WEEK 3: BEHAVIOUR CHANGE MODELS

Learning objectives

• Introduction to concepts and theories of behaviour

• Understanding of the use of behavioural theories in health promotion

• Description and Critical analysis of behavioural models in health promotion

Contents
Learning objectives ....................................................................................................................1
Basic concepts and theories of behaviour .................................................................................2
The contribution of psychology to the understanding of behaviour ........................................2
Behaviour modification theories in the context of health promotion ......................................3
Theories of behaviour change at the individual level................................................................4
The health belief model .............................................................................................................4
The theory of reasoned action (TRA) and the theory of planned behaviour (TPB)...................6
The transtheoretical model and stages of change ....................................................................7
Models of Interpersonal Health Behaviour ...............................................................................8
Community and group intervention models of health behaviour ..........................................11
Community organisation .........................................................................................................11
Diffusion of Innovations theory ...............................................................................................12
Stage theory of Organisational Change ...................................................................................14
Organisational Development Theory .......................................................................................15
Ecological approaches to health ..............................................................................................16
Concluding comment: Exploiting the cumulative action of behavioural theories ..................17
References ...............................................................................................................................18

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Basic concepts and theories of behaviour
The term behaviour describes the set of actions and manifestations of a living organism,
which can be observed using objective methods. Behaviour was a factor of study in all
periods and societies, and the interpretations given were clearly influenced by the general
prevailing perceptions of the world, the prevailing needs, but also the scientific means of
observation and study that each society had at that time. There are several theoretical
approaches to the study and interpretation of behaviour, theories which often appear to be
significantly opposite to each other, although in other cases they complement each other
while it is this range of theories that allowed over time to build a good understanding for
behaviour (Snelling, 2014).

The contribution of psychology to the understanding of behaviour

Psychology, having the human being at the forefront of its research interest, is eminently the
science that uses behaviour in its theoretical approaches. As mentioned earlier there are
several theories, however there are some more dominant and representative ones:

1. Psychoanalytic theory. Perhaps the most well-known and revolutionary approach to

the behaviour of mental processes developed by Sigmund Freud who introduced the
term subconscious. Here behaviour is the expression of basic instincts and instinctual
impulses which are primarily produced by the subconscious. The psychic apparatus
consists of three parts, the Id 1, the Ego 2 and the Superego 3, which, although they
perform individual actions, however, interact with the result that a behaviour appears.
Behaviour appears as a form of defense of the Ego, against the instinctive drives and
impulses, which have the role of the driving force in human behaviour.

2. Behaviourism. This theory was developed as the adversary of the psychoanalytic

approach and was based on the direct observation of stimuli that attract or enhance a
behavioural response. It aims to observe and identify the stimuli that the environment
creates, and which in turn create different responses, which are expressed by the

1
That Id is a collective name for the biological needs and impulses of the individual.
2
The Ego is governed by the principle of reality and its purpose is to satisfy the Id desires by considering the
limitations of reality.
3
The Superego aims at perfection and consists of an organised part of the personality, mainly the unconscious.

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 behaviours that are manifested. In this way it is believed that the prediction, but also
the control of a behaviour will be achieved.

3. The biological dimension of behaviour. The shaping of behaviour seems to involve

mechanisms at the biological level, and therefore hereditary factors may contribute to
the manifestation or not of a behaviour. The extent to which biological and genetic
factors, in contrast to environmental factors, influence behaviour shaping has been the
subject of a long-running conflict among scientists. The prevailing view succeeds in
combining genetic and environmental influences on behaviour. Thus, each individual
has some given genetic material which provides him with specific properties which
can grow, evolve, subside and disappear.

Behaviour modification theories in the context of health promotion

Theory and research precede any practical activity and application in the field of science. A
link is created between them, there is a feedback, and the end result is a creative synthesis
that promotes knowledge and best practice. The behavioural change programs that are most
likely to meet their goals are those based on crystallised knowledge of the behaviours they
aim for and the environment in which they develop (Glanz et al., 2008; Rimer & Glanz,
2005).

Health professionals who work in the field of education and promotion and who design,
implement, and evaluate programs, must know the existing theories and models with which
these theories are expressed. The term theory means a set of interrelated concepts, definitions
and theories which depicts phenomena in a systematic way, by defining relationships
between variables, in order to explain and project these phenomena (Glanz et al., 2008).
Health behaviours are difficult to explain using a single theory. For this reason, models have
been developed which, using data from various theories or even empirical data, try to help
individuals understand a problem within specific circumstances (van Ryn & Heany, 1992).

