Identify and analyze factors that foster or hinder implementation 2.5.2 Develop plans and processes to overcome potential barriers to implementation Appendix B Health education Specialist practice analysis (HeSpa 2015) 411 Area III: Implement Health Education/Promotion 3.1 Coordinate logistics necessary to implement plan 3.1.1 Create an environment conducive to learning 3.1.2 Develop materials to implement plan 3.1.3 Secure resources to implement plan 3.1.4 Arrange for needed services to implement plan 3.1.5 Apply ethical principles to the implementation process 3.1.6 Comply with legal standards that apply to implementation 3.2 Train staff members and volunteers involved in implementation of health education/promotion 3.2.1* Develop training objectives 3.2.2 Recruit individuals needed for implementation 3.2.3* Identify training needs of individuals involved in implementation 3.2.4* Develop training using best practices 3.2.5* Implement training 3.2.6* Provide support and technical assistance to those implementing the plan 3.2.7* Evaluate training 3.2.8* Use evaluation findings to plan/modify future training 3.3 Implement health education/promotion plan 3.3.1 Collect baseline data 3.3.2* Apply theories and/or models of implementation 3.3.3 Assess readiness for implementation 3.3.4 Apply principles of diversity and cultural competence in implementing health education/promotion plan 3.3.5 Implement marketing plan 3.3.6 Deliver health education/promotion as designed 3.3.7 Use a variety of strategies to deliver plan 3.4 Monitor implementation of health education/promotion 3.4.1 Monitor progress in accordance with timeline 3.4.2 Assess progress in achieving objectives 3.4.3 Ensure plan is implemented consistently 3.4.4 Modify plan when needed 3.4.5 Monitor use of resources 3.4.6 Evaluate sustainability of implementation 3.4.7 Ensure compliance with legal standards 3.4.8 Monitor adherence to ethical principles in the implementation of health education/promotion 412 Appendix B Health education Specialist practice analysis (HeSpa 2015) Area IV: Conduct Evaluation and Research Related to Health Education/Promotion 4.1 Develop evaluation plan for health education/promotion 4.1.1* Determine the purpose and goals of evaluation 4.1.2* Develop questions to be answered by the evaluation 4.1.3* Create a logic model to guide the evaluation process 4.1.4* Adapt/modify a logic model to guide the evaluation process 4.1.5* Assess needed and available resources to conduct evaluation 4.1.6* Determine the types of data (for example, qualitative, quantitative) to be collected 4.1.7* Select a model for evaluation 4.1.8* Develop data collection procedures for evaluation 4.1.9** Develop data analysis plan for evaluation 4.1.10* Apply ethical principles to the evaluation process 4.2 Develop a research plan for health education/promotion 4.2.1** Create statement of purpose 4.2.2** Assess feasibility of conducting research 4.2.3** Conduct search for related literature 4.2.4** Analyze and synthesize information found in the literature 4.2.5** Develop research questions and/or hypotheses 4.2.6** Assess the merits and limitations of qualitative and quantitative data collection 4.2.7** Select research design to address the research questions 4.2.8** Determine suitability of existing data collection instruments 4.2.9** Identify research participants 4.2.10** Develop sampling plan to select participants 4.2.11** Develop data collection procedures for research 4.2.12** Develop data analysis plan for research 4.2.13** Develop a plan for non-respondent follow-up 4.2.14** Apply ethical principles to the research process 4.3 Select, adapt and/or create instruments to collect data 4.3.1** Identify existing data collection instruments 4.3.2** Adapt/modify existing data collection instruments 4.3.3** Create new data collection instruments 4.3.4 Identify useable items from existing instruments 4.3.5 Adapt/modify existing items 4.3.6** Create new items to be used in data collection 4.3.7** Pilot test data collection instrument 4.3.8** Establish validity of data collection instruments Appendix B Health education Specialist practice analysis (HeSpa 2015) 413 4.3.9** Ensure that data collection instruments generate reliable data 4.3.10** Ensure fairness of data collection instruments (for example, reduce bias, use language appropriate to priority population) 4.4 Collect and manage data 4.4.1** Train data collectors involved in evaluation and/or research 4.4.2** Collect data based on the evaluation or research plan 4.4.3 Monitor and manage data collection 4.4.4 Use available technology to collect, monitor and manage data 4.4.5 Comply with laws and regulations when collecting, storing, and protecting participant data 4.5 Analyze data 4.5.1** Prepare data for analysis 4.5.2* Analyze data using qualitative methods 4.5.3** Analyze data using descriptive statistical methods 4.5.4** Analyze data using inferential statistical methods 4.5.5** Use technology to analyze data 4.6 Interpret results 4.6.1** Synthesize the analyzed data 4.6.2** Explain how the results address the questions and/or hypotheses 4.6.3** Compare findings to results from other studies or evaluations 4.6.4** Propose possible explanations of findings 4.6.5** Identify limitations of findings 4.6.6** Address delimitations as they relate to findings 4.6.7** Draw conclusions based on findings 4.6.8** Develop recommendations based on findings 4.7 Apply findings 4.7.1 Communicate findings to priority populations, partners, and stakeholders 4.7.2 Solicit feedback from priority populations, partners, and stakeholders 4.7.3 Evaluate feasibility of implementing recommendations 4.7.4 Incorporate findings into program improvement and refinement 4.7.5** Disseminate findings using a variety of methods Area V: Administer and Manage Health Education/ Promotion 5.1 Manage financial resources for health education/promotion programs 5.1.1* Develop financial plan 5.1.2* Evaluate financial needs and resources 5.1.3* Identify internal and/or external funding sources 414 Appendix B Health education Specialist practice analysis (HeSpa 2015) 5.1.4* Prepare budget requests 5.1.5* Develop program budgets 5.1.6* Manage program budgets 5.1.7* Conduct cost analysis for programs 5.1.8* Prepare budget reports 5.1.9* Monitor financial plan 5.1.10* Create requests for funding proposals 5.1.11* Write grant proposals 5.1.12* Conduct reviews of funding proposals 5.1.13* Apply ethical principles when managing financial resources 5.2 Manage technology resources 5.2.1 Assess technology needs to support health education/promotion 5.2.2 Use technology to collect, store and retrieve program management data 5.2.3 Apply ethical principles in managing technology resources 5.2.4 Evaluate emerging technologies for applicability to health education/promotion 5.3 Manage relationships with partners and other stakeholders 5.3.1 Assess capacity of partners and other stakeholders to meet program goals 5.3.2* Facilitate discussions with partners and other stakeholders regarding program resource needs 5.3.3 Create agreements (for example, memoranda of understanding) with partners and other stakeholders 5.3.4 Monitor relationships with partners and other stakeholders 5.3.5* Elicit feedback from partners and other stakeholders 5.3.6 Evaluate relationships with partners and other stakeholders 5.4 Gain acceptance and support for health education/promotion programs 5.4.1 Demonstrate how programs align with organizational structure, mission, and goals 5.4.2 Identify evidence to justify programs 5.4.3 Create a rationale to gain or maintain program support 5.4.4 Use various communication strategies to present rationale 5.5 Demonstrate leadership 5.5.1* Facilitate efforts to achieve organizational mission 5.5.2 Analyze an organization’s culture to determine the extent to which it supports health education/promotion 5.5.3 Develop strategies to reinforce or change organizational culture to support health education/promotion 5.5.4* Facilitate needed changes to organizational culture 5.5.5* Conduct strategic planning 5.5.6* Implement strategic plan 5.5.7* Monitor strategic plan Appendix B Health education Specialist practice analysis (HeSpa 2015) 415 5.5.8 Conduct program quality assurance/process improvement 5.5.9 Comply with existing laws and regulations 5.5.10 Adhere to ethical principles of the profession 5.6 Manage human resources for health education/promotion programs 5.6.1* Assess staffing needs 5.6.2* Develop job descriptions 5.6.3* Apply human resource policies consistent with laws and regulations 5.6.4* Evaluate qualifications of staff members and volunteers needed for program 5.6.5 Recruit staff members and volunteers for programs 5.6.6* Determine staff member and volunteer professional development needs 5.6.7* Develop strategies to enhance staff member and volunteer professional development 5.6.8* Implement strategies to enhance the professional development of staff members and volunteers 5.6.9* Develop and implement strategies to retain staff members and volunteers 5.6.10* Employ conflict resolution techniques 5.6.11* Facilitate team development 5.6.12* Evaluate performance of staff members and volunteers 5.6.13* Monitor performance and/or compliance of funding recipients 5.6.14* Apply ethical principles when managing human resources Area VI: Serve as a Health Education/Promotion Resource Person 6.1 Obtain and disseminate health-related information 6.1.1 Assess needs for health-related information 6.1.2 Identify valid information resources 6.1.3 Evaluate resource materials for accuracy, relevance, and timeliness 6.1.4 Adapt information for consumer 6.1.5 Convey health-related information to consumer 6.2 Train others to use health education/promotion skills 6.2.1* Assess training needs of potential participants 6.2.2* Develop a plan for conducting training 6.2.3* Identify resources needed to conduct training 6.2.4* Implement planned training 6.2.5* Conduct formative and summative evaluations of training 6.2.6* Use evaluative feedback to create future trainings 6.3 Provide advice and consultation on health education/promotion issues 6.3.1* Assess and prioritize requests for advice/consultation 6.3.2* Establish advisory/consultative relationships 416 Appendix B Health education Specialist practice analysis (HeSpa 2015) 6.3.3* Provide expert assistance and guidance 6.3.4* Evaluate the effectiveness of the expert assistance provided 6.3.5* Apply ethical principles in consultative relationships Area VII: Communicate, Promote, and Advocate for Health, Health Education/Promotion, and the Profession 7.1 Identify, develop, and deliver messages using a variety of communication strategies, methods, and techniques 7.1.1 Create messages using communication theories and/or models 7.1.2 Identify level of literacy of intended audience 7.1.3 Tailor messages for intended audience 7.1.4* Pilot test messages and delivery methods 7.1.5* Revise messages based on pilot feedback 7.1.6 Assess and select methods and technologies used to deliver messages 7.1.7 Deliver messages using media and communication strategies 7.1.8 Evaluate the impact of the delivered messages 7.2 Engage in advocacy for health and health education/promotion 7.2.1 Identify current and emerging issues requiring advocacy 7.2.2 Engage stakeholders in advocacy initiatives 7.2.3 Access resources (for example, financial, personnel, information, data) related to identified advocacy needs 7.2.4 Develop advocacy plans in compliance with local, state, and/or federal policies and procedures 7.2.5 Use strategies that advance advocacy goals 7.2.6 Implement advocacy plans 7.2.7 Evaluate advocacy efforts 7.2.8 Comply with organizational policies related to participating in advocacy 7.2.9 Lead advocacy initiatives related to health 7.3 Influence policy and/or systems change to promote health and health education 7.3.1 Assess the impact of existing and proposed policies on health 7.3.2 Assess the impact of existing and proposed policies on health education 7.3.3 Assess the impact of existing systems on health 7.3.4 Project the impact of proposed systems changes on health education 7.3.5 Use evidence-based findings in policy analysis 7.3.6* Develop policies to promote health using evidence-based findings 7.3.7* Identify factors that influence decision-makers 7.3.8* Use policy advocacy techniques to influence decision-makers 7.3.9 Use media advocacy techniques to influence decision-makers 7.3.10 Engage in legislative advocacy Appendix B Health education Specialist practice analysis (HeSpa 2015) 417 7.4 Promote the health education profession 7.4.1 Explain the major responsibilities of the health education specialist 7.4.2 Explain the role of professional organizations in advancing the profession 7.4.3 Explain the benefits of participating in professional organizations 7.4.4 Advocate for professional development of health education specialists 7.4.5 Advocate for the profession 7.4.6 Explain the history of the profession and its current and future implications for professional practice 7.4.7 Explain the role of credentialing (for example, individual, program) in the promotion of the profession 7.4.8 Develop and implement a professional development plan 7.4.9** Serve as a mentor to others in the profession 7.4.10** Develop materials that contribute to the professional literature 7.4.11** Engage in service to advance the profession Source: A competency-based framework for health education specialists—2015. Whitehall, PA: National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). Reprinted by permission of the National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE). 418 Appendix B Health education Specialist practice analysis (HeSpa 2015) 419 accountability in a partnership arrangement, when each organization performs its work as previously arranged. accounting the process of recording and summariz- ing transactions and interpreting their affects on the program budget (Fallon & Zgodzinski, 2012). accuracy standards “ensure that the evaluation produces findings that are considered correct” (CDC, 1999c, p. 29); a standard of evaluation. action research see participatory research. action stage a stage of change in which a person has changed overt behavior for less than six months. active participants those who take part in most group activities. activities the intervention or strategies component of a logic model. act of commission doing something you should not be doing. act of omission not doing something you should be doing. adjourning last stage of team development “in which teams complete their work and disband, if designed to do so” (Gomez-Mejia & Balkin, 2012, p. 391). adjustment the process whereby planners make necessary changes to the program or its implemen- tation based on feedback from participants and partners. Administrative and Policy Assessment part of the fourth phase of PRECEDE-PROCEED, “an analysis of the policies, resources, and circum- stances prevailing in an organizational situation to facilitate or hinder the development of the health program” (Green & Kreuter, 2005, p. G–1). Advanced level 1-health education specialist “The practice level of a health education specialist with a minimum of a baccalaureate degree with professioinal preparation in the field of health education plus various combinations of degree (baccalaureate or master’s) and years of experience” (NCHEC & SOPHE, 2015, p. 89). Advanced level 2-health education specialist “The practice level of a health education specialist with a minimum of a doctoral degree in the field of health education, irrespective of years of experience” (NCHEC & SOPHE, 2015, p. 89). advisory board see planning committee. alpha level the level of statistical significance (usually set at 0.01 or 0.05). alternative hypothesis the hypothesis that holds there is a difference between groups, treatments, or interventions. analysis of variance (ANOVA) a statistical test used to study group differences when the dependent variables involved represent interval or ratio data. anonymity exists when there is no link between personal information and the person’s identity. approaches refers to formative, process, and summative evaluation and suggests these types of evaluation are clearly distinct. attitude objective those that describe the desired attitude of those in the priority population. attitude toward the behavior “the degree to which performance of the behavior is positively or negatively valued” (Ajzen, 2006). audit “review and confirmation that financial reports are accurate and that standard account- ing procedures were used to prepare the reports” (Johnson & Breckon, 2007, p. 288). aversive stimulus unpleasant consequence of a behavior. awareness objective those that describe of what those in the priority population will become aware. barriers things that keep people from obtaining the product or adopting a behavior. baseline data data collected prior to program implementation to serve as a comparison with data collected during the program, or more typically, with data collected at the completion of a program. basic priority rating (BPR) a model used to prioritize needs assessment data. behavior change theories those that help to explain how behavior change takes place. behavioral capability the knowledge and skills necessary to perform a behavior. Glossary 420 Glossary categorical funds those that are earmarked or dedicated to support programs aimed at a specific health problem or determinant (i.e., risk factor). census everyone in a population. CHANGE tool a program planning model created by the Centers for Disease Contol and Prevention to aid in the design and delivery of health community intiatives. chi-square a statistical test that measures the association between two nominal and/or ordinal variables. citizen initiated see grassroots. cluster sampling a probability sample that selects participants from a sampling frame as groups not individuals. coalition “a formal alliance of organizations that come together to work for a common goal” (Butterfoss, 2007, p. 30). cognitive pretesting the process of “an interviewer asking the respondent about how she or he went about answering the survey question or completing a self-completion questionnaire” (Collins, 2003, p. 234). collective efficacy the people’s shared belief in their collective ability to act to produce specific changes. communication channel route through which a message is delivered to a priority population. community “a collective body of individuals identi- fied by common characteristics such as geography, interests, experiences, concerns, or values” (Joint Committee on Health Education and Promotion Terminology, 2012, p. S10). community advocacy a process in which the people of a community become involved in the institutions and decisions that will impact their lives. community building “an orientation to practice focused on community, rather than a strategic framework or approach, and on building capacities, not fixing problems” (Minkler, 2012, p. 10). community capacity “community characteristics affecting its ability to identify, mobilize, and address problems” (Minkler & Wallerstein, 2012, p. 45). community context the general characteristics and circumstances that define a community. community development a “process designed to create conditions of economic and social progress for the whole community with its active participation and fullest possible reliance on the community’s initiative” (United Nations, 1955, p. 6). community empowerment when community members control decision making. community forum a process that brings people from the priority population to discuss problems and needs. behavioral economics a method of analysis that applies psychological insights into economic decision making. behavioral objective an impact objective that describes the action or behavior in which the priority population will engage. beneficence doing good. benefits value or outcome the priority population receives as a result of obtaining the product. best experiences interventions from prior or exist- ing programs of others that have not gone through the critical research and evaluation studies and thus fall short of best practice criteria but nonetheless show promise in being effective. best practices “recommendations for an interven- tion, based on critical review of multiple research and evaluation studies that substantiate the efficacy of the intervention in the populations and circum- stances in which the studies were done, if not its effectiveness in other populations and situations where it might be implemented” (Green & Kreuter, 2005, p. G–1). best processes original intervention strategies that the planners create on their own based on their knowledge and skills of good planning processes. bias a preference that inhibits impartiality. bivariate data analysis analysis of two variables. blind an evaluation wherein participants do not know if they belong to the experimental group or control group. bottom up see grassroots. BPR model 2. 0 an updated version of the basic priority rating (see basic priority rating). budget a statement of the estimated revenues and expenditures with an itemized listing of the nature of each. budget narrative a statement that explains the need for the costs in a budget and how the costs were estimated. built environment “generally refers to an interdisciplinary area of focus that describes the design, construction, management, and land use of human-made surroundings as an interrelated whole, as well as their relationship to human activities over time” (Coupland et al., 2011, p. 6). canned program one that has been developed by an outside group and includes the basic components and materials necessary to implement it. capacity the individual, organizational, and community resources that enable a community to take action. capacity building activities that enhance the resources of individuals, organizations, and communities to improve their effectiveness in taking action. Glossary 421 intervention and then keeping this knowledge at the center of all program planning decisions. contemplation stage a stage of change in which a person intends to take action in the next six months. content validity the “assessment of the correspon- dence between the items composing the instrument and the content domain from which the items were selected” (DiIorio, 2005, p. 213). contest a challenge between two individuals/groups in which the object is to try to outperform the competitor. context assesses the presence of any confounding factors. contingencies what happens if the objectives in a behavior change contract are either met or not met. continuum theory one that identifies variables that influence action and combine them into a prediction equation (Weinstein et al., 1998). contract an agreement between two or more parties that outlines the future behavior of those parties. control group as part of a summative evaluation or research study, a randomly selected group of individuals, similar to the experimental group that does not receive the treatment or program but is compared with the experimental group. convergent validity “the extent to which two measures that purport to be measuring the same topic correlate (that is, converge)” (Bowling, 2005, p. 12). correlation represents the strength and direction of relationships between two variables. cost-benefit analysis (CBA) measures dollars spent on a program versus dollars saved or gained. cost-effectiveness analysis (CEA) measures dollars spent on a program versus the impact achieved. cost-identification analysis compares interven- tions to determine which is least expensive in the context of impact achieved. criterion a major component of an objective that describes how much change will occur. criterion-related validity the “extent to which data generated from a measurement instrument are correlated with the data generated from a mea- sure (criterion) of the phenomenon being studied, usually an individual’s behavior or performance” (Cottrell & McKenzie, 2011, p. 322). critical path method (CPM) similar to PERT (see PERT) but focuses on total time to complete the tasks and the critical dependent tasks. cultural audit an evaluation of the assumptions, values, normative philosophies, and cultural char- acteristics of an organization in order to determine whether they support or hinder that organization’s central mission (Business Dictionary, 2015b). community organizing “the process by which community groups are helped to identify common problems or change targets, mobilize resources, and develop and implement strategies to reach their collective goals” (Minkler & Wallerstein, 2012, p. 37). community participation bottom-up, grassroots mobilization of citizens for the purpose of undertak- ing activities to improve the condition of something in the community. community readiness “the degree to which a community is willing and prepared to take action on an issue” (Tri-Ethnic Center for Prevention Research at Colorado State University, 2014, p. 4). comparison group as part of a summative evaluation or research study, a nonequivalent group (not ran- domly selected) that does not receive the treatment or program but is compared with the experimental group. Competency Update Project (CUP) a six-year, multiphase process carried out by the health educa- tion profession in order to reverify the role of the entry-level health educator and to distinguish it from the role of the advanced-level health educator. competition alternative choices for filling a need; programs or products that send messages that conflict with the behaviors program