It should be noted that the theories of health promotion come mainly from the social sciences
and behavioural sciences, but also from epidemiology and the natural sciences. Psychology,
anthropology and even the principles of marketing (Table 1) have been utilised at the level of

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principles in order to develop theories of health promotion (Dreibelbis et al., 2013;
Zimmerman et al., 2016).

Table 1: Sum-up of the role of marketing and the media

The term social marketing refers to the use of marketing principles and techniques that
affect a target population so that anyone interested voluntarily accepts, rejects,
modifies, or abandons a behaviour for the benefit of one or many groups or society. It is
mainly a mixture of financial, communication and educational techniques.

Media advocacy is a strategy based on the use of the media to inform and raise
awareness of the ways in which the legal, economic, or environmental context affects
the formation of public health with the goal of promoting public health.

Theories of behaviour change at the individual level

This category includes theoretical models of education and health promotion that aim to
modify the behaviour of individuals. The individual is at the core of these programs,
regardless to whether the interventions are addressed to communities or to other groups, as
they all consist of individuals.

The health belief model

This model tries to explain and predict health behaviours by emphasising on the attitudes and
beliefs of individuals. It is based on the view that in order for the individual to adopt a health
behaviour and take action he/she must (Nutbeam, 2006; Conner & Norman, 2017): a) feel
receptive to a negative state of health, b) to believe that this condition will have serious
consequences for them, c) to be convinced that by developing an inherent health behaviour,
they will avoid the negative condition and its consequences and d) to believe that the benefits
of the development of this behaviour, outweigh any obstacles they may encounter. In the core
of this model, as it results from the above-mentioned preconditions, six basic concepts are
identified: (van Ryn & Heany, 1992; Nutbeam, 2006; Glanz et al., 2008)

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 1. Perceived susceptibility. It refers to the chances that the person himself believes that
he has, that his health is affected by a situation. In the case where a disorder has
already manifested then the perceived degree of susceptibility may relate to the
acceptance of the disease or diagnosis.

2. Perceived severity. It concerns the degree of severity that a person attributes to a

condition that he or she may potentially acquire or its consequences if left untreated.
The individual evaluates both the clinical consequences (pain, incapacity, death) of
this condition and the social ones (impact on work, family). The combination of
perceived degree of susceptibility and perceived severity is called perceived threat.

3. Perceived benefits. The benefits that the individual believes he or she will have if he
or she develops a suggested health behaviour. Such benefits may be directly related to
health, such as reducing the risk of developing a disorder, but also non-health benefits
such as saving money.

4. Perceived barriers. These barriers are the result of an evaluation, a 'weighing' of the
individual between the potential benefits and problems that will arise if he adopts a
proposed health behaviour. Examples of such barriers can be the side effects of a
therapeutic approach, the financial cost, the dedication of time, etc.

5. Cues to action. Their study has been conducted more on an empirical level where it is
believed that a person's willingness to follow a behaviour can be activated by the
messages they receive from the environment, such as the publicity that a subject
receives, or even messages that come from the body itself.

6. Self-efficacy. Yet another later concept derived from Bandura's socio-cognitive

theory. (Bandura, 1986). The term self-efficacy is defined as an individual's belief
that he or she can successfully adopt a behaviour that is necessary to have the desired
results.

Other modifiers should also be considered that influence individual beliefs such as
demographics, gender, age, nationality, socio-psychological factors, the social environment,
and structural factors, such as current knowledge. The model of belief in health, while
initially used to study behaviours related to screening and compliance, has evolved into a

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useful tool for both explaining and implementing interventions on a wide range of topics such
as nutrition, sexually transmitted diseases, safe driving, substance abuse, regular screening,
adherence to treatment regimens, etc. This model seems to be more useful in people who
have either developed a disorder, or who are at higher risk of developing a disorder, than in a
healthy population.

The theory of reasoned action (TRA) and the theory of planned behaviour (TPB)
The TRA assumes that the most decisive factor for behaviour is the 'behaviour intention' that
characterises an individual (van Ryn & Heany, 1992). An individual's intention is the
cognitive representation of his willingness to adopt a particular behaviour. The factors that
directly affect the person's intentions are his attitudes regarding the specific behaviour and his
subjective norms related to this behaviour (the way the person thinks that third persons who
are interested in him see it, regarding the specific behaviour) (Glanz et al., 2008; Elder et al.,
1999).