planners are promoting. concepts primary elements or the building blocks of a theory (Glanz et al., 2008b). concurrent validity a form of criterion validity in which a new instrument and an established valid instrument that measure the same characteristics are given to the same population and the new instrument correlates positively with the estab- lished instrument. conditions a major component of an objective that describes when or how the outcome will be observed. confidentiality exists when there is a link between personal information and the person’s identity but that information is protected from others. confounding variable “one that has an unpre- dictable or unexpected impact on the dependent variable” (Cottrell & McKenzie, 2011, p. 324). construct a concept developed, created, or adopted for use with a specific theory (Kerlinger, 1986). construct validity “the degree to which a measure correlates with other measures it is theoretically expected to correlate with” (Valente, 2002, p. 161). consumer-based a process that incorporates the wants, needs, and preferences of the prior- ity population directly into interventions and implementation. consumer orientation a dedicated effort to under- stand a priority population prior to developing an 422 Glossary doers those who are willing to take on work to complete a task. dose the number of program units delivered. double blind study an evaluation wherein neither participants nor those implementing the program know which group is experimental and which group is the control. early adopters in diffusion theory, the second group of people to adopt the innovation; often comprised of opinion leaders. early majority in diffusion theory, the people who are interested in the innovation, but will need external motivation to become involved. ecological framework see socio-ecological approach. educational and ecological assessment the third phase of PRECEDE-PROCEED wherein planners identify predisposing, reinforcing, and enabling factors that contribute to problems identified in earlier phases of the model. effectiveness in evaluation, a measure usually asso- ciated with the outcomes of a program—that is, did the program result in changes in awareness, knowl- edge, attitudes, skills, or especially behavior, and did the program result in improved health status (e.g., less mortality, morbidity, and disability). efficacy expectations people’s competency feelings. elaboration amount of cognitive processing people put into receiving messages. emotional-coping responses dealing with sources of anxiety that surround a behavior. empowerment “[s]ocial action process for people to gain mastery over their lives and the lives of their communities” (Minkler & Wallerstein, 2012, p. 45). enabling factor “any characteristic of the envi- ronment that facilitates action and any skill or resource required to attain a specific behavior” (Green & Kreuter, 2005, p. G–3). Entry-level health education specialist “The practice level of a health education specialist with a minimum of a baccalaureate degree with professio- inal preparation in the field of health education” (NCHEC & SOPHE, 2015, p. 89). environmental objective an impact objective that describes how the environments (e.g., economic, emotional, physical, political, service, social) around the priority population will change. epidemiological assessment the second phase of PRECEDE-PROCEED, wherein planners identify specific health goals or problems that contribute to the social goals or problems identified in Phase 1; and “the identification of etiological factors, or determinants of health in the genetics, behavioral patterns, and environment of the population” (Green & Kreuter, 2005, pp. 11–12). cultural competence “a developmental process defined as a set of values, principles, behaviors, attitudes, and policies that enable health profes- sionals to work effectively across racial, ethnic and linguistically diverse populations” (Joint Committee on Health Education and Promotion Terminology, 2012, p. 16). culturally competent see cultural competence. culturally sensitive relevant and acceptable within the cultural framework. culture the “patterned ways of thought and behavior that characterize a social group, which are learned through socialization processes and persist through time” (Coreil, Bryant, & Henderson, 2001, p. 29). curriculum “a planned set of lessons or courses designed to lead to competence in an area of study” (Gilbert et al., 2015, p. 437). data management the process of organizing, coding, and cleaning data in a useable format for the purpose of analysis and reporting. decision makers those who have the authority to approve a plan (e.g., administrator of an organiza- tion, governing board, chief executive officer). decisional balance refers to the pros and cons of behavioral change. deductive method applying a generally accepted principle to an individual case. Delphi technique a “group process that generates a consensus through a series of questionnaires” (Gilmore, 2012, p. 82). dependent variable an outcome variable or end result indicator in an evaluation or study. descriptive statistics data used to organize, summarize, and describe characteristics of a group. designs forms of different types of summative evaluation. diffusion theory explains a pattern for how innova- tions (e.g., products) are adopted in a population. direct cost the portion of cost that is directly expended in providing a product or service (VentureLine, 2015) direct reinforcement consequence given in a specific situation to increase a behavior. disability “often defined on the basis of specific activities of daily living, work and other functions essential to full participation in community-based living” (USDHHS, 2005, p. 4). discriminant validity “requires that the construct should not correlate with dissimilar (discriminant) variables” (Bowling, 2005, p. 12). disincentive consequence for not acting in a certain way; also used as a means to discourage the con- sumer from purchasing a product or behaving in a certain way. Glossary 423 external validity extent to which the program can be expected to produce similar effects in other populations. face validity if, on the face, a measure appears to measure what it is supposed to measure (McDermott & Sarvela, 1999). feasibility standards “ensure that the evaluation is viable and pragmatic” (CDC, 1999a, p. 27); a standard of evaluation. fidelity ensures that programs are implemented either as intended or as per protocol. field study the most strenuous form of pilot testing in which people from the priority population assess the process being tested in a setting that is just like or closely represents the setting in which the pro- gram will be implemented. financial management “the process of developing and using systems to ensure that funds are spent for the purposes for which they have been appro- priated” (Klingner et al., 2010, p. 88). fiscal accountability “refers to the need for sound accounting, careful documentation of expenses, and tracking or revenues” (Issel, 2014, p. 340). fiscal year (or funding year or FY) 12 months of financial transactions typically running from either January 1st to December 31st or July 1st to June 30th. flex time a system in which employees can vary their work schedule to meet their personal needs. flexibility in terms of program planning, a process that is adapted to the needs of stakeholders. fluidity in terms of program planning, a process that is sequential and logical in nature. focus group an “exploratory process that is used for generating hypotheses, uncovering attitudes and opinions, and acquiring and testing new ideas” (Gilmore 2012, p. 118). formative evaluation “any combination of mea- surements obtained and judgments made before or during the implementation of materials, methods, activities, or programs to control, assure or improve the quality of performance or delivery” (Green & Lewis, 1986, p. 362). formative research a process that identifies differences among subgroups within a population, identifies a subgroup, determines the wants and needs of the subgroup, and identifies factors that influence its behavior, including benefits, barriers, and readiness to change (Bryant, 1998). forming first stage of team development “which brings the team members together so they can get acquainted and discuss their expectations” (Gomez-Mejia & Balkin, 2012, p. 390). Framework a shortened name for the A Competency-Based Framework for Health Education Specialists—2015 (NCHEC & SOPHE, 2015). epidemiology “[t]he study of the occurrence and distribution of health-related events, states and processes in specific populations, including the study of determinants influencing such processes, and the application of this knowledge to control relevant health problems” (Porta, 2014, p. 95). equivalence reliability focuses on whether differ- ent forms of the same instrument when measuring the same participants will produce similar results. ethical issues situations where competing values are at play and program planners need to make a judgment about what is the most appropriate course of action. evaluation the process of determining the value or worth of a health promotion program or any of its components based on predetermined criteria or standards of success identified by stakeholders. evaluation approach see approaches. evaluation consultant an external evaluator. evaluation design see designs. evidence a body of data that can be used to make decisions about planning. Evidence-Based Planning Framework for Public Health a seven-phase model for evidence-based program planning. evidence-based practice process of systematically finding, appraising, and using evidence as the basis for decision making when planning a health pro- motion program (Cottrell & McKenzie, 2011). exchange process of the marketer providing a prod- uct and its benefits to the consumer in trade for the consumer paying a price. executive participants core group who are commit- ted to resolution of the concern. expectancies values people place on an expected outcome. expectations anticipation of certain outcomes from a certain behavior. expenditure a cost incurred while planning, implementing, or evaluating a program. experimental design random assignment to experimental and control groups with measure- ment of both groups. experimental group as part of a summative evalu- ation or research study, a group of individuals that receives the treatment or intervention. external audit one conducted by an independent qualified accountant usually just once a year (Businessdictionary.com, 2011a). external evaluation evaluation conducted by an individual or organization not affiliated with the organization conducting the program. external personnel individuals from outside the planning agency/organization or the priority population. 424 Glossary on behalf of a particular health goal, program, interest, or population” (Joint Committee on Terminology, 2012, p. S17). health assessments (HAs) include instruments known as health risk appraisals/assessments (HRAs), health status assessments (HSAs), various lifestyle-specific assessment instruments, and wellness and behavioral/habit inventories (SPMBoD, 1999). health behavior behaviors that impact a person’s health. health communication “the study and use of communication strategies to inform and influence individual and community decisions that affect health” (USDHHS, 2015a, para. 1). health education “[a]ny combination of planned learning experiences using evidence-based practices and/or sound theories that provide the opportunity to acquire knowledge, attitudes, and skills needed to adopt and maintain healthy behaviors” (Joint Committee on Health Education and Promotion Terminology, 2012, p. S17). health education specialist “[a]n individual who has met, at a minimum, baccalaureate-level required health education academic preparation qualifications, who serves in a variety of settings, and is able to use appropriate educational strate- gies and methods to facilitate the development of policies, procedures, interventions, and systems conducive to the health of individuals, groups, and communities” (Joint Committee on Health Education and Promotion Terminology, 2012, p. S18). health impact assessment “a combination of procedures, methods, and tools by which a policy, program, or project may be judged as to its poten- tial effects on the health of a population, and the distribution of those effects within the population” (ECHP, 1999). HIPAA (Health Insurance Portability and Accountability Act of 1996) (Public Law 104–191) sets national standards that health plans, health care clearinghouses, and health care providers who conduct certain health care transac- tions electronically must implement to protect and guard against the misuse of individually identifiable health information. health literacy ”the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions” (USDHHS, 2015b, para. 1). health numeracy “the degree to which individu- als have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health full-time equivalent (FTE) a unit of measurement that is calculated by dividing the average number of hours a person works by the average number of hours worked by a full-time employee. functionality in terms of program planning, an assurance that the outcome of planning is improved health conditions, not just the production of a program plan. Gantt chart a program management charting method that provides a graphical illustration of the time frame for tasks to be completed and what has been completed to date. gatekeepers those who control, both formally and informally, the political climate of a community. generalizability extent to which a program can be expected to produce similar effects in other populations. Generalized Model a program planning model that consists of five steps plus the quasi-step of pre-planning. GINA (Genetic Information Nondiscrimination Act of 2008) (Public Law 110–233) amends portions of HIPAA by treating genetic information as protected health information, prohibits discrim- ination in health coverage and employment based on genetic information. gifts sums of money or nonmonetary items that are given voluntarily without compensation. goal a broad statement that describes the expected outcome of the program. grant an award of financial assistance, the principal purpose of which is to transfer a thing of value from the grantor to a recipient to carry out a specific purpose. grantsmanship the ability to write grant proposals that are funded. grassroots the creation of “political movement” in which those within the community are responsible for the organizing. grassroots participation “[b]ottom-up efforts of people taking collective actions on their own behalf, and they involve the use of a sophisticated blend of confrontation and cooperation in order to achieve their ends” (Perlman, 1978, p. 65). Guide to Community Preventive Services (Community Guide) the Website that includes the Community Preventive Services Task Force’s findings and the systematic reviews on which they are based. hard money an ongoing source of funding that is part of the operating budget. health advocacy “the processes by which the actions of individuals or groups attempt to bring about social and/or organizational change Glossary 425 influencers those who control resources to facilitate the planning and implementation of a program. informed consent includes: (1) making the par- ticipants fully aware of the relevant information about the program (2) making sure the participants comprehend the information provided; and (3) obtaining the participants voluntary agreement, free of coercion and undue influence, to participate. in-house materials educational materials developed by the program planners. in-kind contributions nonmonetary gifts. innovators in diffusion theory, the very first people to adopt the innovation. inputs in a logic model, the resources that are used to plan, implement, and evaluate a program. institutional review board (IRB) group of individ- uals with authority to grant or deny permission to conduct evaluation or research; it serves to safeguard the rights, privacy, health, and well-being of those involved in the research. institutionalized imbedded in the organization so that it becomes sustained and durable. instrumentation a “collective term that describes all measurement instruments used” (Cottrell & McKenzie, 2011, p. 326). intention an “indication of a person’s readiness to per- form a given behavior, and it is considered to be the immediate antecedent of behavior” (Ajzen, 2006). interaction can be defined in one of two ways: (1) in planning—the degree to which practitioners effectively work and communicate with program participants; (2) in evaluation—when participants in the control or comparison group interact and learn from the experimental group. interactive contact methods data collection methods wherein those collecting the data interact with those from whom the data are being collected. internal audit a frequent and ongoing audit conducted by an employee of the organization not responsible for the accounting practices (BusinessDictionary.com, 2011a). internal consistency the intercorrelations among individual items on the instrument, that is, whether all items on the instrument are measuring part of the total area. internal evaluation evaluation conducted by one or more individuals employed by, or in some other way affiliated with, the organization conducting the program. internal personnel individuals from within the planning agency/organization or from within the priority population. internal validity degree to which change that was measured can be attributed to the program under investigation. information needed to make effective health deci- sions” (Golbeck et al., 2005, p. 375). health promotion “any planned combination of educational, political, environmental, regulatory, or organizational mechanisms that support actions and conditions of living conducive to the health of individuals, groups, and communities” (Joint Committee on Terminology, 2012, p. S19). Healthy Communities Model a planning model that came from a movement that began in the 1980s with assistance from the World Health Organization to mobilize and empower partnerships within cities and communities to enhance health and well-being. Healthy People U. S. government publication that brought together much of what was known about the relationship of personal health behavior and health status. Healthy Plan-It a six-phase planning model developed by the Centers for Disease Control and Prevention in 2000 to strengthen in-country management training capacity in the health sector of developing countries. impact evaluation “the immediate observable effects of a program leading to the intended out- comes of a program; intermediate outcomes” (Green & Lewis, 1986, p. 363). impact objectives a category of objectives comprised of learning (i.e., awareness, knowledge, attitudes, and skills), behavioral, and environmental objectives. implementation the “act of converting planning, goals, and objectives into action through adminis- trative structure, management activities, policies, procedures, regulations, and organizational actions of new programs” (Timmreck, 1997, p. 328). implementation science the study of how evidence-based interventions can be applied to sustain improvements to population health (Lobb & Colditz, 2013) incentive reward for achieving a goal; also used as a means to entice the consumer to purchase the product or adopt a behavior. inclusion ensures that the right partners are involved with a program. independent variable a variable that is manipulated, selected, or measured by the evaluator that causes or exerts some influence on the dependent variable. indirect cost the portion of cost that is indirectly expended in providing a product or service (VentureLine, 2015) inductive method individual cases are studied to formulate a general principle. inferential statistics data used to determine rela- tionships and causality in order to make general- izations or inferences about a population based on findings from a sample. 426 Glossary literature the articles, books, and other documents that explain the past and current knowledge about a particular topic. locus of control perception of the center of control over reinforcement. logic model “a systematic and visual way to present and share your understanding of the relationships among the resources you have to operate your pro- gram, the activities you plan, and the changes or results you hope to achieve” (WKKF, 2004, p. 1). macro practice methods of professional change that deal with issues beyond the individual, family, and small group level. maintenance stage a stage of change in which a person has changed overt behavior for more than six months. management “the process of working with and through others to achieve organizational or pro- gram objectives in an efficient and ethical manner” (Shi & Johnson, 2014, p. 658). MAP-IT Model a planning guide or model used to as- sist communities in adapting Healthy People 2020. MAPP Model Mobilizing for Action through Planning and Partnerships—a six-phase program planning model developed by the National Association of County and City Health Officials in 2001. mapping the visual representation of data by geog- raphy or location, linking information to a place (Kirschenbaum & Russ, 2005). mapping community capacity a process of iden- tifying community assets. market “the set of all people who have an actual or potential interest in a product or service” (Kotler & Clarke, 1987, p. 108). marketing a “set of processes for creating, communi- cating, and delivering value to customers” (American Marketing Association, 2007). marketing mix combination of the product, price, place, and promotion. mean the arithmetic average of all scores in data analysis. measurement the process of applying numerical or nar- rative data from an instrument or other data-yielding tools to objects, events, or people (Windsor, 2015). measurement instrument the item used to measure the variables. measures of central tendency forms of univariate data analysis involving the mean, median, and mode. measures of spread or variation how spread out the scores are in the data set. median the midpoint of all scores in data analysis. memorandum of agreement (MOA) see memorandum of understanding. memorandum of understanding (MOU) “a doc- ument that describes the general principles of an inter-rater reliability rater reliability using two or more raters. interval level measures measurement form that puts data into categories that are mutually exclu- sive, exhaustive, and rank ordered; furthermore, the distance between categories can be measured and there is no absolute zero. intervention are the planned actions that are designed to prevent disease or injury or promote health in the priority population. intervention alignment part of the fourth phase of PRECEDE-PROCEDE wherein planners match appropriate strategies and interventions with pro- jected changes and outcomes identified in earlier phases (Green & Kreuter, 2005). Intervention Mapping Model a six-phase program planning model guided by diagrams and matrices that incorporate outputs of the assessment process with relevant theory to help develop appropriate interventions for priority populations. intra-rater reliability rater reliability that is established by a single rater. justification provides assurance that programs are supported by key stakeholders. key informants individuals with unique knowledge about a topic. knowledge objective an impact objective that describes the information those in the priority population will learn. laggards in diffusion theory, people who are not very interested in innovation and would be the last to adopt it. lapse a single slip back to an old behavior while attempting a behavior change. late majority in diffusion theory, the people who are interested in the innovation but are more skeptical and need external motivation to become involved. learning objectives a sub-category of impact objectives composed of four levels: awareness, knowledge, attitudes, and skills. lesson the amount of material that can be presented during a single educational encounter. lesson plan the written outline of a lesson. level of significance see alpha level. levels of measurement a hierarchy of four measure- ment levels: nominal, ordinal, interval, and ratio. likelihood of taking recommended preven- tive health action weighing the threat of disease against the difference between benefits and barriers. literacy “the ability to use printed and written infor- mation to function in society, to achieve one’s goals, and to develop one’s knowledge and potential” (White & Dillow, 2005, p. 4). Glossary 427 nonproportional stratified random sample a stratified random sample in which the sampling units are selected so that there is equal representa- tion from the strata. norming third stage of team development “charac- terized by resolution of conflict and agreement over team goals and values” (Gomez-Mejia & Balkin, 2012, p. 390). null hypothesis the hypothesis that holds there is no difference between two groups, treatments, or interventions. numeracy the ability to understand and work with numbers; quantitative literacy. objectives precise statements of intended outcome (Gilbert, Sawyer, & McNeill, 2015). observation “notice taken of an indicator” (Green & Lewis, 1986, p. 363). obtrusive observation when people are aware they are being measured, assessed, or tested. occasional participants those who become involved on an irregular basis and usually only when major decisions are made. opinion leaders those who are well respected in a community and can accurately represent the views of the priority population. ordinal level measures measurement form that put data into categories that are mutually exclusive, exhaustive, and rank ordered. organizational culture the formal and informal policies of an organization that express the organi- zation’s values. outcome a major component of an objective that describes what will change as a result of the pro- gram; also the intended results in a logic model. outcome evaluation focuses on “an ultimate goal or product of a program or treatment, gener- ally measured in the health field by mortality or morbidity data in a population, vital measures, symptoms, signs, or physiological indicators on individuals” (Green & Lewis, 1986, p. 364). outcome expectations value placed on expected outcomes. outcome objective an objective that describes the change in health status, social benefits, risk factors, or quality of life of the priority population. outputs the direct results of the program activities or interventions in a logic model. ownership a feeling that is derived from participat- ing in the development of a program. parallel (or equivalent or alternate) forms see equivalence reliability. parametric test a statistical test that depends upon assumptions about the parameters of the population distribution(s) from which the data were drawn. agreement between parties, but does not amount to a substantive contract” (Dictionary. com, 2015). mission statement a short narrative that describes the purpose and focus of a program. mode the score or response that occurs most frequently in data analysis. model “is a composite, a mixture of ideas or con- cepts taken from any number of theories and used together” (Hayden, 2014, p. 2). motivational interviewing “is a collabora- tive, person-centered form of guiding to elicit and strengthen motivation for change (Miller & Rollnick, 2009, p. 137) multiple regression a statistical test that explores the relationships between multiple independent variables and one dependent variable. multiplicity refers to the number of components or activities that make up an intervention. multivariate data analysis analysis of more than two variables. need the “difference between the present situation and a more desirable one” (Gilmore, 2012, p. 8). needs assessment the process of identifying, analyzing, and prioritizing the needs of a priority population. negative punishment removing a positive reinforcer to decrease a behavior. negative reinforcement removing a negative rein- forcer or aversive stimulus to increase a behavior. negligence failing to act as a reasonable (prudent) person would. networking interaction among individuals in order to share information. news hook event that the media would want to cover. no contact methods data collection methods wherein those collecting the data have no contact with those from whom the data are collected. nominal group process a highly structured process in which a few knowledgeable representatives (5 to 7) are asked to qualify and quantify specific needs. nominal level measures measurement form that puts data into categories that are mutually exclusive and exhaustive. nonexperimental design use of pretest and posttest comparisons, or posttest analysis only, without a control group or comparison group. nonmaleficence not causing harm. non-parametric test a statistical test that does not depends upon assumptions about the parameters of the population distribution(s) from which the data were drawn. nonprobability sample a sample in which all members of a survey population do not have an equal and known probability of being selected. 