The subjective norms that characterise an individual are determined by the normative beliefs.
The individual then assesses whether third parties, important to him or her, accept or agree
with the behaviour as well as his or her personal willingness to agree with the views of those
third parties before accepting or rejecting it. The TRA should not be confused with rational
behaviour. The TRA clearly recognises that individuals act as rational beings, who according
to their attitudes and normative beliefs follow specific behaviours or not, however it does not
judge their attitudes and beliefs as logical, irrational, right or wrong (van Ryn & Heany,
1992). TRA has been used successfully to explain or predict health behaviours such as
smoking, alcohol use, contraception, safe driving, exercise and vaccination coverage, and
breast examination. TPB is essentially an advanced form of TRA. The need to develop this
theory arose from the fact that TRA is not very satisfactory in terms of predicting or
explaining behaviours when individuals have reduced control over the adoption of specific
behaviours due to external factors. Thus, while an individual's intention to adopt a behaviour
may be strong, he may not realize it due to factors outside his locus of control. (Ajzen, 1991;
Ajzen, 2002).

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The concept of perceived behavioural control was added to the TRA, and the theory of TPB
was created, which argues that behaviour is determined by both intentions and the
individual's ability to control. If a person has an increased feeling of control over the
existence of factors that promote the adoption of a particular behaviour, then the perceived
control regarding that behaviour also increases (Glanz et al., 2008).

TPB has been used mainly for the analysis of health behaviours related to physical exercise,
but also sexual behaviour, the use of seat belts while driving and the adoption of ecological
methodologies (Glanz et al., 2008; Godin & Kok, 1996).

The transtheoretical model and stages of change

This model is a synthesis of various theories, flowing from the field of psychology and
behavioural sciences, which uses five stages to describe the process by which a behaviour can
be modified (Prochaska et al., 2013). It is a circular model in the stages of which individuals
can return. The five stages at the core of this model are:

1. The Precontemplation stage. At this stage, the person has no intention of taking any
action in order to change behaviours in the near future. This includes people who have
repeatedly tried to change behaviours without success, or who are ignorant or lacking
in knowledge of the consequences of their behaviour.

2. Contemplation stage. This stage includes individuals who intend to change within the
next months. The fact that they are aware of the positive consequences of a change
but also the negative ones, can lead to it staying at this stage for very long periods of
time as they hesitate in their decision to move on. These individuals are not fully
prepared to engage in traditional health education and promotion programs.

3. Preparation. At this stage individuals intend to change behaviour soon. They have an
action plan and have made decisions, such as participating in a health education
program, consulting a specialist, or developing a method of self-help. It is the
appropriate target population for inclusion in a health education program.

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 4. Action. At this stage, people have made obvious changes in behaviour and lifestyle in
recent months. It should be emphasized that the stage of action according to the
theoretical model is not synonymous with behaviour change.

5. Maintenance. At this stage individuals are called upon to maintain change to avoid
relapse through appropriate procedures and options. It has been observed that at this
stage individuals do not act on changes with the same frequency as in the previous
stage. At this stage there is a risk of relapse.

6. Exit. Although the model basically consists of five stages there is the case of a sixth:
the exit stage. In this last stage, people have eliminated any ‘temptation’ to relapse
and experience a strong sense of self-efficacy. This stage mainly concerns abusive
behaviours such as alcohol, drugs, and smoking.

Health professionals, should be recognising each time in which stage of change individuals
are, can modify the treatment and promotion interventions, in such a way as to meet the
needs of each stage, thus increasing the chances that the intervention will be successful. for
example, strategies for behaviour change are suitable for people who are in the stages of
action or maintenance. Providing knowledge and raising awareness are appropriate for
someone who is in the stage before the prospect of change while interventions aimed at
empowering oneself are more suitable for people in the stage of change. Finally, decision-
making interventions are more appropriate for people who are in the preparation stage
(Prochaska et al., 1992).

Models of Interpersonal Health Behaviour

The theories that fall into this category recognise that individuals are social beings and as
such develop a sense of self and beliefs about their personal effectiveness and competence, in
the context of interaction and interpersonal interactions with other individuals in their family,
social and professional environment. Therefore, the interpersonal environment can influence
or predict the development of a behaviour and ultimately the state of health of individuals.
Theories and models that fall into this category which is know as the Social Cognitive
Theory.