428 Glossary planning models those used for planning, imple- menting, and evaluating programs. planning parameters the boundaries in which the planning committee must work when planning, implementing, and evaluating the program. planning team see planning committee. population as it relates to sampling, those in the universe specified by time or place. population-based approach planning processes used with large populations. positive punishment adding something to a situation that decreases a behavior. positive reinforcement a consequence of a behav- ior that is enjoyable or makes a person feel good. posttest testing components of a program, service, or product with the priority population after the completion of a program. potential building blocks located resources originating outside the neighborhood and controlled by people outside. PRECEDE-PROCEED Model (Predisposing, Reinforcing, Enabling Constructs in Ecological Diagnosis and Evaluation—Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) a widely known and robust eight-phase program planning model. precontemplation stage a stage of change in which a person has no intentions to take action in the next six months. predictive validity a form of criterion validity in which the measurement used will be correlated with another measurement of the same phenomenon at another time. predisposing factor “any characteristic of a person or population that motivates behavior prior to the occurrence of the behavior” (Green & Kreuter, 2005, p. G–6). pre-experimental design see nonexperimental design. preliminary review a form of pilot testing in which colleagues of planners review a process being tested. preparation stage a stage of change in which a per- son intends to take action in the next 30 days and has taken some behavioral steps in this decision. pre-pilot a form of pilot testing in which five or six people from the priority population assess the process being tested. pre-planning a process carried out prior to the formal planning process that allows a core group of people to gather answers to key planning questions. pretest testing components of a program, service, or product with the priority population prior to implementation. pretesting can be defined in one of two ways: (1) getting feedback from the priority population participation and relevance “community organizing that ‘starts where the people are’ and engages community members as equals” (Minkler & Wallerstein, 2012, p. 45). participatory data collection members of the priority population participate in data collection. participatory research has been “defined as sys- tematic inquiry, with the collaboration of those affected by the issue being studied, for the purposes of education and of taking action or effecting change” (Mercer et al., 2008, p. 409). partnering the association of two more entities working together on a project of common interest. peer education a process wherein individuals are educated by others who have similar characteristics or standing as themselves. penetration rate number in the priority population exposed or reached. perceived barriers costs that must be overcome in order to follow a health recommendation. perceived behavioral control perceived ease or difficulty of performing the behavior. perceived benefits belief that a certain action could improve one’s health. perceived seriousness/severity belief that if a disease or condition were contracted it could be serious. perceived susceptibility belief that one is vulner- able to a certain disease or condition. perceived threat belief that one is vulnerable to a serious health problem or to the sequelae of that illness or condition. performing fourth stage of team development “characterized by a focus on the performance of the tasks delegated to the team” (Gomez-Mejia & Balkin, 2012, p. 391). phased in implementation of a program by limiting the number of people able to start the program at any given time. photovoice those in the priority population are provided with cameras and skills training, then use the cameras to convey their own images of the community’s problems and strengths. pilot testing a set of procedures used to try out various processes during program develop- ment using a small group of participants prior to implementation. place where the priority population has access to the product or where they may engage in the desired behavior. PATCH an acronym for a planning process called Planned Approach to Community Health. planning committee group of individuals who are responsible for creating a program and then over- seeing its implementation and evaluation. Glossary 429 program significance measures the meaningfulness of a program (based on stakeholder preferences) regardless of statistical significance. promotion marketing communication strategy for letting a priority population know about a product and how to obtain or purchase it. proportional stratified random sample a strati- fied random sample in which the sampling units are selected in the same proportion that the strata exist in the survey population. proposal a formal written request for funding. propriety standards “ensure that the evalua- tion is ethical” (CDC, 1999a, p. 27); a standard of evaluation. proxy measure an outcome measure that provides evidence that a behavior has occurred. prudent acting as a reasonable person would act in a given situation. psychometric qualities an instrument’s validity, reliability, and fairness. public domain available for anyone to use without permission. punishment any event that follows a behavior which decreases the probability that the same behavior will be repeated in the future. qualitative data information presented in narrative form used in evaluation to provide detailed sum- maries or descriptions of observations, interactions, or verbal accounts (e.g., data from focus groups, in- depth interviews). qualitative measures are “data collected with the use of narrative and observational approaches to understand individuals’ knowledge, percep- tions, attitudes and behaviors” (Harris, 2010 p. 208). qualitative method an inductive method that produces narrative data. quality in evaluation, a measure usually associated with how a program is implemented and what can be done to improve program delivery. quantitative data information expressed in numerical terms that can be compared on scales. quantitative measures “are numerical data collected to understand individuals’ knowledge, understanding, perceptions, and behavior” (Harris, 2010, p. 208). quantitative method a deductive method that produces numeric data. quasi-experimental design use of a treatment group and a nonequivalent (nonrandomized) comparison group with measurement of both groups. random selection a method of selecting partici- pants in which all in the survey population have an equal chance or known probability of being selected. on products, messages, and materials before launching a social marketing campaign, and (2) collecting baseline data prior to program imple- mentation that will be compared with posttest data to measure the effectiveness of programs. price what the priority population gives up to obtain the product and its associated benefits. primary building blocks assets located in the neighborhood and largely under the control of those who live in the neighborhood. primary data original data collected by the planners. primary prevention measures that forestall the onset of illness or injury during the prepathogen- esis period. priority population the people for whom the program is intended. probability sample a sample in which all in the survey population have an equal and known probability of being selected. process evaluation “is used to monitor and docu- ment program implementation and can aid in understanding the relationship between specific program elements and program outcomes” (Saunders, Evans, & Joshi, 2005, p. 134). process objective an objective that expresses the tasks or activities to be carried out by the program planners. processes of change a construct of the transtheo- retical model that describes the covert and overt activities that people use to progress through the stages of change (Prochaska et al., 2008). product something (e.g., goods, services, events, experiences, information, ideas, or behaviors) that fulfills a need customers have and provides a benefit they value; obtained for a price in the exchange. profit margin the percent of financial gain after all the expenses are paid. PERT acronym for Program Evaluation and Review Technique; a program management charting method that provides a graphical illustration of the time frame for tasks to be completed that includes three estimates of time—optimistic, pessimistic, and probabilistic. program kickoff see program launch. program launch the first day of program implementation. program monitoring involves the ongoing collection and analysis of data and other infor- mation to determine if the program is operating as planned. program ownership a feeling by those in the pri- ority population that the program in part belongs to them. program rollout see program launch. 430 Glossary response ensuring that an adequate number of people participate in a program. return on investment (ROI) “measures the costs of a program (i.e., the investment) versus the financial return realized by that program” (Cavallo, 2006, p. 1). Role Delineation Project a comprehensive process that led to the creation of the responsibilities and competencies of the entry-level health educator. sample a part of the whole. sampling the process of selecting a sample. sampling frame a list or quasi-list of all sampling units. sampling unit an element or set of elements con- sidered for selection as part of a sample (Babbie, 1992); for example, an individual, organization, or geographical area. satisfaction approval after participation. scope the breadth and depth of the material covered in a curriculum. secondary building blocks assets located in the neighborhood but largely controlled by people outside. secondary data those data that have been collected by someone else and are available for use by the planners. secondary prevention measures that lead to early diagnosis and prompt treatment of a disease, illness, or injury to limit disability, impairment, or depen- dency and prevent more severe pathogenesis. seed dollars funds designated to start up a new program or project. segmentation process of identifying groups of consumers that share similar characteristics and will respond in a like way to a marketing strategy. segmenting the act of segmentation. self-assessments a process wherein an individual assesses himself or herself. self-control gaining control over one’s own behav- ior through monitoring and adjusting it. self-efficacy people’s confidence in their ability to perform a certain behavior or task. self-regulation see self-control. self-reinforcement reinforcing oneself for a behavior performed in an appropriate manner. self-report when individuals or groups answer questions about themselves. sensitivity “the ability of the test to identify correctly all screened individuals who actually have the dis- ease [problem]” (Friis & Sellers, 2009, p. 422). sequence order in which the content of a curriculum is presented. significant other one who has an important relation- ship (e.g., friend, family member, partner, spouse) with another. random-digit dialing (RDD) a method of select- ing participants using random combinations of numbers to call telephone numbers. range the difference between the highest and lowest scores in data analysis. rater (or observer) reliability associated with the consistent measurement (or rating) of an observed event by the same or different individuals (or judges or raters) (McDermott & Sarvela, 1999). ratio level measures measurement form that puts data into categories that are mutually exclusive, exhaustive, and rank ordered; furthermore, the distance between categories can be measured and there is an absolute zero. reach portion of the priority population that has an opportunity to participate in a program. recidivism slipping back to an old behavior after attempting a behavior change. reciprocal determinism behavior changes that result from the interaction between the person and the environment. recruitment making those in the priority population aware of a program. reforming a phase of team development when the team may continue on by refocusing its efforts on other tasks or problems. reinforcement any event that follows a behavior which increases the probability that the same behavior will be repeated in the future (Skinner, 1953). reinforcing factor “any reward or punishment following or anticipated as a consequence of a behavior, serving to strengthen the motivation for the behavior after it occurs” (Green & Kreuter, 2005, p. G–7). relapse breakdown or failure in a person’s attempt to change or modify a behavior (Marlatt & George, 1998). relapse prevention a self-control program to help individuals to anticipate and cope with the problem of relapse in the behavior change process (Marlatt & George, 1998). reliability “an empirical estimate of the extent to which an instrument produces the same result (measure or score), if applied two or more times” (Windsor, 2015, p. 196). request for application (RFA) a formal statement that invites grant or cooperative agreement appli- cations for a specific task. request for proposal (RFP) a call made by funding agencies to alert individuals and organizations that it will receive and review grant proposals. resources the “human, fiscal, and technical assets available” (Johnson & Breckon, 2007, p. 296) to plan, implement, and evaluate a program. Glossary 431 specificity “the ability of the test to identify only nondiseased individuals who actually do not have the disease” (Friis & Sellers, 2009, p. 424). stability reliability (test-retest reliability) estimate of consistency over a period of time (Crocker & Algina, 1986) stage a step in the change process. stage theory a theory composed of an ordered set of categories into which people can be classified, and for which factors could be identified that could induce movement from one category to the next (Weinstein & Sandman, 2002a). stakeholders any person, community, or organiza- tion with a vested interest in a health program, usually decision makers, program partners, or clients. standards of evaluation utility, feasibility, propri- ety, and accuracy (see definitions for each term in other parts of the glossary). statistical significance “is a statement regard- ing the likelihood that observed variable values happened by chance” (Sharma & Petosa, 2014, p. 281). steering committee see planning committee. storming second stage of team development “in which team members voice differences about team goals and procedures” (Gomez-Mejia & Balkin, 2012, p. 390). strata in terms of sampling, subgroups of the survey population. strategy a general plan of action for affecting a health problem; it may encompass several activities (CDC, 2003). stratified random sample a probability sample that first divides the survey population into strata and then randomly selects participants from each strata. subjective norm “the perceived social pres- sure to engage or not to engage in a behavior” (Ajzen, 2006). SAM (suitability assessment of materials) an instru- ment that can be used to determine the suitability of educational of materials. summative evaluation “any combination of mea- surements and judgments that permit conclusions to be drawn about impact, outcome or benefits of a program or method” (Green & Lewis, 1986, p. 366). support ensures that programs have appropriate built-in reinforcement components to assist par- ticipants with the expected level of involvement and/or behavior change. supporting participants those who are seldom involved but help to swell the ranks of a program and may contribute in nonactive ways or through financial contributions. simple random sample (SRS) most basic process for selecting a random sample. single-step survey a means of gathering data in which collectors obtain the data from individuals or groups with a single contact. skill development objective an impact objective that describes the skill those in a priority population will be able to perform. sliding-scale fee a fee structure based on one’s ability to pay. SMART Model (Social Marketing Assessment and Response Tool) a seven-phase social marketing planning model developed in 1998. SMART objectives ones that are specific, measurable, achievable, realistic, and time-phased (CDC, 2003). social assessment the first phase of PRECEDE- PROCEED wherein planners seek to subjectively define the quality of life (problems and priorities) of those in the priority population. social capital “the processes and conditions among people and organizations that lead to their accom- plishing a goal of mutual social benefit, usually characterized by interrelated constucts of trust, cooperation, civic engagement, and reciprocity, reinforced by networking” (Last, 2007, p. 347) social context “is the sociocultural forces that shape people’s day-to-day experiences and that directly and indirectly affect health and behavior (Burke et al., 2009, p. 56S). social marketing the use of marketing principles to design programs that facilitate voluntary behavior change for the purpose of improved personal or societal well-being. social math “the practice of translating statistics and other data so they become interesting to the jour- nalist, and meaningful to the audience” (Dorfman et al., 2004, p. 112). social media (or interactive media) any type me- dia that uses the Internet and other technologies to enhance social interaction for shaing and discuss- ing infomation. social network “web of social relationships and the structural characteristics of that web” (IOM, 2001, p. 7). social support a network of individuals that pro- vides assistance or encouragement to a person who is engaging in a new behavior. socio-ecological approach (or ecological prespective) recognizing that human beavior shapes and is shaped by multiple levels of influence. soft money a source of funding that is not an ongoing part of an operating budget. speakers’ bureau a service offered by various groups with experts who are willing to present information to others. 432 Glossary variables in order to explain and predict the events of the situations” (Glanz et al., 2008b, p. 26). three Fs of program planning fluidity, flexibility, and functionality (see definitions for each term in other parts of the glossary). treatment see intervention. triple blind study an evaluation wherein neither the participants, nor those implementing the program, nor the evaluators, know which group is experimental and which group is the control. t -test a statistical test involving interval or ratio data that assesses whether the means of two groups are statistically different from each other. Type I error rejecting the null hypothesis when it is actually true. Type II error failing to reject the null hypothesis when it is, in fact, not true. Type III error failure to implement the health edu- cation intervention properly (Basch et al., 1985). unit plan “an orderly, self-contained collection of activities educationally designed to meet a set of objectives” (Gilbert et al., 2015, p. 202). univariate data analysis analysis of one variable. universe as it relates to sampling, all those unspecific by time and place. unobtrusive observation when people are not aware they are being measured, assessed, or tested. utility standards “ensure that the information needs of evaluation users are satisfied” (CDC, 1999a, p. 27); a standard of evaluation. validity whether an instrument correctly measures what it is intended to measure. variable a construct, characteristic, or attribute that can be measured or observed. vendors those who sell their products to program planners. vicarious reinforcement observation of another being reinforced. vision statement a description of where a program will be in the future. volunteers those who serve an organization or cause without pay or compensation. walk-through an observation completed by walk- ing through an area at various times on different days looking for indicators of health. windshield tour an observation completed by driving through an area at various times on different days looking for indicators of health. survey population in terms of sampling, those in the universe specified by time or place, and who are accessible. SWOT (Strengths, Weaknesses, Opportunities, and Threats) an approach to planning that minimizes planning time and moves quickly to action steps by assessing internal strengths and weaknesses as well as external opportunities and threats, usually displayed in a 2 × 2 matrix. systematic sample a probability sample that selects participants from a sampling frame by taking every Nth person after a random start. tailoring “any combination of information or change strategies intended to reach one specific person, based upon characteristics that are unique to that person, related to the outcome of interest, and have been derived from an individual assess- ment” (Kreuter & Skinner, 2000, p. 1). task development time line a program management charting method that provides a graphical illustra- tion of the time frame for tasks to be completed. task force “a self-contained group of ‘doers’ that is not ongoing. It is convened for a narrow purpose over a defined timeframe at the request of another body or committee” (Butterfoss, 2013, p. 7). team “a small group of people with complementary skills who are committed to a common purpose, a set of performance goals, and an approach for which they hold themselves mutually account- able” (Gomez-Mejia & Balkin, 2012, p. 384). technical assistance (or technical support or capacity building assistance) a relationship in which individuals with specific knowledge and skills share them, via advice and training, with those who need them. technical resources (or other resources) includes all other resources besides human or financial. temptation “the intensity of urges to engage in a specific behavior when in difficult situations” (Prochaska et al., 2008, p. 102). termination a stage of change in which a person who has changed a behavior has zero temptation to return to the old behavior. tertiary prevention measure aimed at rehabilita- tion following significant pathogenesis. test–retest reliability see stability reliability. theory “a set of interrelated concepts, definitions, and propositions that presents a systematic view of events or situations by specifying relations among 433 RefeRences Abroms, L. 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B., 168 Ahlers-Schmidt, C. R., 201 Airhihenbuwa, C. O., 7 Aitaoto, N., 248 Ajzen, I., 160, 161, 162 Alexander, G., 81, 82 Alexander, G. R., 70, 166 Algina, J., 113, 116, 118 Allen, J., 19, 36 Allen, R. S., 164 Alvarez, C. M., 299, 308 Alvarsson, M., 53 American Association of Health Edu- cation (AAHE), 7, 9 American Cancer Society (ACS), 24, 60, 69, 85, 266, 274, 277, 279, 288, 333 American College of Sports Medicine (ACSM), 225 American Congress of Obstetricians and Gynecologists (ACOG), 340 American Evaluation Association (AEA), 132, 363 American Heart Association (AHA), 25, 55, 85, 266 American Legion, 182 American Lung Association, 274, 277 American Marketing Association (AMA), 291, 316 American Psychological Association, (APA), 86 American Public Health Association (APHA), 215 American Society for Quality (ASQ), 348 Ammary-Risch, N. J., 194 Anderson, D. R., 196, 220 Anderson, J. G., 82 Andreasen, A. R., 291, 313 Angadi, S. S., 186 Angus, K., 168, 187 Anspaugh, D. J., 324, 326 Anspaugh, S. L., 324 Arias, E., 2 Arkin, E. B., 199 Ashraf, N., 218, 219, 220 Asset-Based Community Develop- ment (ABCD) Institute, North- western University, 256 Association for Community Health Improvement, 65 Association of State and Territorial Health Officials (ASTHO), 39, 401 Auld, M. E., 4 Aziz, N., 196 B Baack, D., 307 Babbie, E., 121, 124, 126 Bagozzi, R. P., 293 Baird, M., 10 Baker, E. A., 26, 43, 68, 230 Balkin, D. B., 270, 271, 326, 329, 330 Bandura, A., 171, 176, 177, 178 Banks, B., 53 Baranowski, T., 72, 157, 177, 178 Barden, J., 165, 166 Bardhoshi, G., 81 Baric, L., 229 Barker, J. C., 155 Barnes, M. D., 195, 212, 292 Barnett, K., 94 Bartholonew, L. K., 34, 50, 51, 63, 322 Bartol, K. M., 58 Basch, C. E., 192, 196, 197, 342 Bates, I. J., 9 Baun, M. P., 197 Bebeau, D., 155 Beck, A. T., 115, 116 Becker, M. H., 157, 162 Becker, S. J., 306 Bee, P., 53 Behrens, R., 19 Belch, G. E., 301, 306 Belch, M. A., 301, 306 Bell, L., 80 Bennett, G. G., 199 Bennion, S. R., 199, 200 Bensley, L. B., 339 Beresford, S. A. A., 197 Bergen, G., 68 Bernard, A. L., 78 Bernoff, J., 199, 200 Beyer, K. M. M., 90 Bhatt, S., 305 Billingham, K., 68 Binkley, C., 48 Birnbaum, A. S., 308 Bishop, A., 48 Bishop, D. B., 192, 229 Bizer, G. Y., 165 Black, J. S., 36 Blalock, S. J., 157 Blanchard, L., 80 Block, L. E., 209 Blumberg, S. J., 75 Blumenthal, D., 53 Bockarjova, M., 164 Boeka, A., 165 Boles, S. M., 233 Boltong, A., 101 Bonzo, S. E., 335 Borba, C. P. C., 154 Borg, W. R., 128 Boston University School of Public Health, 187 Bowling, A., 71, 72, 111, 115, 116, 121 Bradshaw, T., 53 Brager, G., 246, 254 Braithwaite, R. L., 245 Brandt, E. N., Jr., 10 Braun, K. L., 248, 335 Breckon, D. J., 10, 12, 17, 35, 204, 261, 282, 283, 322, 324, 326, 329, 330, 331 Breen, M., 281 Brennan, L., 196 Brennan Ramirez, L. K., 68, 69, 101, 208 Breslow, L., 2, 4 Briñol, P., 165, 167 Brissette, I. F., 90 Bronfenbrenner, U., 155 Brown, K. M., 194 Brown, L. D., 248 Brown-Connolly, N. E., 305 Brown-Johnson, C. G., 306 Brownson, R. C., 25, 43, 96, 204, 209, 210, 226, 230 Bryan, R. L., 204 Bryant, C., 53, 56, 57 Bryant, C. A., 294, 297, 300, 373 Buckner, A., 53 Bui, L., 164 Bunyan, W., 46 Burke, N. J., 155 Burris, M. A., 80, 81 BusinessDictionary.Com, 217, 331 Butterfoss, F. D., 247, 248, 249, 267, 270, 271, 355 Byrd, J. C., 201 C Cairrney, J., 72 Calao, R., 219 California Department of Health Services, 59 California Healthy Cities, 51 California State University, Chico, 88, 104 Campbell, D. T., 381–82, 383 460 Name Index Dove, C., 90 Downey, L. H., 81 Dreisinger, M., 230 Drum, C. E., 342, 344 Dunn, W. N., 209 E Edberg, M., 154, 179, 181 Edington, D., 36 Educational Resources Information Center (ERIC), 87, 385 Edwards, P. J., 75 Edwards, R. W., 184–85, 186 Eggen, P., 135 Elder, J. P., 308 Elks, 182 Embrace, 296 Eng, E., 80 Engels, R., 50 England, L. J., 306 English, J., 305 Environmental Protection Agency (EPA), 85 Erfurt, J. C., 192 Ervice, J., 29 Estrada, C., 201 European Social Marketing Association, 316 Evans, M. H., 354, 370 Everett, C. J., 3 Evers, K. E., 168, 172 F Facebook, 199 Fagen, M. C., 59, 94 Fallahzadeh, H., 48 Fallon, L. F., 268, 282, 283, 329, 330, 346 Farrell, D., 196 Feinberg, M. E., 248 Fernández, M. E., 34, 50, 51 Fertman, C. I., 278 Fielding, R. C., 43, 96, 146, 226 Fink, A., 352, 355, 381, 388, 389 Fishbein, M., 160 Fisher, E. B., 155 Fisher, J. D., 167, 168 Fisher, W. A., 167 Fitzpatrick, J. L., 361, 392, 394, 395 Flickr, 199 Flint’s Youth Violence Prevention Center (FYVPC), 80 Flores, L. M., 210 Floyd, D. L., 163, 164 FluidSurveys, 76 Food & Drug Administration (FDA), 85 Forde, I., 101 Forsen, J. W., 117 Forthofer, M. S., 53, 57, 297, 300 Francisco, V. T., 355 Franco, O. H., 2 Frankish, C. J., 233 Freire, K. E., 225, 226 French, S. A., 218 Friedan, T. R., 210 Friedman, A. L., 304 Friedman, A. R., 253 Friis, R. H., 116 Fulkerson, K. N., 302, 303 Furlong, N., 392 Communities of Practice (CoP) for Public Health, 150 Community Health Assessment and Group Evaluation, 52 Community Preventive Services Task Force (CPSTF), 32, 38, 82 Concha, J. B., 305 Conner, M., 50 Connolly-Schoonen, J., 186 Connor, J., 297 Connors, M. C., 221 Cook, T. D., 381–82, 383 Corburn, J., 90 Cottrell, R. R., 8, 25, 73, 76, 88, 107, 110, 111, 113, 114, 116, 117, 118, 124, 125, 126, 129, 135, 141, 153, 180, 339, 361, 389 Council for the Accreditation of Educator Preparation (CAEP), 9 Council on Education for Public Health (CEPH), 9 County Health Rankings, 85, 99 Coupland, K., 211 Courtney, A., 306 Cowdery, J. E., 153 Cox, F. M., 241 Cozby, P. C., 126 Craig, C. L., 114 Cramer, R. J., 165 Creative Research Systems, 132 Creswell, J. W., 389 Crocker, L., 113, 116, 118 Crosby, R. A., 10, 152, 153, 154, 166, 181 Crowther, M. R., 164 Culley, C., 344 Culross, P., 210 Cummings, B., 227 Cummings, C., 187 Curfs, L., 50 Cvengros, J., 158 D Dane, F. C., 130 Datta, J., 359 Davidson, A., 211 Davis, P. C., 271 Davis, R., 210 Dedhia, R. C., 368 Deeds, S. G., 5, 89, 136, 137, 138 DeJoy, D. M., 20 Della, L. J., 20 Dessler, G., 327, 328, 330 DeVellis, R., 179 Devito-Staub, G., 46 Dickson, P. R., 299, 308 DiClemente, C. C., 170 DiClemente, R. J., 10, 152, 153, 154, 166 Dietrich, T., 297 Diez Roux, A. V., 25 Dignan, M. B., 73, 118, 324, 376 DiIorio, C. K., 111, 114, 116 Dillow, S., 200, 201 Dishman, R. K., 177 Dismuke, S. E., 201 Doak, C. C., 272, 273 Doak, L. G., 272, 273 Doll, L. S., 335 D’Onofrio, C. N., 233 Dorfman, L., 29 Campbell, M., 53 Campbell Collaboration, 27 Canadian Evaluation Society (CES), 364 Canadian Task Force on Preventive Health Care, 27 Cancer Control and Population Sci- ences, National Cancer Institute (NCI), 190 Cancer Prevention Resource Center (CPRC), University of Rhode Island, 190 Capwell, E. M., 355 Carbin, M. G., 115, 116 Carey, J. W., 227 Carlos, B. R., 268, 269 Carnemolla, M., 3 Carovano, K., 81 Castellan, N. J., Jr., 109 Catalani, C., 81 Cavallo, D., 23 CDC Wonder, 104 Centers for Disease Control and Pre- vention (CDC), 2, 22, 23, 24, 25, 26, 30, 31, 32, 45, 52, 53, 57, 65, 74, 79, 85, 90, 100, 101, 104, 112, 136, 145, 150, 190, 193, 199, 201, 202, 209, 211, 230, 233, 236, 247, 248, 253, 267, 288, 289, 301, 321, 322, 333–34, 348, 356, 357, 358, 362, 364, 374, 375, 397, 401 Centers for Medicare & Medicaid Services (CMS), 29, 101 Central Intelligence Agency (CIA), 2 Centre for Reviews And Dissemina- tion: The University Of York, 27 Chambers, D. A., 25 Champion, V. L., 118, 162 Chang, S. J., 167 Chaplin, J. P., 152 Chapman, L. S., 19, 24, 26, 33, 34, 35, 36, 197, 212, 218, 220, 221, 333 Checkoway, B., 212 Chen, H. T., 354, 355, 381 Chen, J., 296 Choi, S., 167 Chriqui, J. F., 209 Christensen, A., 158 Christensen, B., 197 Clark, N. M., 177, 253, 254, 255 Clarke, R. N., 294 Cleary, M. J., 136, 137 Cleary, P. D., 186 Clow, K. E., 307 Coalition for a Smokefree Philadelphia County, 32 Coalition of National Health Education Organizations (CNHEO), 338–39, 348 Coca-Cola, 55 Cocrane, 27 Cohen, J., 113 Cohen, J. T., 24 Colditz, G. A., 335 Cole, R., 48 Cole, S. L., 335 Collins, C., 201, 227 Collins, D., 129 Collins, J., 52 Colorado State University, 184, 186 Name Index 461 Jalili, Z., 48 Janz, N. K., 118, 162 Jaycees, 279 Jeffery, R. W., 218 Jenkins, L., 200 Jensen, M. A. C., 270 Jin, Y., 200 Jobe, J. B., 308 John, R., 304 Johnson, A., 267, 269, 326, 327, 328, 345, 346 Johnson, G., 58 Johnson, J. A., 35, 261, 282, 283, 322, 326, 329, 330, 331 Johnson, K., 48 Johnson, S., 168 Joint Committee on Health Education and Promotion Termino logy, 4, 5, 11, 212, 237, 271 Jones, C. J., 162 Jones, P., 227 Jones-Webb, R., 335 Joseph, G., 155 Joshi, P., 354, 370 Jumper-Thurman, P., 184–85, 186 Jungblut, A., 200 K Kaiser Family Foundation (KFF), 99, 104 Kaiser Permanente, 307 Karamehic-Muratovic, A., 230 Karwalajtys, T., 212, 242 Kasprzyk, D., 161 Kauchak, D., 135 Kawachi, I., 181 Kegler, M. C., 153, 154, 166, 248 Keller, K. L., 300, 369 Kelly, K. J., 297 Kerby, D. S., 304 Kerlinger, F. N., 152, 153 Kerner, J. F., 25 Kilingner, D. E., 270 Kim, D., 181 Kim, S-A., 167 Kimptron, T., 344 King, A. C., 297 King, D. E., 3 Kinzie, M. B., 205, 206 Kirsch, I. S., 200 Kirschenbaum, J., 90 Kiwanis, 33 Kleinjan, M., 50 Kline, M. V., 93, 192 Klingner, D. E., 327, 329, 330 Knickman, J. R., 3 Kochanek, K. D., 2 Koelen, M., 358, 359 Kok, G., 34, 50, 51, 373 Kolstad, A., 200 Kotler, P., 291, 294, 300, 301, 312 Krahn, G., 342, 344 Kramer, L., 80, 81 Kramer, S., 116 Krawiec, T. S., 152 Krefetz, D. G., 115 Krenz, V. D., 93 Kreps, G. L., 195, 196 Kretzmann, J. P., 249, 250, 251, 252 Hancock, T., 71, 80 Hanlon, J. J., 94 Hannon, C., 335 Hannon, P. A., 197 Hanson, C. L., 199 Harlow, L. L., 170 Harris, E., 152 Harris, J. H., 265, 266 Harris, J. R., 197 Harris, M. J., 107, 113, 354, 382 Harshbarger, C., 227 Hartman, J. M., 117 Hasnain, M., 196 Hastings, G., 300 Haveman, R. H., 218, 220 Hawe, P., 233 Hawkins, J., 90 Hayden, J., 152, 182 Hayes-Constant, T., 48 Health Communication Capacity Collaborative, National Cancer Institute (NCI), 190 Health Enhancement Research Organization, 102 Heaney, C. A., 176, 179, 180 Helitzer, D., 321 Heller, T., 344 Hendrie, D., 24 Henry J. Kaiser Family Foundation, 85 Herbert, K., 29 Hergenrather, K. C., 81 Hershey, J., 45 Hether, H. J., 307 Hill, K., 211 Hillier, A., 90 Hippocrates, 339 Hitt, M. A., 36, 326, 327 Holmes-Chavez, A., 52 Hopkins, B. R., 114 Hopkins, K. D., 114 Horacek, T., 48 Howlett, B., 25 Hu, F. B., 2 Huff, R. M., 93, 192 Hunkins, F. P., 205 Hunnicutt, D., 11, 19, 35, 82, 210, 217, 218 Hunter, G. K., 299, 308 Hunter, M., 199, 213, 214 Hurlburt, R. T., 109 Hutchinson, P. M., 80 Hylander, B., 53 Hyner, G. C., 82 Hynes, M., 154 I Indiana Healthy Cities, 51 Institute of Medicine (IOM), 10, 69, 155, 176, 179, 211, 223, 224 International Social Marketing Association, 316 Ireson, C. L., 81 Israel, B. A., 176, 179, 180 Issel, L. M., 268, 269, 324, 345, 381 Iton, A., 90 J Jackson, C., 50 Jacobs, J. A., 359 Jacobsen, D., 135 G Gaesser, G. A., 186 Gagne, R., 205 Galbraith, J. S., 227 Galer-Unti, R. A., 212, 213 Gall, M. D., 128 Gambatese, J. A., 28 Gantt, H., 324 Garcia, J., 245 Garvin, C. D., 241 Gaston, A., 164 Gelaude, D., 227 George, D., 113 George, W. H., 186, 187 Gerberding, J. L., 2 Getha-Taylor, H., 271 Gilbert, G. G., 136, 204, 205, 206, 272 Giles, W., 52 Gillespie, K. N., 26, 43 Gilmore, G. D., 33, 67, 68, 77, 79, 81, 84, 94, 125 Girvan, J. T., 8, 180 Gittell, R., 182 Glantz, S. A., 306 Glanz, K., 90, 152, 153, 154, 155, 156, 157, 172, 175, 176, 178–79, 183, 192, 229 Glasgow, R. E., 199, 233, 359 Goetzel, R. Z., 20, 24, 101, 102 Golaszewski, T., 36, 217 Golbeck, A. L., 201 Goldman, K. D., 184, 322 Goldsmith, M., 338 Goldstein, M. G., 171 Goldstein, S. M., 248 Gomez-Mejia, L. R., 270, 271, 326, 329, 330 Gonzales, A., 50 Goode, A. D., 196 Goodhard, F. W., 80 Goodlad, J. I., 205 Goodman, R. M., 36, 68, 184, 335 Goodson, P., 152, 153, 154, 176 Goodwin, A., 209 Google Charts, 401 Gordon, J. R., 187 Gottlieb, N. H., 34, 50, 51 Graff, R., 90 Grant Central Station, 285 Grants. Gov, 289 Grattan, B. J., Jr., 186 Green, L. W., 3, 4, 13, 48, 49, 50, 79, 97, 123, 136, 146, 184, 203, 209, 230, 238, 353, 354, 355, 374 Greenberg, E., 200 Greenberg, M. T., 248 Greene-Moton, E., 271 Grier, S., 373 Grossmeier, J., 196 Grudzien, L., 222, 330 Grunbaum, J. A., 68 Gulab, N. A., 115 Gurley, L., 142 Guyer, M., 280 H Haire-Joshu, D., 210 Hall, C. L., 157 Hall, J. H., 81 462 Name Index Mullan, B., 164 Munro, S., 187 Murphy, S. L., 2 MySpace, 199 N National Assessment of Adult Literacy (NAAL), 200, 201 National Association of County and City Health Officials (NACCHO), 32, 45, 46, 64 National Business Group on Health, 25, 102 National Cancer Institute (NCI), 27, 57, 79, 85, 167, 190, 194, 203, 230, 308, 312, 359, 373, 376, 401 National Center for Chronic Disease Prevention and Health Promo- tion (NCCDPHP), 135, 138, 141 National Center for Cultural Compe- tence (NCCC), 236 National Center for Health Statistics (NCHS), 2, 22, 104, 117, 131, 401 National Center for Injury Prevention and Control (NCIPC), 29, 190 National Commission for Certifying Agencies (NCCA), 7 National Commission for Health Education Credentialing, Inc. (NCHEC), 6, 7, 8, 9, 14, 18, 42, 70, 106, 134, 155, 193, 239, 262, 292, 320, 351, 352, 388 National Commission for Protec- tion of Human Subjects of Biomedical and Behavioral Research, 339 National Committee for Quality Assurance, 25 National Highway Traffic Safety Ad- ministration (NHTSA), 68, 401 National Institutes of Health (NIH), 289 National Research Council of the National Academies (NRC), 100, 211 National Social Marketing Centre (NSMC), 317 National Task Force on the Preparation and Practice of Health Educators, 6 Ndjakani, Y., 53 Neely, J. G., 117 Neiger, B. L., 53, 54, 59, 94, 95, 96, 135, 136, 137, 174, 194, 195, 199, 212, 292, 302, 303, 308, 369 Nelson, T., 335 NetMBA, 326 Neumann, P. J., 24 Neutens, J. J., 76, 84 Newcomer, K. E., 389 Newsvine, 199 Norcross, J. C., 170 Norman, G. R., 72 Northwestern University, 256 Norwood, S. L., 127 Nutbeam, D., 152 Nye, R. D., 158, 159 Nyswander, M., 238 Malone, S., 168 Marcarin, S., 89 Marks, J. S., 2 Marlatt, G. A., 186, 187 Martin, D. C., 58 Martinez-Cossio, N., 271 Martin-Hryniewicz, M., 201 Masoudy, G., 48 Mastin, B., 302 Mausner, J. S., 116 Maylahn, C. M., 43, 96, 226 Mays, D., 154 Mazloomymahmoodabad, S., 48 McAlister, A. L., 178, 180 McCaffery, K., 164 McCall, D., 229 McCaul, K. D., 186 McClelland, A., 68 McClendon, B. T., 164 McCormack-Brown, K., 53, 57, 292 McCubbin, J., 344 McDade-Montez, E., 158, 159 McDermott, R. J., 53, 57, 92, 108, 114, 116, 126, 128, 324, 377 McDonald, M., 306 McEachen, R., 50 McGinnis, J. M., 3, 24, 220 McGraw, H. C., 203 McIntosh, L. D., 230 McIntyre, C., 196 McKee, P., 335 McKenzie, J. F., 8, 24, 25, 33, 35, 36, 73, 76, 107, 110, 111, 113, 114, 115, 116, 117, 118, 124, 125, 126, 129, 135, 141, 174, 180, 199, 238, 244, 245, 265, 292, 361, 389 McKleroy, V. S., 226, 227 McKnight, J. L., 249, 250, 251, 252 McLellan, D. L., 197 McLeroy, K. R., 153, 155 McMaster University, 27 McMath, B. F., 165 McNeil, D., 211 McNeill, E. B., 136, 204 Mendy, V. L., 90 Mercer, S. L., 91 Mercy, J. A., 335 Meriam Library at California State University, Chico, 88, 104 Mertz, C. K., 299 Metzler, M., 68 Meyer, K., 335 Mico, P. R., 136 Miller, T., 24 Miller, T. W., 302 Miller, W. R., 197, 253 Mindell, J. S., 101 Minelli, M. J., 10, 12, 17, 204, 324 Minkler, M., 71, 80, 81, 176, 181, 212, 238, 240, 241, 242, 248, 249, 250, 251, 252 Mishoe, S. C., 202 Mokdad, A. H., 2 Monaghan, P. F., 302 Mondros, J. B., 246 Montaño, D. E., 161 Moore, C., 46 Morrel-Samuels, S., 80, 81 Muir Gray, J. A., 26 Kreuter, Marshall, W., 4, 13, 48, 49, 50, 57, 97, 136, 203, 209, 230 Kreuter, Matthew, W., 196, 204 Krupa, G., 229 Kumpfer, K., 218, 220 Kutner, M., 200, 201 L Lachance, L. L., 253 Lachenmayr, S., 212, 213 Laine, J., 24 Lalonde, M., 3 Lambert, C., 218 Lancaster, B., 57 Landers, P. S., 304 Landis, D., 53, 57 Lando, J., 321 Last, J. M., 240 Latimer, A. E., 196 Lauritzen, T., 197 Lawton, R., 50 Lee, N. R., 301, 312 Lee, P., 168 Leedy, P. D., 126 Leet, T. L., 26, 43 Lefebvre, R. C., 306, 307, 308 Leffelman, B., 19, 210 Leiserowitz, A., 299 Lemmers, L., 50 Leo, C., 297 Lesch, N., 197 Leventhal, H., 186 Lewin, K., 162 Lewin, S., 187 Lewis, F. M., 79, 123, 353, 354, 355, 374 Lewis, J., 46 Li, C., 199, 200 Li, T., 2 Liang, B. A., 306 Lindenberger, J. H., 294 Lindsey, L. L. M., 300 Ling, P. M., 306 LinkedIn, 199 Linnan, L., 354, 370 Linnan, L. A., 197 Lions Club, 33, 182, 279 Llewellyn, C., 162 Lobb, R., 335 Lobo, R., 359 Lokken, K., 165 Lovato, C. Y., 233 Lovelace, E., 392 Lovelace, K., 392 Lovelace, K. A., 270 Lovell, K., 53 Lucan, S. C., 90 Luke, D. A., 210 Luke, J. V., 75 Lunt, J., 50 Luquis, R. R., 233, 271, 272 Luszczynska, A., 160 Lynch, M., 301 M MacAskill, S., 300 Mackey, T., 306 MacKintosh, A. M., 300 Maibach, E. W., 199, 299 Mainous, A. G., 3 Mallery, P., 113 Name Index 463 S Saegert, S., 181 Salazar, L. E., 10, 152, 154 Salleh, N., 164–65 Sallis, J. F., 155, 177 Salovey, P., 196 Samson, A., 218 Samueli Institute, 102 Sandbaek, A., 197 Sandman, P. M., 157, 173 Sarvela, P. D., 92, 108, 114, 116, 126, 128, 324, 377 Sauber-Schatz, E. K., 68 Saunders, J. R., 361 Saunders, R. P., 354, 370 Sawyer, B. J., 186 Sawyer, R. G., 136, 204 Schaafsma, D., 50 Schechtner, C. B., 90 Schiavo, R., 33, 195, 334 Schmaltz, K. J., 322 Schmid, K. L., 196 Schmidtz, C. C., 322 Scholes, K., 58 Schultz, P. W., 293, 304 Scutchfield, F. D., 81 Seabert, D. M., 8, 180 Seaverson, E. L. D., 196 Seekins, T., 344 Selig, S., 271 Sellers, T. A., 116 Serxner, S. A., 220 Sexty, R. W., 58 Shannon, W. J., 233 Sharma, M., 71, 154, 168, 381, 382, 383, 389, 391 Shea, S., 192 Shelton, T. G., 25 Sherrill, W. W., 307 Shi, L., 267, 269, 326, 327, 328, 345, 346 Shumaker, S., 171 Shuper, P. A., 167 Siegel, S., 109 Simons-Morton, B., 153, 154, 155, 156, 158–59, 160, 173 Simpson, V. L., 82 Skinner, B. F., 157–60 Skinner, C. S., 162, 196 Slater, M. D., 297 Sleet, D. A., 234, 335 Smith, H., 162 Snow, L., 242 Society for Public Health Education, Inc. (SOPHE), 7, 8, 9, 18, 42, 70, 106, 134, 155, 193, 213, 215, 239, 262, 292, 320, 351, 352, 388 Society of Prospective Medicine (SPM), 169 Soet, J. E., 196, 197 Solomon, D. D., 358, 359 Song, M., 167 Soni, A., 196 Spaulding, D. T., 353, 355 Spencer, L., 168 Spiegelman, D., 2 SPM Board of Directors (SPMBoD), 81 Stacy, R. D., 128 Stamatakis, K. A., 209 Stanley, J. C., 114 Staples, L., 253 Prevention Research Center (PRC), 43 Prochaska, J. O., 168, 169, 170, 171, 172 Public Health Accreditation Board (PHAB), 69 Public Health Law Program, 236 Putman, R. D., 181, 182 Pyschological Assessment Resources, Inc. (PAR), 117 Q Qualtrics, 76, 132 QuestiionPro, 76 Quigley, R., 101 R Rafferty, A. P., 3 Raju, J. D., 196 Ramaprasad, J., 308 Rand Organization, 385 Rankin, L. L., 271 Real Simple Syndication (RSS), 199 Redding, C. A., 168, 169, 170, 171, 172 Reeves, M. J., 3 Reigelman, R., 208 Rhodes, S. D., 81 Richards, T. B., 90 Riedel, J., 219 Rikhy, S., 211 Rimer, B. K., 152, 153, 154, 156, 157, 172, 175, 176, 178–79, 183 Rimmer, J., 344 Rink, M. J., 19 Rivers, S. E., 196 Road Crew, 302 Robbins, L. C., 81 Robert Wood Johnson Foundation, 22, 25, 39, 279 Robinson, K. L., 359 Robison, J., 218 Rockefeller Foundation, 279 Rogers, E. M., 183, 184 Rogers, R. W., 160, 163, 164 Rogo, E. J., 25 Rollnick, S., 197 Romas, J. A., 154 Root, J. H., 272, 273 Rosati, M. J., 335, 336 Rosenstock, I. M., 157, 158, 159, 162, 176–77, 178 Roser-Renouf, C., 299 Ross, H. S., 136 Ross, M. G., 240, 242 Rossi, J. S., 169, 170 Rossi, S. R., 169 Rothman, A. J., 157 Rothman, J., 241, 242 Rothschild, M. L., 292, 293, 302 Rotter, J. B., 176, 179 Rowe, A., 68 Roy, L., 168 Rubak, S., 197 Ruberto, R. A., 90 Rubinson, L., 76, 84 Ruiter, R. A., 373 Rundle-Thiele, S., 297 Runyan, C. W., 225, 226 Rushton, G., 90 Ryan, M., 19 O Occupational Outlook Handbook, 14 O’Donnell, M. P., 24 Oetting, E. R., 184–85, 186 Office of Disease and Health Promotion, 3 Office of Health Information and Health Promotion, 3 Office of Minority Health (OMH), 271, 289 Offiong, C., 46 Oji, V., 46 Olevitch, L., 196 Oliphant, J. A., 218 Oliver, T. R., 208 Olusanya, O., 46 Online Evaluation Resource Library (OERL), 385 Orenstein, D. R., 177 Ornstein, A. C., 205 Otero-Sabogal, R., 233 Owen, N., 155 Ozminkowski, R. J., 20, 24 P Pagels, A., 53 Painter, J. F., 154 Panagiotou, G., 57 Parcel, G. S., 34, 50, 51, 157, 177, 180, 319 Parkinson, R. S., 128, 136, 137, 322, 331 Parsons, B. A., 322 Partida, S., 50 Paschal, A. M., 201 Pasick, R. J., 155, 233 Patton, M. Q., 218, 376 Paulsen, C., 200 Pavlov, I., 157 Peek, B. T., 201 Pell Institute, 322 Pellmar, T. C., 10, 229 Pennsylvania Department of Health, 22 Pérez, M. A., 233, 271 Perlman, J., 240 Perrin, K. M., 354, 355 Perry, C. L., 177, 180 Perryman, B., 90 Pescatello, L. S., 218, 220 Pestronk, R. M., 80 Petersen, D. J., 70 Peterson, J. J., 344 Petosa, R. L., 71, 381, 382, 383, 389, 391 Pett, M., 218, 220 Pettigrew, M., 359 Petty, R. E., 165, 166, 167 Pew Research Center, 76 Phillips, M. A., 164 Picarella, R., 33 Pinger, R. R., 238, 244, 245 Plested, B. A., 184–85, 186 Poelen, E., 50 Poland, B., 229 Poole, K., 218, 220 Porta, M., 22, 68 Porter, L. W., 36 Prapavessis, H., 164 Prentice-Dunn, S., 160, 163, 164, 165 Prevention Institute, 25, 33, 39 464 Name Index Web Center for Social Research Methods, 132, 385 Weinreich Communications, 317 Weinstein, N. D., 157, 173, 174 Weiss, C. H., 108, 399 Wellness Council of America (WELCOA), 25, 217, 288 WellSteps, 38 Wendel, M. L., 153 West, B. A., 68 Western Michigan University (WMU), 384 Wheeler, S. C., 165 White, G. W., 344 White, S., 200, 201 Whitehead, D., 164, 221 Whittingham, J., 373 Wiecha, J. L., 335 Wilbur, C., 218 Willard-Grace, R., 197 Williams, B., 321 Williams, S., 79 Williams, S. M., 321 Williams-Russo, P., 3 Wilson, H., 306 Wilson, M. G., 20, 223 Wilson, N., 176, 238 Wilson, S. M., 246 Winder, A. E., 9 Windsor, R. A., 72, 106, 111, 112, 113, 116, 117, 124, 353, 354, 355, 368, 378 Winkler, J., 48 Wirtz, P. W., 389 W. K. Kellogg Foundation (WKKF), 28, 279, 321, 322 Woodruff, K., 29 Woods, N. K., 248, 254 Woolcock, M., 182 World Congress on Public Health (WCPH), 81 World Health Organization (WHO), 22, 27, 30, 33, 51, 101, 210, 364, 385 Worthen, B. R., 361 Wright, P. A., 245 Wu, C. S. T., 164 Wurzbach, M. E., 268, 269, 396 X Xu, J., 2 Y Yamane, T., 128 Yi, W. K., 81 Yost, E., 168 Young, K., 271 YouTube, 199 Z Zaltman, G., 291 Zambon, A., 194 Zgodzinski, E. J., 268, 282, 283, 329, 330, 346 Zimbile, F., 373 Zimmerman, F. J., 218 Zoomerang, 76 Zuti, W. B., 265 United Way, 279 University of Kansas, 58, 81, 256, 322 University of Nevada, Reno, Coope- rative Extension (UNRCE), 270 University of Rhode Island (URI), 169, 190 University of Wisconsin, 31 University of Wisconsin Population Health Institute, 22, 32, 39, 99 University of York, 27 U.S. Bureau of the Census, 85 U.S. Bureau of Labor Statistics (BLS), 9, 14 U.S. Department of Agriculture, 198 U.S. Department of Commerce And Labor, 9 U.S. Department of Education (USDE), 87, 200 U.S. Department of Health, Education, and Welfare (USDHEW), 3, 146 U.S. Department of Health and H uman Services (USDHHS), 3, 25, 29, 46, 47, 48, 52, 74, 86, 142, 146, 147, 148, 194, 200, 201, 247, 339, 341, 342, 348, 397 U.S. Department of Justice, 334–35 U.S. Department of Labor (USDOL), 222, 330, 348 U.S. National Library of Medicine, 86 U.S. Preventive Services Task Force, 27 U.S. Public Health Service, 356 Utah Department of Health, 369 V Valente, T. W., 109, 179, 180, 223, 355, 358, 359, 389, 391 van Dam, R. M., 2 Van Der Wagen, L., 268, 269 Vaughn, E. J., 93 Velicer, W. F., 169, 170 VentureLine, 284 Vidal, A., 182 Viswanath, K., 152, 154, 172, 175 Vogele, C., 4 Vogt, T. M., 233 Volmink, J., 187 Voogt, C., 50 W Wallace, M. S., 117 Wallerstein, N., 80, 81, 176, 181, 212, 238, 240, 241, 242 Wallston, B. S., 179 Wallston, K. A., 179 Walsh, D. C., 53, 54 Walter, C., 248 Wang, C. C., 80, 81 Warren, M. R., 181, 254 Washington State Department of Health, 257 Washington University, 43 Washington University Prevention Research Center, 43, 44 Washtenaw County Public Health (WCPH), 80 Watson, J. B., 157 Wayman, J., 296 State Health Access Data Assistance Center (SHADAC), 75 Staten, L. K., 308 Stead, M., 300 Steckler, A., 155, 184, 335, 354, 370 Steer, R. A., 115, 116 Steg, L., 164 STEPS Centre, 81 Stevens, S. S., 108 Strecher, V. J., 118, 157, 178 Streiner, D. L., 72 Stroup, D. F., 2 Strycker, L. A., 34, 35 Sturgis, S., 321 Su, Z., 205 Subramanian, S. V., 181 Substance Abuse and Mental Health Services Administration (SAMHSA), 27, 85, 197 Suggs, L. S., 196 Sullivan, L. M., 374 Surveygizmo, 76 SurveyMonkey, 76 Sutton, S., 160, 173 Sutton, S. R., 157 Suzuki, R., 344 Swan, D. W., 248 Swanson, L, 184–85, 186 Swart, T., 187 Swartz, K., 