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Social Cognitive theory. It is one of the most important theories in the field of health
education and promotion, as it has effectively linked previous theories to behaviour
modification, which had a less structured structure, introduced new ways and practices in
health education and theoretical ideas from other scientific fields to better understand and
predict behaviours at the health level. This theory, on the one hand, illuminates the dynamics
that characterise behaviour, thus helping to interpret and predict it, and, on the other hand,
allows the planning of interventions in order to activate behaviour modification (Glanz et al.,
2008; Ewles & Simnet, 2003). Social cognitive theory recognises that individuals influence
and are influenced by the world in which they live and argues that the evaluation of changes
in behavioural level depends on the constant interaction of three factors, the environment, the
individual, and the behaviour (Bandura, 2001). Its basic concepts are (Glanz et al., 2008;
Bandura, 1986; Bandura, 1995).

1. Environment and situations. The term ‘environment’ refers to all the factors that
affect behaviour and are external to the individual. These factors concern both the
physical and the social environment. The term ‘situation’ refers to the cognitive or
mental depiction of the environment, carried out by the individual, and which
influences behaviour.

2. Behavioural capability. A behaviour is recognised as a multidimensional and complex

phenomenon with various appearances. The concept of behavioural capability is
based on the fact that in order for a person to manifest a specific behaviour, they must
have knowledge of what that behaviour is as well as the way in which this behaviour
is performed.

3. Reinforcement. This concept is one of the most basic concepts of the social learning
theory, on which the socio-cognitive theory is based. Rewarding or disapproving of a
behaviour may or may not affect its recurrence in the future.

4. Outcome expectations. The individual learns that when they choose a behaviour, then
as a result, specific events will occur. Thus, with the adoption of different behaviours
they can finally predict events that will occur each time depending on the behaviour
that will follow. This ability is developed in four main ways: a) from previous

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 experience, b) from observing others, c) listening to stories, and d) from emotional or
physical reactions to behaviours.

5. Outcome expectancies. The term differs from the previous one in that the expected
results represent the value that an individual attaches to specific results. This value
can be quantified and be positive or negative.

6. Self-efficacy. The term refers to a person's confidence in his or her ability to perform
a particular activity, including the person's belief that he or she can successfully
overcome any obstacles.

7. Self-control of performance. One of the main goals of health promotion programs is

for individuals to gain control over their health-related behaviour. Here the word
performance refers to the emphasis on achieving a goal. It is also important in
programs and interventions aimed at developing performance control that the goals
set are specific, measurable, and not general.

8. Management of emotional arousal. When a person is in a state of intense emotional

charge and alertness, then they often develop defense mechanisms. If these
mechanisms are successful then the feelings of fear, anxiety, or aggression are
reduced. It is important that these are recognised as they can adversely affect any
intervention program. For example, managing stress with relaxation programs or
other methods would be necessary for a person who starts smoking cessation and
experiences intense stress due to this change.

9. Observational learning. By observing the behaviour of others, the person can gain
important knowledge, which is acquired by observing the activities and the
encouragement they receive, positive or negative. This methodology is useful in
changing the behaviours of families. For example, children can observe their parents'
behaviours related to their diet, driving behaviour, alcohol consumption and see what
the results are, and whether there are rewards or punishments depending on their
actions.

10. Reciprocal determinism. The rationale here is that behaviour is not a static
phenomenon but contains a dynamic element and is shaped by environmental factors

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 and the individual, which all together interact and co-shape. This methodology is
related to the continuous and simultaneous interaction of behaviour, environment, and
the individual.

Community and group intervention models of health behaviour

The principles of health education and promotion are not only addressed to the individual, but
one of the main goals is to achieve health at the level of societies and groups, thus confirming
a deep connection between the sciences of health promotion and public health. The theories
developed at this level help to understand the ways in which social systems function and
change, as well as the methods that can activate communities and organisations in this
direction. Theories and theoretical models that fall into this category can be used to organise
programs and interventions that are designed and directed by organisations and bodies whose
role, among others, is the protection and promotion of health. Such bodies and organisations
are schools, workplaces, government agencies, social groups, and health services.