26 Szreter, S., 182 T Taboada-Palomino, L., 48 Tao, Z. W., 81 Tappe, M. K., 212, 213 Task Force on Community Prevention Services, 26, 27 Taylor, L., 101 TechTarget, 324 Terry, P. E., 36, 196, 217, 220 Tervalon, M., 245 Teufel-Shone, N. I., 79 Thackeray, R., 53, 54, 59, 94, 135, 174, 194, 195, 199, 200, 212, 213, 214, 292, 297, 302, 303, 369 Thompson, J. P., 181 Thorndike, E. L., 157 Tiemstra, J. D., 196 Timmreck, T. C., 90, 116, 319, 322, 324, 345, 358 Tomioka, M., 335 Toomey, T., 335 Tortolero-Luna, G., 50 Trickett, E. J., 63 Tri-Ethnic Center for Prevention Research at Colorado State University, 184, 186 Tropiano, E., 271 Tropman, J. E., 241 True, W. R., 26, 43 Trust for America’s Health (TFAH), 23, 25 Tsark, J., 248 Tuckman, B. W., 270, 271 Turnock, B. J., 238 Twitter, 199 U Ueda, Y., 307 United Nations (UN), 240 465 Subject Index A AAHE (American Association of Health Education), 7 Ability to pay, 277 Accountability, 367, 369 Accounting, 329 Accreditation of health education teacher preparation programs, 9 Accreditation Standards and Measures, 69 Accuracy standards, 358 Achieving Healthier Communities through MAPP: A User’s Handbook, 45 Action (participatory) research, 91 Action stage, 169, 170, 171, 172 Active participants, 246 Activities, 321 Act of commission, 340 Act of omission, 340 Actual behavioral control, 162 ADA (Americans with Disabilities Act), 330 Ad hoc versus permanent committee, 36 Adjourning (mourning) stage (team development), 271 Adjustment, 367, 369 Administrative and policy assessment (PRECEDE-PROCEED), 49, 50 Adopter categories (diffusion theory), 183–84 Adult learning principles, 204 Advanced Level-1 health educator/ education specialist, 7 Advanced Level-2 health educator/ education specialist, 7 Advertising, 306 Advisory board, 33 Advocacy strategies (community), for health, 212–15 Affordable Care Act (ACA), 221–22, 330 Age Discrimination Employment Act, 330 Agency sponsorship, 278–79 Agenda setting, 209 Alcoholics Anonymous (AA), 223 Alpha coefficients, 113 Alpha level, 391 Alpha testing, 373 Alternate-forms reliability, 114, 116 Alternative hypothesis, 391 American Association of Health Education (AAHE), 7 American Public Health Association (APHA), 215 Americans with Disabilities Act (ADA), 330 Analysis of variance (ANOVA), 392 Anonymity, 341 AOL, 88 APHA (American Public Health Association), 215 APHA Legislative Advocacy Handbook: A Guide for Effective Public Health Advocacy, 215 Approaches, defined, 365 Area sample, 125, 126 Ask, 88 Assets of communities, 251, 252 Assumptions of health promotion, 9–10 Attitude objectives, 137 Attitude toward the behavior, 160–61 Attrition (internal validity), 381 Audit, 217, 329–30, 331 Augmented products, 301 Aversive stimulus, 159 Awareness objectives, 20, 137 B Barriers, 295, 304 Baseline data, 360 Basic Priority Rating (BPR) model, 44, 94–95 Basic Priority Rating (BPR) model 2.0, 59, 60, 95–96 Beck Depression Inventory (BDI), 115–16 Behavior, 3, 10, 295 Behavioral capability, 177, 180 Behavioral economics, 218–19 Behavioral objectives, 137, 138, 144 Behavioral Risk Factor Surveillance System (BRFSS), 22 Behavioral segmentation, 298 Behavior change theories, 154–86 cognitive-behavioral model of the relapse process, 186–87 community level theories, 182–86 ecological perspective, 156 interpersonal level theories, 176–82 intrapersonal level theories, 157–75 level of influence and category, 158 Behavior modification activities, 215–16 Behavior Theory in Health Promotion Practice and Research (Simons- Morton et al.), 154 The Belmont Report: Ethical Prin- ciples and Guidelines for the Protection of Human Subject Research, 339 Beneficence, 339 Benefits, 295, 301 Benefits and values of health promotion programs, 24–25 Best experience, 230 Best guess, 30 Best practices, 230 Best processes, 230 Bias introduction of, 117 as limitation on self-report data, 72 Biased data, 117 bing, 88 Biometric screenings, 211 Bivariate data analysis, 389, 390, 391–92 Blind study, 383 Blogs, 199 Blueprint of public health planning, 142 Body mass index (BMI), 106–7 Bonding social capital, 182 Bottom-up organizing, 244 Boundary-spanning, 270 BPR (basis priority rating) model, 44, 94–95 BPR model 2.0, 59, 60, 95–96 Brand, 295 Bridge building, 270 Bridging social capital, 182 Buddy system, 223 Budget narrative, 285 Budgets, 282–86 Building blocks, 250, 252 Built environment, 211 C CAEP (Council for the Accreditation of Educator Preparation), 9 Campbellian validity typology, 381–82 Canned program, 274–75 466 Subject Index identifying solutions and select- ing intervention strategies, 254 implementing, 254–55 looping back, 254–55 maintaining (sustaining), 254–55 organizing the people, 245–48, 249 processes of, 241–55 recognizing the issue, 244 responsibilities and competencies for health education specia lists, 239 steps in, listed, 243 terms associated with, 240 typology, 242 understanding diversity, 247 volunteers in, 248 Community participation, 238 Community partnerships, 238 Community readiness model (CRM), 184–86 Community team, 52 Community Tool Box, 58, 65, 103, 131, 150, 256, 316, 364 Comparison group, 378 Compensatory equalization of treat- ments (internal validity), 382 Compensatory rivalry (internal validity), 382 Competencies for health education. See Responsibilities and com- petencies for health education specialists Competency-based criteria, 6–9 A Competency-Based Framework for Health Education Specialist (2010; 2015), 7 A Competency-Based Framework for Health Educators, 7 A Competency-Based Framework for the Professional Development of Certified Health Education Specialists (NCHEC, 1996), 6 Competition, 295–96 Complex interventions, 233 Complexity, defined, 137 Concepts, 153 Concurrent validity, 115 Condition (objectives), 141 Confidence, 169 Confidentiality, 341 Confounding variables, 374 Consciousness raising, 169 Consensus, 241, 253 Consent form, 337 Consistency, internal, 113, 116 Consolidated Omnibus Budget Reconciliation Act (COBRA), 330 Constructs defined, 153 in design of new health promotion interventions, 231–32 social cognitive theory (SCT), 180 transtheoretical model, 169 Construct validity, 115, 116 Consumer, 294 Consumer analysis phase (SMART), 54, 56 Commission, 340 Commitment devices, 219 Communication channel, 195–96 Communities of Practice (CoP) for Public Health, 150 Community defined, 11, 237 health promotion programs and, 19 priority population, 11–12 values and benefits to, from health promotion programs, 24 Community Action Plan, in CHANGE tool, 52, 53 Community advocacy, 212–15 Community analysis, 68 Community assessment, 43–44, 68 Community-Based Prevention Marketing, 57 Community Based Prevention Marketing Model, 53 Community building, 212, 237–38. See also Community organizing defined, 249 processes of, 241–55 responsibilities and competencies for health education special- ists, 239 steps in, listed, 243 typology, 242 Community capacity, 68–69, 70, 240 Community capacity develop- ment, 241 Community channel, 197 Community context, 43–44 Community development, 240 Community diagnosis, 68 Community empowerment, 238 Community forum, 77, 78, 84 The Community Guide. See Guide to Community Preventive Services Community Health Assessment aNd Group Evaluation (CHANGE) tool, 52–53 Community health needs assessment (CHNA), 69, 91 Community level theories, 182–86 community readiness model (CRM), 184–86 diffusion theory, 183–84 Community mobilization strategies, 212–15 Community organization, 212 Community organizing, 237–38. See also Community building assessing community needs and assets, 248–52 assets of communities, 251, 252 background and assumptions, 238, 240–41 coalitions, 247, 249 consensus, 253 defined, 240–41 determining priorities and setting goals, 252–53 evaluating, 254–55 final steps in, 254–55 gaining entry into the community, 244–45 Capacity, 68–69, 367, 368 Capacity building, 70 Capacity-building assistance (CBA), 267 Capital equipment, 276 Capital expenditures, 276 Case studies, 377 Catalog of Federal Domestic Assistance (CFDA), 280 Categorical funds, 69 CDC. See Centers for Disease Control and Prevention (CDC) CDC Framework for Program Evalua- tion in Public Health, 364, 374 CDC WONDER, 104 Cell phones, 214 Census, 121 Centers for Disease Control and Prevention (CDC), 52, 356–58 Healthy Plan-It, 57 Central tendency, measures of, 391 CEPH (Council on Education for Public Health), 9 Certification, 8 Certified Health Education Specialist (CHES), 7, 8 Change processes of, 169, 171 stages of, 169 CHANGE (Community Health Assessment aNd Group Evaluation) tool, 52–53, 57, 65 Change vision attributes, 246 Channel analysis phase (SMART), 54, 56 Charter certification, 8 CHES (Certified Health Education Specialist), 7, 8 Chi-square, 391–92 CHNA (Community health needs assessment), 69, 91 Chronic Disease Cost Calculator Version 2, 24, 39 Chronic diseases, 2, 23–24 CINAHL (Cumulative Index To Nursing & Allied Health Literature), 87 Citizen-initiated organizing, 244 Citizen participation, 240 Civil Rights Act, 330 CLAS (Culturally and Linguistically Appropriate Services), 271 Close-ended responses, 119 Cluster sampling, 125, 126 Coalition, 247, 249 Coalition of National Health Educa- tion Organizations (CNHEO), 338–39 Code of Ethics for the Health Education Profession (CNHEO), 338–39 Cognitive-behavioral model of the relapse process, 186–87, 231–32 Cognitive pretesting, 129 Cohen’s kappa coefficient, 113–14 Collaborative public management, 270 Collaborator Multiplier, 33 Collaborators, 33 Collective efficacy, 178, 180 Subject Index 467 Dose, 192, 370, 371 Double blind study, 383 Draft ideas, 310 Draft messages, 312 Dramatic relief, 169 Driving School Home, 60, 61 Drug-Free Workplace Act, 330 DuckDuckGo, 88 E Early adopters, 183, 184 Early majority, 183 eCards, 199 Ecological framework (program planning), 62–63 Ecological perspective (health behaviors or conditions) defined, 155 levels of influence, 156 Economics, 218 Educational and ecological assess- ment (PRECEDE/PROCEED), 49–50 Education Resource Information Center (ERIC), 87, 385 Effectiveness, 351 Efficacy expectations, 178 Elaboration, 165 Elaboration likelihood model of persuasion (ELM), 165–67, 231–32 Electioneering, 213 Electronic interviews, 76–77, 83 Electronic media, 307 ELM (elaboration likelihood model of persuasion), 165–67, 231–32 Emergency care plan, 338 Emerging Theories in Health Promotion Practice and Research: Strate- gies for Improving Public Health (DiClemente, Crosby, & Kegler), 154 Emotional–coping response, 178, 180 Emotional support, 223 Empathy, 198 Employee Retirement Income Security Act, 330 Employees/employers, values and benefits to, from health promotion programs, 24 Empowering, 11 Empowerment, 240 Enabling factors, 49 Entry-level health educator/ education specialist, 6, 7 Environmental change strategies, 210–11 Environmental factors, 96–97 Environmental objectives, 137, 138, 144 Environmental reevaluation, 169 Epidemiological assessment phase (PRECEDE/PROCEED), 49 Epidemiological data, 22–23, 297 Epidemiology, 22 Equal Pay Act, 330 Curriculum, 204 for health promotion programs, 263, 272–75 plans, 205 D Data characteristics of (measurement), 111–17 presenting, 397–98 primary, 71–82, 83–84 quantitative and qualitative, 92 secondary, 71, 82, 84–90 Data analysis, 387–95 applications, 393–94 bivariate, 389, 390, 391–92 interpreting, 394–95 level of measurement and, 391 multivariate, 389, 390, 392 in needs assessment, 93–96, 99–100 statistical techniques, 389–90 univariate, 389, 390–91 Data gaps, 92 Data gathering in CHANGE tool, 52, 53 for needs assessment, 71–90, 91–93, 98–99 Data management, 388–90 Death, most common and actual causes of, 2 Decisional balance, 169, 171 Decision makers, 11 support for health promotion program, 18–20 top-level management, 19–20 Deductive, 375 Delphi technique, 44, 77, 83, 377 Democracy, 241 Demographic segmentation, 298 Dependent variables, 389 Descriptive statistics, 389 Designs defined, 365 evaluation, 375–76, 377, 378–80 Developing intervention materials and pretesting phase (SMART), 54, 57 Diffusion theory, 183–84 Digg, 199 Digital communication, 307 Direct cost, 284 Direct marketing, 306 Direct observation, 79–80, 372 Direct reinforcement, 177 Disabilities, participants with, 343–44 Discovery meeting, 309 Discriminant validity, 116 Diseases, chronic, 2, 23–24 Disincentives and incentives, using to influence health behaviors, 218–23 Diversity, understanding, 247 Document, 200 Documenting programs, 345–46 Doers and influencers, 34 Consumer-based programs, 291 Consumer orientation, 294–95, 367, 368 Consumers, 294 Contemplation stage, 169, 170, 171, 172 Content analysis, 377 Content validity, 114–15, 116 Contests, using to motivate, 223 Context, 370, 371 Contingencies, 224 Continuous monitoring, 312–13 Continuum theories, 157 Contract, using to motivate, 224 Contributions, 279 Control group, 376–78 Convenience sample, 127 Convergent validity, 115–16 Cooperative agreements, 278 Coping appraisal, 164 Corporations, 279, 280 Correlations, 392 Cost-benefit analysis (CBA), 23, 368 Cost-effectiveness analysis (CEA), 368 Cost-identification analysis, 368 Costs, of chronic diseases, 23–24 Cost sharing, 278 Council for the Accreditation of Educator Preparation (CAEP), 9 Council on Education for Public Health (CEPH), 9 Counterconditioning, 169 County Health Rankings, 38–39 County Health Rankings & Roadmaps, 22 Covert antecedents, 187 CRAPP Test. See Currency, Relevance, Authority, Accuracy, Purpose (CRAAP) Test Creative agency, 309–10 Criterion (objectives), 141 Criterion-related validity, 115, 116 Critical path method (CPM), 324, 326 Cronbach’s alpha reliability coefficient, 113 Cross-sectional (point-in-time) surveys, 71–73 Cultural audit, 217 Cultural competence, 245, 271 Cultural humility, 245 Culturally and Linguistically Appro- priate Services (CLAS), 271 Culturally sensitive, 233, 245 Culture importance in health promotion programs, 271 organizational culture activities, 217–18 Cumulative Index to Nursing & Allied Health Literature (CINAHL), 87 CUP (National Health Educator Com- petencies Update Project), 7 Currency, Relevance, Authority, Accuracy, Purpose (CRAAP) Test, 88, 104 468 Subject Index Forming stage (team development), 270 Fostering Sustainable Behavior and Community-Based Social Marketing, 316 Foundations, 279 4Ps of marketing, 56 Framework accreditation and approval of academic health education programs, 9 areas of responsibility, 6–9, 7–8 defined, 6 examination to certify health educators, 8 for program evaluation, 356–58 uses of, 8–9 A Framework for the Development of Competency-Based Curricula for Entry Level Educators (NCHEC), 6 Framing, 219 Freedom from Smoking program, 277 FreshStart program, 277 Fry Readability Formula, 202 Full-time equivalent (FTE), 285 Functionality, in program planning, 62 G Gamblers Anonymous, 223 Gantt charts, 324, 326, 372 Gatekeepers, 245 Gateway to Health Communication & Social Marketing Practice (CDC), 65, 236 Generalizability, 382–83 Generalized Model, 11, 41–43, 58–62 Genetic Information Nondiscrimina- tion Act (GINA), 330 Geographic information systems (GIS), 90 Geographic segmentation, 298 Georgetown Social Marketing Listserv, 317 Getting to Outcomes: Promoting Accountability through Methods and Tools for Planning, Implementation, and Evaluation, 364 Gift, 279 GINA (Genetic Information Nondis- crimination Act of 2008), 221–22 Global perspective, of rationale for health promotion programs, 26, 28 Goals in community organizing, 252–53 defined, 135 in Generalized Model, 42 objectives versus, 136 program goals, examples of, 136 Gold Medal Schools, 60, 61 Gold standard, 115 Google, 88 Google charts, 399 Government, as grant maker, 279, 280 Government agencies, as sources of secondary data, 82, 85 Evidence-based practice, 25–26, 30 Evidence pyramid, 25–26 Exchange, 293–94 Exclusive social capital, 182 Executive participants, 246 Existing records, data from, 85–86 Expectancies, 177, 180 Expectancy effect, 382 Expectations, 177, 180 Experience Documentation Opportunity (EDO), 8–9 Experience skills, 246 Experimental design, 378, 379 Experimental group, 376–78 Expert panel reviews, 372 External audit, 331 External evaluation, 361 External money, 279 External personnel, 265–66 External validity, of evaluation, 382–83 F Face-to-face interviews, 75, 83 Face validity, 114, 116 Facilitative leadership, 270 Facilitators, training of, 342, 344–45 Fair Labor Standards Act, 330 Family and Medical Leave Act (FMLA), 329, 330 Feasibility standards, 358 Federal legislation impacting human resources, 330 Federal Register (FR), 280, 281 Fee collection, 341 Fidelity, 370 Field testing, 332, 373 Financial management, 329, 331 Financial resources, for health promotion programs, 263, 276 budgets, 282–86 combining sources, 282 cooperative agreements, 278 cost sharing, 278 grants and gifts, 279–82 organization/agency sponsorship, 278–79 participant fee, 277 third-party support, 277–78 Fiscal accountability, 329 Fiscal year, 329 Fixed responses, 119 Flesch-Kincaid Grade Level Readability Formula, 202 Flexibility, in program planning, 62 Flex time, 264 Fluidity, in program planning, 62 FluidSurveys, 76 Focus group, 78–79, 84, 372, 377 Fog-Gunning Index, 202 Forced response options, 119 Formative evaluation, 254. See also Process evaluation defined, 352 elements of, 366–70 focus of, 366 procedures used in, 372 Formative research, 56 Equipment, for health promotion programs, 263, 276 Equivalence reliability, 114, 116 Equivalent forms reliability, 114, 116 ERIC (Education Resource Information Center), 87, 385 Essentials of Health Behavior: Social and Behavioral Theory in Public Health (Edberg), 154 Ethical issues in evaluation, 360–61 in implementation, 338–40 of measurement, 129–30 Ethnographic studies, 377 Evaluation, 351–64. See also Data analysis; Data management approaches, 365–85 in community organizing, 254–55 defined, 352 designs, 365–85, 378–80 determining who will conduct, 361–62 ethical considerations, 360–61 in evidence-based planning framework for public health, 44 experimental, control, and comparison groups, 376–78 external, 361 external validity, 382–83 formative, 352–53, 366–74 framework for, 356–58 in Generalized Model, 42 impact, 353, 354 internal, 361 internal validity, 381–82 interpreting data analysis, 394–95 measurement in, 107–8 objectives related to, 136, 137 outcome, 353, 354 in PRECEDE-PROCEED planning model, 50 problems or barriers in, 358–59 process, 352–53, 354, 370–71 in program planning stages, 360 purpose of, 354–55 qualitative methods used in, 377 reporting, 396–99 responsibilities and competencies for health education specialists, 352, 366 results, 362 selecting a design, 375–76, 377 in SMART, 54, 57 standards of, 358 summative, 352–53, 354, 374 terminology, 352–54 Evaluation consultant, 361 Evaluation phase PRECEDE-PROCEED model, 49, 50 SMART, 54, 57 Evidence, 367 defined, 25–26 in health promotion program planning, 25–27 Evidence-based interventions, 335–36 Evidence-Based Planning for Public Health, 64 Evidence-Based Planning Framework for Public Health, 43–44, 57 Subject Index 469 H.E.R.E. (Health Education Resource Exchange), 257 HERO Employee Health Management Best Practices Scorecard, 102 Heuristics, 165 High-risk situations, 187 HIPAA, 86, 221–22, 341 Hippocratic Oath, 339 Historical analysis, 377 History (internal validity), 381 Homogeneous sample, 127 Horizontal relationships, 254 Human resources management (HRM), 327–29 I Impact evaluation, 353, 354 Impact objectives, 137–38, 143–44 Implementation, 319–48 adoption of program, 323 in community organizing, 254–55 concerns, 336–46 defined, 322 documenting and reporting, 345–46 ending or sustaining program, 335 ethical issues, 338–40 of evidence-based interventions, 335–36 in evidence-based planning frame- work for public health, 44 facilitator training, 342, 344–45 first day of, 333–34 in Generalized Model, 42, 61 identifying and prioritizing tasks, 323–26 legal concerns, 340–41 logic models, 321–22, 323 management system, 326–31 in MAP-IT, 47–48 monitoring, 334–35 phases of, 322–35 of policy, 209 in PRECEDE-PROCEED planning model, 49, 50 problems, dealing with, 345 procedural and/or participants’ manual, 341–42 program participants with dis- abilities, 342, 343–44 program registration and fee col- lection, 341 putting plans into action, 331–35 recordkeeping procedures, 341 responsibilities and competencies for health education special- ists, 320 safety and medical concerns, 336–38 total, 333 Implementation phase (SMART), 54, 57 Implementation science, 335 Incentives and disincentives, using to influence health behavior, 218–23 Inclusion, 367, 369 Health education strategies, 203–6, 207–8 Health Educator Job Analysis (HEJA), 7 Health Evidence Network (HEN), 27 Healthfinder, 289 Health impact assessment (HIA), 100–101 Health Information and Health Promotion Act, 3 Health Insurance Portability and Accountability Act of 1996 (HIPAA), 86, 221–22, 330, 341 Health literacy, 200–201 Health numeracy, 201 Health policy/enforcement strategies, 206, 208–10 Health promotion, 4, 5 assumptions of, 9–10 program planning, 10–12 Health promotion interventions, creating, 225–33 adapting, 226–28 adopting, 226 designing, 228–33 planning, 225–26 Health promotion program. See also Marketing process; Program planning models creating program rationale, 18–37 Generalized Model and, 11 planning committee, 33–35 planning parameters, 36–37 planning process, 17–39 values and benefits of, 24–25 Health-related community service strategies, 211–12 Health-related costs, 23–24 Health risk appraisals (HRAs), 81–82 Health risk assessments (HRAs), 81–82 Health screening, 215 Health status assessments (HSAs), 81–82 Healthy Cities. See Healthy Communities movement Healthy Communities, 57 Healthy Communities movement, 51–53 Healthy People, 3, 14, 141, 142, 146 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, 146 Healthy People 2010, 146 Healthy People 2020, 46, 60 goal of objectives from, 142 mission statement, goals, and objectives, 146–47 target setting methods, 142 topic areas, 148 Website, 64, 150 Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (USDHEW), 3, 14, 141, 142, 146. See also Healthy People Healthy Plan-It (CDC), 57 Helping relationships, 169 Grant money gift versus, 279 grant, defined, 279 locating, 279–81 submitting proposals, 281–82 Grants.Gov Website, 280, 281, 289 Grantsmanship skills, 279 Grant writing, 58 Grassroots participation, 213, 240, 244 Group consensus, 241 Group interviews, 77, 83 Guide to Clinical Preventive Services, 27 Guide to Community Preventive Services (CDC), 26, 27, 38, 44, 230, 236 Guide to Effectively Educating State and Local Policymakers (SOPHE), 215 Guide to Writing Social Media (CDC), 199 H Hard money, 279 Hawthorne effect, 383 Health advocacy, 212 Health assessments (HAs), 81–82 Health behavior, 3, 23. See also Behavior Health Behavior and Health Education: Theory, Research and Practice (Glanz, Rimer, & Viswanath), 154 Health behavior change, 10 Health Behavior Constructs: Theory, Measurement and Research, 132 Health Behavior Theory for Public Health (DiClemente, Salazar, & Crosby), 154 Health belief model (HBM), 162–63, 231–32 Health Care and Education Recon- ciliation Act of 2010, 221–22 Health coaching, 197 Health communication defined, 194 strategies used in interventions, 194–203 Health Communication Model (Na- tional Cancer Institute), 57 The Health Communicator’s Social Media Toolkit (CDC), 199 Health-contingent wellness pro- grams, 222 Health education, 4, 5 strategies used in interventions, 203–6, 207–8 Health Education Resource Exchange (H.E.R.E.), 257 Health Education Specialist Practice Analysis (HESPA), 7 Health education specialists Advanced Level-1, 7 Advanced Level-2, 7 competencies and responsibilities of, 6–9 defined, 4–5 entry-level, 6 levels of prevention and, 6 role of, 5–6 470 Subject Index K Key informants, 73, 372 Knowledge objectives, 137. See also Learning objectives L Labor-Management Reporting and Disclosure Act (LMRDA), 330 Laggards, 183, 184 Lapse, 186 Late adopters, 184 Late majority, 183 Leading by Example (LBE) Instrument, 20 Learning objectives, 137–38, 143–44 Legal concerns, for health promotion programs, 340–41 Lesson plan, 205 Lessons, 205 Letter of agreement, 278 Level of significance, 391 Levels of measurement, 108–11, 112 Liability, reducing risk of, 340–41 Lifestyle characteristics, 2, 3 Lifestyle imbalances, 187 Likelihood of taking recommended preventive health action, 163 Likert scales, 119 Linking social capital, 182 Literacy, 200 Literature in evidence-based planning frame- work for public health, 44 program rationale development, 20 searches, conducting, 87–88, 89 in segmentation, 297 as source of secondary data, 86 Lobbying, 212, 213 Local health departments (LHDs), 279 Locality development, 241 Locus of control, 179, 180 Logic models, 44, 321–22, 323 Long-term objective, 138 M Macro practice, 240 Maintenance stage, 169, 170, 171, 172 Making Health Communication Programs Work (NCI), 308 Management, defined, 326 Management system, 326–31 Manuals, 341–42 MAP-IT (Mobilize, Assess, Plan, Implement and Track): A Guide to Using Healthy People 2020 in Your Community, 46–48, 57, 64–65 MAPP (Mobilizing for Action through Planning and Partner- ships) model, 45–46, 57, 92 Mapping, 90, 249 Mapping community capacity, 250 Market, 294 Market analysis phase (SMART), 54, 56 environmental change strategies, 210–11 in Generalized Model, 42, 60–61 health communication strategies, 194–203 health education strategies, 203–6, 207–8 health policy/enforcement strategies, 206, 208–10 health-related community service strategies, 211–12 identifying strategies, 254 incentives and disincentives, using to influence health behaviors, 218–23 limitations of, 231–32 needs assessment and, 69 organizational culture activities, 217–18 planning, 225–26 responsibilities and competencies for health education special- ists, 193 in SMART, 54, 57 social activities to support behavior change, 223 social gatherings, 224 social networks, 224–25 strategies, types of, 193–225 support groups and buddy system, 223–24 Interviews electronic, 76–77, 83 as evaluation method, 377 face-to-face, 75, 83 for formative evaluation, 372 group, 77, 83 telephone, 75–76, 83 Intrapersonal channel, 196 Intrapersonal level theories, 157–75 elaboration likelihood model of persuasion (ELM), 165–67 health belief model (HBM), 162–63 information-motivation- behavioral (IMB) skills model, 167–68 precaution adoption process model (PAPM), 173–75 protection motivation theory (PMT), 163–65 stimulus response (SR) theory, 157–60 theory of planned behavior (TPB), 160–62 theory of reasoned action (TRA), 160–62 transtheoretical model (TTM), 168–73 Intra-rater reliability, 113–14 Introduction to Health Behavior (Hayden), 154 Introduction to program evaluation for public health programs: A self-study guide, 364 J Justification, 367 Inclusive social capital, 182 Independent variables, 389 In-depth interviews, 372, 377 Indirect cost, 284 Indirect observation, 80 Individual initiated, 197 Inductive method, 375 Inferential statistics, 389 Influencers and doers, 34 Informal interviews, 372 Informational support, 223 Information-motivation-behavioral (IMB) skills model, 167–68, 231–32 Informed consent, 336 In-house materials, 272 In-kind contributions, 279 Innovators, 183 Inputs, 321 Institutionalization, of a health promotion program, 36 Institutional review boards (IRBs), 361 Instructional resources, for health promotion programs, 263, 272–75 Instrumental support, 223 Instrumentation, 110, 381 Instruments, measurement, 117–21 Intention, 160 Interaction, 367, 370, 382 Interactional skills, 246 Interactive contact methods, 71 Interactive media, 196, 199 Intermediate objective, 138 Internal audit, 331 Internal consistency, 113, 116 Internal evaluation, 361 Internal personnel, 264, 266 Internal Revenue Code, 69 Internal validity, 381–82 International perspective, of rationale for health promotion programs, 28 International Physical Activity Questionnaire (IPAQ), 114 Interpersonal channel, 197 Interpersonal communication, 176 Interpersonal level theories, 176–82 social capital theory, 181–82 social cognitive theory (SCT), 176–79, 180 social network theory (SNT), 179–81 Interpretation of data analysis, 394–95 Inter-rater reliability, 113–14 Interval level measures, 109 Intervention alignment, 50 Intervention alignment (PRECEDE/ PROCEED), 49 Intervention mapping, 50–51, 57 Interventions, 191–236. See also Health promotion interven- tions, creating behavior modification activities, 215–16 community mobilization strate- gies, 212–15 complex, 233 defined, 192 designing, 228–33 Subject Index 471 Needs, 67, 295 Needs assessment about, 21–22 analyzing data, 93–96, 99–100 application of needs assessment process, 98–100 BPR model, 94–95 BPR model 2.0, 95–96 conducting, 90–100 data gathering for, 71–90, 98–99 data mapping technology, 88, 90 defined, 21, 68 determining purpose and scope, 91, 98 example, 59 expectations from, 70 gathering data, 91–93 in Generalized Model, 42 health impact assessment (HIA) and, 100–101 identifying program focus, 97–98, 100 identifying risk factors linked to health problem, 96–97, 100 importance of, 69 in MAP-IT, 47 organizational health assessment and, 101–2 reasons for, 68–69 responsibilities and competencies for health education special- ists, 70 technology for mapping, 90 validating prioritized needs, 98, 100 when not needed, 69 Negative punishment, 159 Negative reinforcement, 159 Negligence, 340 Neoclassical economics, 218 Networking, 97, 224–25 A New Perspective on the Health of Canadians (Lalonde), 3 News hook, 334 Nine Events of Instruction (Gagne), 205–6 No contact methods, 71 Nominal group process, 79, 84, 377 Nominal Group technique, 44 Nominal level measures, 108 Nonexperimental design, 378–79 Nongovernment agencies, as source of secondary data, 84, 85 Nonmaleficence, 339 Non-parametric tests, 390 Nonprobability samples, 126–27 Nonproportional stratified random sample, 126 Norming stage (team development), 271 Null hypothesis, 391 Numeracy, 200 Numerical data, 109 O Objective evidence, 25–26 Objectives achievement of, 355 defined, 136 Minimal-contact method of data collection, 79 Minimal contact observational methods, 71 Mission statement defined, 134 examples, 135 responsibilities and competencies for health education special- ists, 134 Mobilize, Assess, Plan, Implement and Track (MAP-IT), 46–48, 57, 64–65 Mobilizing for Action through Plan- ning and Partnerships (MAPP) model, 45–46, 57, 92 Mode, 391 Models defined, 152 responsibilities and competencies for health education special- ists, 155 theories versus, 152 types of, 154 Modules, 205 Monitoring continuous, 312–13 of program implementation, 334–35 Morbidity Mortality Weekly Report (MMWR), 85 Motivation, using contests and contracts for, 223–24 Motivational interviewing (MI), 197, 198 Mourning stage (team development), 271 Multidirectional communication (MDC) model, 194–95 Multi-level voting, 44 Multiple regression, 392 Multiplicity, 192, 367, 369 Multistep survey, 77 Multivariate data analysis, 389, 390, 392 N National Action Plan to Improve Health Literacy (USDHHS), 201 National Assessment of Adult Literacy (NAAL), 200, 201 National Bone Health Campaign, 307, 308 National Commission for Certifying Agencies (NCCA), 7 National Commission for Health Education Credentialing, Inc. (NCHEC), 7, 8, 14 National Health and Nutrition Examination Survey (NHANES), 22 National Health Educator Competencies Update Project (CUP), 7 National Health Interview Survey (NHIS), 22 National Registry of Evidence-based Programs and Practices, 27 Marketing, 291–317. See also Market- ing mix; Marketing process defined, 291 diffusion theory, 184 responsibilities and competencies for health education special- ists, 292 social marketing and, 291–93 Marketing mix, 56 defined, 301 place, 305 price, 302–5 product, 301–2 promotion, 306–9 for social marketing, 293 Marketing process competition, 295–96 consumer orientation, 294–95 continuous monitoring, 312–13 exchange, 293–94 health promotion programs, 293–313 marketing mix for, 301–9 pretesting, 310–12, 313 segmentation, 296–301 Mass media channel, 197–98, 199 Master Certified Health Education Specialist (MCHES), 7, 8 Maturation (internal validity), 381 Maximum variation sampling, 127 Mean, 391 Measurement, 105–32 bias free, 117 defined, 106 ethical issues, 129–30 importance in program planning and evaluation, 107–8 instruments used for, 117–21, 123 levels of, 108–11, 112 objectives and, 137 pilot testing, 127–29 psychometric qualities, 111 quantitative and qualitative measures, 107 questions and levels of, 112 reliability, 112–14 responsibilities and competencies for health education special- ists, 106 sample size, 127, 128 sampling, 121–27 types of, 111, 112 validity, 114–16 Measurement instruments, 110–11, 117–21, 123 Measures of central tendency, 391 Measures of spread or variation, 391 Media advocacy, 213 Median, 391 Medical concerns, of implementa- tion, 336–38 Medical Subject Headings (MeSH®), 87 Medline, 86–87 Meetings, 77–78, 84 Memorandum of agreement (MOA), 278 Memorandum of understanding (MOU), 278 472 Subject Index Policy formulation, 209 Policy modification, 209 Population, 122–23 Population-based approach (program planning), 62–63 Positive punishment, 159 Positive reinforcement, 159 POST (people, objectives, strategy, technology), 199–200 Posttest, 378 Potential building blocks, 250 Precaution adoption process model (PAPM), 173–75, 231–32 PRECEDE-PROCEED planning model, 57 administrative and policy assessment, 49, 50 for data analysis, 93 educational and ecological assessment, 49–50 epidemiological assessment, 49 implementation phase, 49, 50 intervention alignment and administrative and policy assessment, 50 intervention mapping and, 50–51 outcome evaluation, 49, 50 phases of, listed, 48–50 process impact, 49, 50 social assessment, situational analysis, and, 48, 49 Precontemplation stage, 169, 170, 171, 172 Predictive validity, 115 Predisposing factors (behavioral), 49 Pregnancy Discrimination Act, 330 Preliminary planning phase (SMART), 54, 55–57 Preliminary review (pilot testing), 128 Preparation stage, 169, 170, 171, 172 Pre-pilots, 129 Pre-planning, 11, 12, 42, 59 Presentation, of measurement data, 120–21 Presenteeism, 36 Pretest, 54, 57, 378 Pretesting, 310–12, 129, 313, 373 Prevention, levels of, 6 Price (marketing variable), 293, 295, 302–5 Primary building blocks, 250 Primary data advantages of, 71 collection methods, 83–84 defined, 71 sources of, 71–82 Primary prevention, 6 Priority population, 11–12, 56, 69, 73, 272, 294 Priority setting, in data analysis, 93–94 Privacy, 86, 341 Privacy Rule, 86, 341. See also HIPAA Probability sample, 123–26 Problem statement, 28 Parallel forms of reliability, 114, 116 Parametric tests, 389 Participant fee, 277 Participant-observer studies, 377 Participants, 71 Participants’ manual, 341–42 Participation and relevance, 240 Participatory data collection, 80 Participatory research, 91 Participatory wellness programs, 222 Partnering, 33 Partnerships, Healthy Communities movement and, 51–52 Patient Protection and Affordable Care Act (PPAC and ACA), 69, 101, 221–22, 330 Peer education, 264 Penetration rate, 194 Perceived barriers, 162 Perceived behavioral control, 161–62 Perceived benefits, 163 Perceived seriousness/severity, 163 Perceived susceptibility, 163 Perceived threat, 162 Performing stage (team develop- ment), 271 Permanent committee, temporary committee versus, 36 Personalizing, 196 Personal responsibility model, 3 Personal selling, 307 Personnel, for health promotion programs, 263 combined internal and external, 266 cultural factors, 271 external, 265–66 internal, 264, 266 items related to, 267–71 teams, 269–71 technical assistance, 267 vendors, 265 volunteers, 267–69 PERT (program evaluation and re- view technique) charts, 324 Phasing in, 332–33 Photo novella, 80 Photo sharing, 199 Photovoice, 80–81 Piloting, 127, 332 Pilot study, 127 Pilot test, 127–29 Pilot testing, 332, 373–74 “Pink Book,” 308 Place (marketing variable), 293, 295, 305 Placebo effect, 383 Planning, in MAP-IT, 47 Planning and policy practice, 241 Planning committee, 33–35 Planning models, 154. See also Program planning models Planning parameters, 36–37 Planning team, 33 Podcasts, 199 Point-in-time surveys, 71–73 Policy adoption, 209 Policy assessment,  209 Objectives (continued) in design of new health promo- tion interventions, 231–32 developing, 139 development criteria, 139 elements of, 139–42 examples, 143–45 goals versus, 136 hierarchy of, and relation to evaluation, 137 levels of, 136–38, 143–45 for the nation, 142, 146–48 SMART and, 141, 145 target setting methods, 142 template for writing, 146 time needed to reach outcome, 138 Observation advantages and disadvantages, 84 defined, 79 direct, 79–80, 372 indirect, 80 obtrusive, 80 photovoice, 80–81 unobtrusive, 80, 377 windshield tour (walk-through), 80 Observational learning, 177 Obtrusive observation, 80 Occasional participants, 246 Occupational Outlook Handbook, 14 Occupational Safety and Health (OSH) Act, 330 Office of Disease and Health Promotion, 3 Office of Health Information and Health Promotion, 3 Omission, 340 Onboarding, 328 Opinion leaders, 73, 184 Optimal Healing Environment (OHE) Assessment™, 102 Ordinal data, 110 Ordinal level measures, 108–9 Organizational culture, 36 Organizational culture activities, 217–18 Organization channel, 197 Organization sponsorship, 278–79 Orientation, 328 Ottawa Charter for Health Promotion, 210 Outcome, defined, 140 Outcome evaluation, 50, 353, 354 Outcome expectations, 178 Outcome objectives, 137, 138, 145 Outcomes, of programs, 136, 137, 321, 322 Outcome verbs, for objectives, 135, 140–41 Outputs, 321 Outreach, 197 Overeaters Anonymous, 223 Ownership, 253, 277 P PADS (planning, acquisition, devel- opment, sanction), 327–29 PAPM (precaution adoption process model), 173–75, 231–32 Subject Index 473 planning committee, 33–35 planning parameters, 36–37 steps in creating, 20–30 title, 26 writing content of, 26, 28–30 Reach, 367, 369, 370, 371 Reactive effects, 382 Readability tests, 202 Real simple syndication (RSS) feeds, 199 Recidivism, 186 Reciprocal determinism, 178, 180 Recorders, 77 Recordkeeping procedures, 341 Recruitment, 367, 369, 370, 371 Reforming stage (team develop- ment), 271 Registration and fee collection, 341 Reinforcement, 158–59, 177, 180 Reinforcement management, 169 Reinforcing factors (behavioral), 49–50 Relapse, 171 cognitive-behavioral model of the process, 186–87 defined, 186 recidivism, 186 Relapse prevention (RP), 187 Release of liability, 337 Relevant data, 91–92 Reliability defined, 112 summary of types of, 113–14, 116 Reporting or documenting pro- grams, 345–46 Report of the 2011 Joint Committee on Health Education and Promotion Terminology, 4 Reports (evaluation), 396–99 designing (written), 397, 398 how and when to present, 398–99 importance of, 396 increasing utilization of the results, 399 presenting data, 397–98 what to include in, 398 Request for application (RFA), 58, 281 Request for proposal (RFP), 58, 281 Research-tested Intervention Programs, 27 Resentful demoralization of respon- dents (internal validity), 382 Resources curricula and instructional, 263 defined, 19, 261–62 equipment, 263 financial, 263 in formative evaluation, 367, 368 identification and allocation of, 261–89 necessary, for planning, imple- menting, and evaluating, 263 personnel, 263, 264–71 “price tag” of, 262 responsibilities and competencies for health education special- ists, 262 space, 263 supplies, 263 Protocol checklist, 372 Prototype, 57 Proxy (indirect) measure, 73, 80 Proxy reporter, 72 Prudent manner, acting in, 340 Psychometric qualities, 111 Psychosocial variables, as segmenta- tion, 298 PsycINFO®, 86 Public domain, 117 Public Health Service Act, 101 Publicity, 307 Public relations, 307 PubMed®, 86–87 Punishment, 158, 159 Pygmalion effect, 382 Q Qualitative data, 92 Qualitative measures, 107 Qualitative method, 375–76, 377 Quality, 351 Quality circles, 372, 377 Qualtrics, 76, 132 Quantifying the issue, 43–44 Quantitative data, 92 Quantitative literacy, 200 Quantitative measures, 107 Quantitative method, 375 Quasi-experimental design, 378, 379 Questionnaires in measurement instruments, 111 written, 73–75, 83 QuestionPro, 76 Questions in measurement instruments, 111, 112 in objective development, 139 in self-report data, 112 wording for measurement instruments, 118–19 Quota, 127 R Random-digit dialing (RDD), 75–76 Randomization, 382 Random numbers, 124–25 Random samples nonproportional stratified, 126 proportional stratified, 125, 126 simple, 124, 126 stratified, 125 Random selection, 123–24 Range, 391 Rater reliability, 113–14, 116 Rating Websites, 199 Ratio level measures, 109 Rationale for health promotion program, 18–37 example rationale, 30–32 identifying background informa- tion, 20–27 information and data types, 21–27 listing references, 30, 32 need to gain support of decision makers, 18–20 Procedural/participants’ manual, 341–42 Processes of change, 169, 171 Process evaluation, 352–53, 354. See also Formative evaluation defined, 352 elements of, 370–71 pilot testing, 373–74 pretesting, 373 Process impact, 50 Process objectives, 136–37, 143 Product (marketing variable), 293, 295, 301–2 Professional development plan, 328 Profit margin, 277 Program and evaluation forms, 372 Program evaluation and review technique (PERT), 324 Program focus, in needs assessment, 97–98, 100 Program goals. See Goals Program kickoff, 333 Program launch, 333 Program monitoring, 334–35 Program ownership, 34 Program planning, 10–12 evaluation in, 360 measurement in, 107–8 three Fs of, 62–63 Program planning models defined, 41 Generalized Model, 11, 41–43, 58–62 Health Communication Model, 57 Healthy Communities movement, 51–53 Healthy Plan-It (CDC), 57 intervention mapping, 50–51 MAP-IT (Mobilize, Assess, Plan, Implement and Track), 46–48, 57, 64–65 MAPP (Mobilizing for Action through Planning and Partner- ships) model, 45–46, 57, 92 PRECEDE-PROCEED, 48–51 SMART (Social Marketing As- sessment and Response Tool), 53–57 SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis, 57–58 three Fs of program planning, 62–63 uses of, 41 Program registration, 341 Program rollout, 333 Program significance, 395 Promoting Health/Preventing Disease: Objectives for the Nation (USD- HHS), 3, 146 Promotion (marketing variable), 293, 295, 306–9 Promotional strategy, 309–10 Proportional stratified random sample, 125, 126 Proposal (grant), 281–82 Proprietary standards, 358 Prose, 200 Protection motivation theory (PMT), 163–65, 231–32 474 Subject Index evaluation phase, 54, 57 implementation phase, 54, 57 market analysis phase, 54, 56 for needs assessment, 92 objectives and, 141, 145 phases of, listed, 54 preliminary planning phase, 54, 55–57 SMART objectives, 133, 141, 145, 148 SMOG (Simple Measure of Gobble- degook) Readability Formula, 202–3 Smoking, health and financial costs, 23 Snowball sample, 127 Social action, 241 Social activities to support behavior change, 223 Social advocacy, 241 Social assessment, 48, 49 Social assessment and situational analysis (PRECEDE-PROCEED), 48, 49 Social bookmarking, 199 Social capital, 176, 181, 240 Social capital theory, 181–82 Social cognitive theory (SCT), 153, 176–79, 180, 231–32 Social context, 155 Social desirability, 382 Social gaming, 199 Social gatherings, as intervention, 224 Social integration, 176 Social journaling, 199 Social learning, 176 Social liberation, 169 Social marketing. See also SMART (Social Marketing Assessment and Response Tool) approach to design interventions, 292 benefits or core products in, 303 defined, 291 example, 293 marketing and, 291–93 marketing mix/4Ps for, 293 products in, 302 Social Marketing Assessment and Response Tool (SMART). See SMART (Social Marketing Assessment and Response Tool) planning model Social math, 29 Social media, 196, 199–200 Social modeling, 177 Social networking, 199, 214 Social networks, 176 Social networks, as intervention, 224–25 Social network theory (SNT), 179–81 Social news, 199 Social planning, 241 Social power, 176 Social Security Act (1935), 330 Social solidarity, 241 Social support, 176 Scope (curriculum), 204–5 Search engines, on World Wide Web, 88 Searching, 199 Secondary building blocks, 250 Secondary data defined, 71 drawbacks of, 71 for needs assessment, 92 in segmentation, 297 sources of, 82, 84–90 Secondary prevention, 6 Second opinion, 98 Seed dollars, 280 Segmentation, of populations advantages, 296–97 defined, 296 in design of new health promo- tion interventions, 230, 233 examples of categories and vari- ables, 298 in health promotion program, 296–301 for preconception health care example, 301 steps in, 299–300 Selection (internal validity), 381 Self-assessments, 81–82, 84 Self-control, 177, 180 Self-efficacy, 153, 162, 163, 169, 171, 180, 198 Self-liberation, 169 Self-reevaluation, 169 Self-regulation, 177, 180 Self-reinforcement, 177 Self-report data accuracy of, increasing, 72 advantages and disadvantages, 71–72 defined, 71 importance of, 71–72 limitations of, 72 questions used in (example), 112 Sensitivity, of tests, 116 Sequence (curriculum), 204–5 Service-learning, 53 Settings approach, 229 Seventeen magazine, 308 Short-term objective, 138 Significant others, 73 Simple random sample (SRS), 124, 126 Simply Put: A guide for creating easy- to-understand materials (CDC), 201–2 Single-step (cross-sectional) surveys, 71–73 Situational analysis, 48, 49 Skill development objectives, 137 Sliding-scale fee, 277 SMART (Social Marketing Assessment and Response Tool) planning model, 294 channel analysis phase, 54, 56 consumer analysis phase, 54, 56 defined, 53 develop interventions, materials, and pretest phase, 54, 57 Respect for persons principle, 339 Respondents, 71 Response, 367, 369, 370, 371 Response efficacy, 164 Response options, in measurement instruments, 119–20 Responsibilities and competencies for health education specialists community organizing and community building, 239 comparison of areas of responsi- bility, 8 data management, 388 evaluation, 352 evaluation approaches and designs, 366 implementation, 320 interventions, 193 marketing health promotion interventions, 292 measurement, 106 mission statement, goals, and objectives, 134 needs assessment, 70 program planning, 18, 42 resources for health promotion programs, 262 theories and models in health promotion, 155 Responsibilities and competencies for health educators, 6–9 exam to certify health educators, 8–9 Retest, 113 Return on investment (ROI), 23 Reward, 159, 164 Reynolds Adolescent Depression (RAD) scale, 115–16 Role Delineation Project, 6, 7 S Safety concerns, of implementation, 336–38 Sales promotion, 307 SAM (suitability assessment of mate- rials instrument), 272–74 Sample, 121, 123 Sample size, 127 Sampling, 121–27 cluster (area), 125, 126 defined, 123 nonprobability sample, 126–27 probability sampling, 123–26 proportional stratified, 126 proportional stratified random, 125 sample size, 127, 128 simple random, 124, 126 stratified random, 125 systematic, 125, 126 Sampling frame, 124 Sampling unit, 121 Satisfaction, 367, 370 Saving, 199 Scales, 111 Scholarships, 277 Subject Index 475 Theory-based intervention methods, 51 Theory in Health Promotion Research and Practice (Goodson), 154 Theory of planned behavior (TPB), 160–62, 190, 231–32 Theory of reasoned action (TRA), 160–62 Third-party support, 277–78 This Day in History, 348 Threat appraisal process, 164 Three Fs of program planning, 62–63 Time lines, 324 Timetables, 324 Tools of Change, 316 Total implementation, 333 Town hall meeting, 77, 84 Tracking, in MAP-IT, 48 Traditional economics, 218 Training manual, 342 Transtheoretical model (TTM), 168–73, 231–32 Treatment, 192 Triple blind study, 383 t-tests, 392 Turf struggles, 253 12-step programs, 223 Type I error, 391 Type II error, 391 Type III error, 342, 359 U Unit plans, 205 Univariate data analysis, 389, 390–91 Universe, 122, 123 Unobtrusive observation, 80, 377 Utility standards, 358 V Validation, in needs assessment, 98, 100 Validity defined, 114 external validity of evaluation, 382–83 internal validity of evaluation, 381–82 of measurement, 114–16 sensitivity, specificity, and, 116 summary of types of, 116 Value-expectancy theories, 160 Values and benefits of health promo- tion programs, 24–25 Variables, 153, 389 Variation, measures of, 391 Vendors, 265 VERB program, promoting physical activity, 306 Verbs, for program outcomes, 135, 140–41 Vertical relationships, 254 Vicarious reinforcement, 177 Survey instruments, 111, 120–21, 372 SurveyMonkey, 76 Survey population, 123 Surveys multistep, 77 single-step (cross-sectional), 71–73 SWOT (Strengths, Weaknesses, Opportunities, and Threats), 57–58 Syndication, 199 Systematic sample, 125, 126 Systems approach, 192 Systems change, 238 T Tagging, 199 Tailored messages, 167 Tailoring (intervention activities), 196 Target audience, 294 Targeting, 196 Task development time lines (TDTLs), 324, 325 Task force, 247 Task Force on Community Preventive Services, 26, 27 Teams, 269–71 Technical assistance (TA), 267 Technical resources management, 331 Technical skills, 246 Technical support, 267 Technology. See also Social media for data mapping, 88, 90 digital communication, 307 multidirectional communication (MDC) model and, 194–95 using to collect needs assessment data, 76–77, 80–81, 88, 90 Teen People magazine, 308 Telephone interviews, 75–76, 83 Temporary committee, permanent committee versus, 36 Temptation, 169, 171–72 Termination stage, 170, 171 Tertiary prevention, 6 Testing (internal validity), 381 Test-retest reliability, 113 Tests, 111 Text messaging, 199 Theoretical Foundations of Health Education and Health Promotion (Sharma & Romas), 154 Theories. See also Behavior change theories; Models concepts, 153 constructs, 153 defined, 152 limitations of, 187–88 models versus, 152 responsibilities and competencies for health education special- ists, 155 types of, 154 variables, 153 Social video sharing, 199 Society for Public Health Education (SOPHE), 7, 8 Socio-ecological approach application of, 156 defined, 155 Soft money, 279 Space, for health promotion programs, 263, 275–76 Speakers’ bureaus, 265–66 Specificity, of tests, 116 SRS (simple random sample), 124, 126 Stability reliability, 113, 116 Stage construct, 169 Stages of Change Model. See Transtheoretical model Stage theories, 157 precaution adoption process model (PAPM), 173–75, 231–32 transtheoretical model (TTM), 168–73, 231–32 Stakeholders defined, 11 engaging in program evaluation, 356–57 in planning committee, 59 Standard Occupation Classification, 9 Standards for Culturally and Linguis- tically Appropriate Services (CLAS) in Health and Health Care, 271 Standards for Privacy of Individually Identifiable Health Information (The Privacy Rule), 86, 341. See also HIPAA Standards of evaluation, 358 Statement of the problem, 28 Statistical Abstract of the United States, 85 Statistical regression (internal valid- ity), 381 Statistical significance, 391 Statistics. See Data analysis Steering committee, 33 Stimulus control, 169 Stimulus response (SR) theory, 157–60 Storming stage (team development), 270–71 Strands, 205 Strata, 125 Strategy, defined, 193 Stratified random sample, 125 Subjective evidence, 25–26 Subjective norm, 161 Suitability assessment of materials (SAM), 272–74 Summative evaluation, 254, 352, 354, 374 Supplies, for health promotion programs, 263, 276 Support, 19, 367, 369 Support groups, 223–24 Supporting participants, 246 surveygizmo, 76 476 Subject Index World Health Statistics Report, 22 World Wide Web (WWW), searching via, 88 Written questionnaires, 73–75, 83 Written reports, designing, 397, 398 Y Yahoo, 88 Youth Risk Behavior Surveillance System (YRBSS), 22, 85 Z Zoomerang, 76 Web 2.0, 199 Webinars, 199 Weight Watchers, 223 WELCOA Quick-Inventory (Wellness Council of America), 217 Wellness Impact Scorecard (WIS- CORE®), 102 WellSteps, 38 Widgets, 199 Windshield tour, 80 Wireless-only households, 75 Working groups, teams versus, 270 World Health Organization (WHO), 51 Vietnam Era Veterans’ Readjustment Assistance Act, 330 Visioning (MAPP), 46 Vision statement, 134–35 Vocational Rehabilitation Act, 330 Voluntary health agencies, 279, 280 Volunteers in community organizing, 248 as personnel, 267–69 W Waiver of liability, 337 Walk-through, 80 477 Cover Edhar Shvets/Shutterstock Chapter 1 p. 2 Based on Miniño, Xu, & Kochanek (2010). Mokdad, Marks, Stroup, & Greberding (2004, 2005); p. 3 Green 1999, p.69. Green, L. W. (1999). Health education’s contributions to public health in the twentieth century: A glimpse through health promotion’s rear-view mirror. In J. E. Fielding, L.B. Lave, & B. Starfield (Eds.), Annual review of public health (pp. 67–88). Palo Alto, CA: Annual Reviews; p. 4 Breslow 1999, p. 1031. Breslow, L. (1999). From disease prevention to health promotion. Journal of the American Medical Association, 281(11), 1030–1033; p. 4 American Journal of Health Education, Report of the 2011 Joint Committee on Health Education and Promotion Terminology, p 13; p. 5 Pearson Education; p. 9 U.S. Department of Labor Bureau of Labor Statistics (BLS), (Standard Occupation Classification [SOC] 21-1091), Paragraph 1, 2015; p. 11 Adapted from Public Health: Administration and Practice. George E. Pickett and John J. Hanlon. Copyright © 1990 by McGraw Hill Education; p. 12 Pearson Education. Chapter 2 p. 19 Art of Health Promotion. L. S. Chapman. Copyright © 1997 by The American Journal of Health Promotion. Reproduced with permission. p. 20 Pearson Education; p. 21 Pearson Education; p. 22 Adapted from ACS (2009). CDC (2010c). and Chapman (1997); p. 24 McGinnis and colleagues (2002). McGinnis, J. M., Williams-Russo, P., & Knickman, J.R. (2002). The case for more active policy atten- tion to health promotion. Health Affairs, 21(2), 78–93; p. 25 Pearson Education; p. 27 Pearson Education; p. 28 TM Toole, J Gambatese; The trajectories of prevention through design in construction. Journal of Safety Research, 39(2) pp. 225–230; p. 28 Pearson Education; p. 30 (WHO, 2014, para. 4); pp. 31–32 Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: comprehen- sive tobacco control programs. www.thecommunityguide.org/ tobacco/comprehensive.html. Last updated: 11/13/2014; p. 35 Pearson Education. Chapter 3 p. 42 Pearson Education; p. 45 Achieving Healthier Communities through MAPP: A User’s Handbook. Copyright © 2009 by the National Association of County and City Health Officials. Reprinted with permission; p. 49 Adapted from Health Promotion Planning. Lawrence W. Green and Marshall W. Kreuter. Copyright © 2005 by McGraw-Hill. Chapter 4 p. 68 Brennan Ramirez et al, 2008, p. 54. Brennan Ramirez, L. K., Baker, E. A., & Metzler, M. (2008). Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta: Centers for Disease Control and Prevention. Retrieved March 29,2011, from http://www. cdc.gov/nccdphp/dach/chaps; p. 74 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (no date), p. A3–12; p. 87 Pearson Education; p. 89 Adapted from Deeds (1992) and Marcarin (1995); p. 90 Pearson Education; p. 95 Neiger, Thackeray, & Fagen, 2011, p. 166, 168. S.Neiger, B. L., Thackeray, R., & Fagen, M. C. (2011). Basic priority rating model 2.0: Current ap- plications for priority setting in health promotion prac- tice. Health Promotion Practice, 12(2), 166–171. © 2011 Sage Publications; p. 97 Green L, Kreuter M. (1999). Health pro- motion planning: An educational and ecological approach. 3rd edition. Mountain View, CA: Mayfield Publishing Company; p. 101 Based on (WHO, 2015, para. 1). Chapter 5 p. 110 Pearson Education; p. 122 Pearson Education; p. 123 Pearson Education; p. 127 Pearson Education. Chapter 7 p. 152 Nutbeam and Harris 1999. Nutbeam, D., & Harris, E. (1999). Theory in a nutshell: A guide to health promo- tion theory. Sydney, Australia: McGraw-Hill; p. 153 Pearson Education; p. 158 Pearson Education; p. 160 Pearson Education; p. 161 Theory of Planned Behavior Diagram. Icek Ajzen. Copyright © 2006 by Icek Ajzen. Reprinted with permission; p. 162 Theory of Planned Behavior Diagram. Icek Ajzen. Copyright © 2006 by Icek Ajzen. Reprinted with permission; p. 162 Champion, V.L., & Skinner, C.S. (2008). The health belief model. In Glanz K, Rimer BK, Viswanath K, Eds. (4th ed). Health Behavior and Health Education: Theory, Research, and Practice. San Francisco: Jossey-Bass. pp. 45-65. (graph on p48); p. 163 Pearson Education; p. 164 Prentice-Dunn and Rogers 1986, p. 156. Prentice-Dunn, S., & Rogers, R. W. (1986). Protection motivation theory and preventive; p. 167 “Changing AIDS-Risk Behavior.” J. D. and W. A. Fisher from Psychological Bulletin 111(3). Copyright © 1992 by the American Psychological Association.; p. 171 “Models for Provider-Patient Interaction: Applications to Health Behavior Change.” M. G. Goldstein from The Handbook of Health Behavior Change by Sally Shumaker. Reproduced with permission of Springer Publishing Company, Incorporated via Copyright Clearance Center; p. 172 Prochaska et al., 2008, 103. Prochaska, J. O, Redding, C. A., & Evers, K. E. (2008). The transtheoretical model and stages of change. In K. Glanz, B. K. Rimer, & K. Viswanath Credits http://www.thecommunityguide.org/tobacco/comprehensive.html http://www.cdc.gov/nccdphp/dach/chaps http://www.cdc.gov/nccdphp/dach/chaps http://www.thecommunityguide.org/tobacco/comprehensive.html 478 Credits (Eds.), Health behavior and health education: Theory, re- search, and practice (4th ed., pp. 97–121). San Francisco: Jossey-Bass; p. 173 Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis; James N. Weinstein, D.O., M.S., Tor D. Tosteson, Sc.D., Jon D. Lurie, M.D., M.S., Anna N.A. Tosteson, Sc.D., Emily Blood, M.S., Brett Hanscom, M.S., Harry Herkowitz, M.D., Frank Cammisa, M.D., Todd Albert, M.D., Scott D. Boden, M.D., Alan Hilibrand, M.D., Harley Goldberg, D.O., Sigurd Berven, M.D., and Howard An, M.D. for the SPORT Investigators. New England Journal of Medicine, 2008; 358:794-810 February 21, 2008. © 2008 Massachusetts Medical Society; p. 174 Pearson Education; p. 175 Based on: Health Behavior and Health Education: Theory, Research, and Practice, by Karen Glanz, Barbara K. Rimer, and K. Viswanath. Copyright © 2008 by John Wiley & Sons, Inc.; p. 178 Glanz and Rimer 1995 p. 15. Glanz, K., & Rimer, B. K. (1995). Theory at a glance: A guide for health promotion practice (NIH Pub. No. 95–3896). Washington, DC: National Cancer Institute; p. 181 Edberg, 2007, p.59. Edberg, M. (2007). Essentials of health behavior: Social and behavioral theory in public health. Sudbury, MA: Jones & Bartlett; p. 182 Based on Introduction to Health Behavior Theory. by J. Hayden. Copyright © 2014 by Jones & Bartlett Learning; p. health: Beyond the health belief model. Health Education Research: Theory and Practice, 1(3), 153–161. Oxford University Press; p. 183 Pearson Education; p. 185 “Community readiness: Research to prac- tice.” Ruth W. Edwards, Pamela Jumper-Thurman, Barbara A. Plested, Eugene R. Oetting, Louis Swanson, in Journal of Community Psychology 28(3). Copyright © 2000 by John Wiley & Sons, Inc; p. 186 “Community readiness: Research to practice.” Ruth W. Edwards, Pamela Jumper-Thurman, Barbara A. Plested, Eugene R. Oetting, Louis Swanson, in Journal of Community Psychology 28(3). Copyright © 2000 by John Wiley & Sons, Inc. Chapter 8 p. 195 Thackeray, R., & Neiger, B. L. (2009). A multidirec- tional communication model: Implications for social mar- keting practice. Health Promotion Practice, 10(2), 171–175. © 2009 Sage Publications; p. 198 Adapted from United States Department of Agriculture (n.d.); p. 200 Pearson Education; p. 200 Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey; Kirsch, Jungeblut, Jenkins, & Kolstad. U.S. Department of Education Office of Educational Research and Improvement; p. 201 White & Dillow (2005). White, S., & Dillow, S. (2005). Key con- cepts and features of the 2003 National Assessment of Adult Literacy (NCES 2006-471). Washington, DC: National Center for Education Statistics, U.S. Department of Education; p. 205 Pearson Education; p. 206 Pearson Education; p. 216 Pearson Education; p. 222 © 2009 Larry Grudzien, Attorney at Law. All Right Reserved; p. 226 McKleroy et al. 2006. McKleroy, V. S., Galbraith, J. S., Cummings, B., Jones, P., Harshbarger, C., Collins, C., Gelaude, D., Carey, J. W., & ADAPT Team. (2006). Adapting evidence-based behavioral interventions for new settings and target populations. AIDS Education and Prevention, 19(Suppl. A), 59–73; p. 228 Pearson Education; p. 231 Pearson Education. Chapter 9 p. 238 An Introduction to Community & Public Health, James F. McKenzie, Robert R. Pinger, © 2015 Jones & Bartlett Learning; p. 241 Minkler, M., & Wallerstein, N. (2012). Improving health through community organiza- tion and community building: Perspectives from health education and social work. In M. Minkler (Ed.). Community organizing and community building for health and welfare (3rd ed., p. 44). New Brunswick, NJ: Rutgers University Press; p. 242 Minkler, Meredith and Nina Wallerstein. “Figure 3.1: Community Organization and Community— Building Typology” in Community Organizing and Community Building for Health and Welfare. Copyright © 2012 by Meredith Minkler. Reprinted by permission of Rutgers University Press; p. 243 Pearson Education; p. 247 Butterfoss, 2007, p. 30. Butterfoss, F. D. (2007). Coalitions and partnerships in community health. San Francisco: Jossey-Bass; p. 250 Kretzman, John P. and John L. McKnight. “Figure 10.1: Neighborhood Needs Map”, “Mapping Community Capacity” in Community Organizing and Community Building for Health and Welfare. Copyright © 2012 by Meredith Minkler. Reprinted by permission of Rutgers University Press; p. 251 Kretzman, John P. and John L. McKnight. “Figure 10.2: Neighborhood Assets Map”, “Mapping Community Capacity” in Community Organizing and Community Building for Health and Welfare. Copyright © 2012 by Meredith Minkler. Reprinted by permission of Rutgers University Press. Chapter 10 p. 265 Adapted from: “How to Select the Right Vendor for Your Company’s Selecting Health Promotion Program.” J. H. Harris, J. F. McKenzie, and W. B. Zuti, from Fitness in Business 1. Copyright © 1986 by American School Health Association.; p. 266 Pearson Education; p. 270 Pearson Education; p. 272 Teaching Patients with Low Literacy Skills, 2nd Edition. C. C. Doak, L. G. Doak, & J. H. Root. Copyright © 1996 by J. B. Lippincott Company. Reprinted with permission of the authors; p. 283 Pearson Education; p. 286 Pearson Education. Chapter 11 p. 295 Pearson Education; p. 298 Pearson Education; p. 301 Adapted from Lynch, Squires, Lewis, Moultrie, Kish-Doto, Boudewyns, et al, 2014; p. 309 Staten LK, Birnbaum AS, Jobe JB, Elder JP. A typology of middle school girls: Audience seg- mentation related to physical activity. Health Education & Behavior. 2006;33:66–80; p. 313 Pearson Education. Chapter 12 p. 321 Pearson Education; p. 324 Pearson Education; p. 323 Pearson Education; p. 325 Pearson Education; p. 326 Pearson Education; p. 331 Pearson Education; p. 334 United States Department of Justice. Chapter 13 p. 356 CDC (1999c), p. 4. Chapter 14 p. 367 Pearson Education; p. 370 Adapted from Steckler & Linnan (2002); and Saunders, Evans, & Joshi (2005); p. 372 Pearson Education; p. 379 Pearson Education; p. 380 Pearson Education; p. 380 Pearson Education. Chapter 15 p. 395 Fitzpatrick, J. L., Sanders, J. R., & Worthen, B. R. (2004). Program Evaluation: Alternative Approaches and Practical Guidelines (3rd ed.). United States, Pearson; p. 396 Wurzback, Mary Ellen, Ed. (2002) Community Health Education and Practice (2e) United States, Jones & Bartlett Learning; p. 399 Weiss, C. (1984). Increasing the likelihood of influencing decisions. In L. Rutman (Ed.), Evaluation research methods: A basic guide (pp. 159–190). Beverly Hills, CA: Sage. Cover Title Page ������������������ Copyright Page ���������������������� Contents ���������������� Preface ��������������� Acknowledgments ����������������������� Chapter 1 Health Education, Health Promotion, Health Education Specialists, and Program Planning Health Education and Health Promotion ��������������������������������������������� Health Education Specialists ������������������������������������ Assumptions of Health Promotion ��������������������������������������� Program Planning ������������������������ Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Part I Planning A Health Promotion Program Chapter 2 Starting the Planning Process The Need for Creating a Rationale to Gain the Support of Decision Makers �������������������������������������������������������������������������������� Steps in Creating a Program Rationale ��������������������������������������������� Step 1: Identify Appropriate Background Information ����������������������������������������������������������� Step 2: Title the Rationale ����������������������������������� Step 3: Writing the Content of the Rationale ���������������������������������������������������� Step 4: Listing the References Used to Create the Rationale ������������������������������������������������������������������� Planning Committee �������������������������� Parameters for Planning ������������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Chapter 3 Program Planning Models in Health Promotion Evidence-Based Planning Framework for Public Health Mobilizing for Action Through Planning and Partnerships (MAPP) MAP-IT PRECEDE-PROCEED The Eight Phases of PRECEDE-PROCEED Intervention Mapping ���������������������������� Healthy Communities ��������������������������� SMART The Phases of SMART Other Planning Models ����������������������������� An Application of the Generalized Model ����������������������������������������������� Final Thoughts on Choosing a Planning Model ��������������������������������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Chapter 4 Assessing Needs What to Expect from a Needs Assessment ���������������������������������������������� Acquiring Needs Assessment Data ��������������������������������������� Sources of Primary Data ������������������������������� Sources of Secondary Data ��������������������������������� Steps for Conducting a Literature Search ������������������������������������������������ Using Technology to Map Needs Assessment Data ����������������������������������������������������� Conducting a Needs Assessment ������������������������������������� Step 1: Determining the Purpose and Scope of the Needs Assessment ������������������������������������������������������������������������� Step 2: Gathering Data ������������������������������ Step 3: Analyzing the Data ���������������������������������� Step 4: Identifying the Risk Factors Linked to the Health Problem ������������������������������������������������������������������������� Step 5: Identifying the Program Focus ��������������������������������������������� Step 6: Validating the Prioritized Needs ������������������������������������������������ Application of the Six-Step Needs Assessment Process Special Types of Health Assessments ������������������������������������������� Health Impact Assessment �������������������������������� Organizational Health Assessment ���������������������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Chapter 5 Measurement, Measures, Measurement Instruments, and Sampling Measurement ������������������� The Importance of Measurement in Program Planning and Evaluation ������������������������������������������������������������������������ Levels of Measurement ����������������������������� Types of Measures ������������������������� Desirable Characteristics of Data ����������������������������������������� Reliability ������������������� Validity ���������������� Bias Free ����������������� Measurement Instruments ������������������������������� Using an Existing Measurement Instrument ������������������������������������������������ Creating a Measurement Instrument ����������������������������������������� Sampling ���������������� Probability Sample �������������������������� Nonprobability Sample ����������������������������� Sample Size ������������������� Pilot Testing ��������������������� Ethical Issues Associated with Measurement �������������������������������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Chapter 6 Mission Statement, Goals, and Objectives Mission Statement ������������������������� Program Goals ��������������������� Objectives ������������������ Different Levels of Objectives �������������������������������������� Consideration of the Time Needed to Reach the Outcome of an Objective ����������������������������������������������������������������������������� Developing Objectives ����������������������������� Questions to Be Answered When Developing Objectives ����������������������������������������������������������� Elements of an Objective �������������������������������� Goals and Objectives for the Nation ������������������������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Chapter 7 Theories and Models Commonly Used for Health Promotion Interventions Types of Theories and Models ������������������������������������ Behavior Change Theories �������������������������������� Intrapersonal Level Theories ������������������������������������ Interpersonal Level Theories ������������������������������������ Community Level Theories �������������������������������� Cognitive-Behavioral Model of the Relapse Process Limitations of Theory ����������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Chapter 8 Interventions Types of Intervention Strategies ���������������������������������������� Health Communication Strategies ��������������������������������������� Health Education Strategies ����������������������������������� Health Policy/Enforcement Strategies Environmental Change Strategies ��������������������������������������� Health-Related Community Service Strategies Community Mobilization Strategies ����������������������������������������� Other Strategies ������������������������ Creating Health Promotion Interventions ����������������������������������������������� Intervention Planning ����������������������������� Adopting a Health Promotion Intervention ������������������������������������������������ Adapting a Health Promotion Intervention ������������������������������������������������ Designing a New Health Promotion Intervention ����������������������������������������������������� Limtations of Interventions ����������������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Chapter 9 Community Organizing and Community Building Community Organizing Background and Assumptions ������������������������������������������������������� The Processes of Community Organizing and Community Building �������������������������������������������������������������������� Recognizing the Issue ����������������������������� Gaining Entry into the Community ���������������������������������������� Organizing the People ����������������������������� Assessing the Community ������������������������������� Determining Priorities and Setting Goals ������������������������������������������������ Arriving at a Solution and Selecting Intervention Strategies �������������������������������������������������������������������� Final Steps in the Community Organizing and Building Processes ���������������������������������������������������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Part II Implementing a Health Promotion Program Chapter 10 Identification and Allocation of Resources Personnel ����������������� Internal Personnel �������������������������� External Personnel �������������������������� Combination of Internal and External Personnel ������������������������������������������������������ Items Related to Personnel ���������������������������������� Curricula and Other Instructional Resources ��������������������������������������������������� Space ������������� Equipment and Supplies ������������������������������ Financial Resources ��������������������������� Participant Fee ����������������������� Third-Party Support Cost Sharing �������������������� Cooperative Agreements ������������������������������ Organization/Agency Sponsorship Grants and Gifts ������������������������ Combining Sources ������������������������� Preparing and Monitoring a Budget ����������������������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Marketing and Social Marketing �������������������������������������� Chapter 11 Marketing: Developing Programs that Respond to the Wants and Needs of the Priority Population Marketing and Social Marketing The Marketing Process and Health Promotion Programs ����������������������������������������������������������� Exchange ���������������� Consumer Orientation ���������������������������� Segmentation �������������������� Marketing Mix ��������������������� Pretesting ������������������ Continuous Monitoring ����������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Chapter 12 Implementation: Strategies and Associated Concerns Logic Models �������������������� Defining Implementation ������������������������������� Phases of Program Implementation ���������������������������������������� Phase 1: Adoption of the Program ���������������������������������������� Phase 2: Identifying and Prioritizing the Tasks to Be Completed ����������������������������������������������������������������������� Phase 3: Establishing a System of Management ���������������������������������������������������� Phase 4: Putting the Plans into Action ���������������������������������������������� Phase 5: Ending or Sustaining a Program ����������������������������������������������� Implementation of Evidence-Based Interventions Concerns Associated with Implementation ����������������������������������������������� Safety and Medical Concerns ����������������������������������� Ethical Issues ���������������������� Legal Concerns ���������������������� Program Registration and Fee Collection ����������������������������������������������� Procedures for Record Keeping ������������������������������������� Procedural Manual And/or Participants’ Manual ����������������������������������������������������� Program Participants with Disabilities ���������������������������������������������� Training for Facilitators ��������������������������������� Dealing with Problems ����������������������������� Documenting and Reporting ��������������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Part III Evaluating a Health Promotion Program Chapter 13 Evaluation: An Overview Basic Terminology ������������������������� Purpose of Evaluation ����������������������������� Framework for Program Evaluation ���������������������������������������� Practical Problems or Barriers in Conducting an Evaluation ������������������������������������������������������������������ Evaluation in the Program Planning Stages ������������������������������������������������� Ethical Considerations ������������������������������ Who Will Conduct the Evaluation? ���������������������������������������� Evaluation Results �������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Chapter 14 Evaluation Approaches and Designs Formative Evaluation ���������������������������� Pretesting ������������������ Pilot Testing ��������������������� Summative Evaluation ���������������������������� Selecting an Evaluation Design �������������������������������������� Experimental, Control, and Comparison Groups ���������������������������������������������������� Evaluation Designs �������������������������� Internal Validity ������������������������� External Validity ������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Chapter 15 Data Analysis and Reporting Data Management ����������������������� Data Analysis ��������������������� Univariate Data Analyses �������������������������������� Bivariate Data Analyses ������������������������������� Multivariate Data Analyses ���������������������������������� Applications of Data Analyses ������������������������������������� Interpreting the Data ����������������������������� Evaluation Reporting ���������������������������� Designing the Written Report ������������������������������������ Presenting Data ����������������������� How and When to Present the Report ������������������������������������������ Increasing Utilization of the Results ��������������������������������������������� Summary ��������������� Review Questions ������������������������ Activities ������������������ Weblinks ���������������� Appendix A Code of Ethics for the Health Education Profession Appendix B Health Education Specialist Practice Analysis (HESPA 2015)– Responsibilities, Competencies and Sub-Competencies Glossary References Name Index Subject Index Text Credits 2016-04-15T08:57:48+0000 Preflight Ticket Signature

thoughtfully respond to the 2 posts. Please make sure to reference both your course textbook, as well as the website utilized, using APA 6th Edition Format.

Ruby Navarro

 

Week 2 Discussion 1

COLLAPSE

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Utilizing Chapter 1 of the course textbook, briefly describe the history of health program planning and evaluation in the U.S.

What one event stands out as a significant catalyst in this process, and why?

 

Since the 1900s, there has been tremendous progress in persons’ health, such as the eradication of smallpox and poliomyelitis, through education and interventions created at that time of history. The government made progress by creating a primary disease prevention change. Health promotions were the turning point in the past; in 1974, Canada published “A New Perspective on the Health of Canadians,” soon to follow was the United States passing PL 94-317, “the Health Information and Health Promotion Act.”  Next followed the U.S. governments “Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention, connecting links that defined personal behaviors and health status. Healthy People shared similar messages to past publications; Healthy People’s uniqueness was research, easily readable, and available to the public. In 1979 the Role Delineation Project started, creating, and defining roles of entry-level health educators. This progress into other positions.

 

Bibliography

James F. McKenzie, P. M. (2017,2013,2009). Health Education, Health Promotion, Health Education Specialists, and Program Planning. In Planning, Implementing, and Evaluating Health Promotion Programs (p. 2).

 

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Victor Musa 

Week 2 Discussion

COLLAPSE

Top of Form

Utilizing Chapter 1 of the course textbook, briefly describe the history of health program planning and evaluation in the U.S. What one event stands out as a significant catalyst in this process and why?

 

 According to our textbook, (McKenzie, Neiger, & Thackeray, 2017), program planning is a process that is designed to address questions such as “What is needed?” and “How will the needs be addresses?” Through a systematic process, the answers to these questions form the basis of an intervention approach. Program evaluation on the other hand focuses on addressing whether the intervention is working. Evaluation includes questions related to how and if a program is working as it was intended and if there are any unintended consequences. The history of health program planning and evaluation in the United States began in the early 1900s, and the first evaluation took place in the area of education. During that time, the need for health education spread to the public health arena, but it was writers, social workers, visiting nurses, and journalists who were doing the education, not health specialists, as we know them to do today.

 One event that stood out as a significant catalyst in a health program planning is the reason why health education specialist was formed. The role of the health education specialist in the United States as we know it today, is one that has evolved over time based on the need to provide people with education interventions to enhance their health. As we gained more knowledge about the relation between disease and health behavior, it was realized that the journalists, visiting nurses, writers, and primary care givers (dentist, physicians, and other independent practitioners) were unable to provide the needed health education. The combination of heavy workload of the primary care givers, and the lack of formal training in the process of educating others created the need for health education specialist. The reason why this stood out to me is because when we think of health education specialist, we would normally not think of writers or journalists as one of them, but through our reading, we have learned that they were once considered as such and we also see how far the role of health education specialists have come.

 

Reference

McKenzie, J.F., Neiger, B.L., & Thackeray, R. (2017). Planning, implementing, & evaluating health promotion programs: A primer (7th Ed.). San Francisco, CA: Pearson/Benjamin Cummings.

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