Community organisation
The term social organisation refers to the process by which social groups are supported in
order to identify themselves, to activate available resources, and, consequently, to develop
and implement strategies in order to meet these objectives. There are three most common
models of change in terms of social organisation that can be used synergistically (Glanz et al.,
2008)

1. Locality or community development uses a range of people with the aim of enabling the
community to recognise and then solve its problems. This is achieved based on the
development of resources and competencies, the existence of consensus and focus on clear
goals.

2. Social planning, by setting specific goals, tries to solve substantial problems.

3. Social action aimed at increasing the community's capacity to solve problems and promote
change that will help to successfully address social exclusion and inequalities.

The theory of social organisation, although it can be expressed in different models, it includes
some structural features which characterise it as theory (Glanz et al., 2008).
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1. Empowerment. It refers to the mobilisation of community members and the increase of
their skills in terms of problem solving. A useful definition of empowerment in the context of
community states that empowerment is the process of social action by which individuals and
societies gain control of their lives, in the context of changing the social and political
environment, in order to increase the quality of life and to promote equality (Wallerstein,
1992).

2. Community competence. This term can be considered synonymous with self-efficacy

analysed in the context of theories of behaviour change at the individual level. It refers to the
confidence that communities can solve their problems and have the skills to do so. A
community is characterised as adequate when members can and do work together effectively
to identify needs and problems, agree on ways, and means to be used, and work together
successfully to achieve the social goals they have set.

3. Participation and relevance. These two concepts coexist. They refer to the active
participation of citizens and the existence of a common sense of willingness for change.

4. Issue selection. This concept refers to the identification and selection of topics for action
that can be more easily addressed and thus the chances of a successful response are greater.
The topics chosen must be specific, addressable, unite community members, be relevant to
individuals, be relevant to most of the community and be part of a broader plan or strategy.

5. Critical consciousness. This term includes the active participation of citizens in the search
for the basic and main causes of the problems they face.

The application of this theory and the approaches developed on this basis, can cover a wide
range of behaviours that are not limited to health issues. Finally, an ancillary strategy that can
be used in parallel with the models of community organisation is media advocacy. This
method can enhance interventions and programs of healthy social and public health policy.

Diffusion of Innovations theory

The theory of diffusion of innovations contributes to the better evaluation of the issues that
arise from the use of new technologies and methods as well as to the methodology followed
in order to disseminate these innovations. Essentially, the theory of the diffusion of

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innovations examines and analyses the methods by which new ideas, products and social
practices are spread in the social context, from one society to another, and the way in which
these innovations are adopted and the change that follows. Especially in the field of public
health and health promotion, the dissemination of results regarding new successful methods
is not easy but is rather a challenge that health professionals are called upon to face. The term
diffusion means the process by which an innovation, in a period of time, is transferred,
through specific communication channels, to individuals of a social system. The term
innovation denotes an idea, a practice, or an object that is perceived as new by one or more
individuals (Rogers, 2003). By emphasizing on the characteristics of the innovation, the
likelihood that these innovations will be adopted and therefore their diffusion will be possible
increases. Key characteristics of innovations which are determined by the theory of diffusion
of innovations are:

 The relative advantage of the innovation

 Its compatibility, i.e., the degree to which innovation is compatible with the audience.

 Its complexity, i.e., the degree to which it can be used easily.

 The possibility of testing innovation

 The possibility of observation, i.e., the degree to which the effect of the innovation is
obvious and measurable.

 The effect on social relations

 Its reversibility, i.e., if it can be stopped easily, or even if the consequences are
reversible.

 The power of communication, that is, if it can be easily understood.

 The time required, i.e., if it can be adopted in the shortest possible time.

 The degree of risk and uncertainty

 The degree of commitment required, i.e., to what extent it can be adopted with the
lowest degree of commitment, and

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  The possibility of conversion, i.e., to what extent it can be upgraded and modified
within the time frame.

The stages that compose the theory of diffusion of innovations are (Glanz et al., 2008):

1. Development of innovation

2. Dissemination. Identifying all available media and communication systems to be utilised in

the best possible way for the diffusion of innovation in the target population.

3. Adoption. Here the characteristics of the population are studied, the factors that encourage
the use and any obstacles that will prevent the use.

4. Application. Here emphasis is placed on self-efficacy and user skills.

5. Maintenance. Continuity in the use of innovation.

The successful diffusion of innovations is not an easy process and requires change, whether it
is addressed to the individual, or to society, or to smaller groups and organisations. Programs
based on this theory are a particular challenge for health professionals, as their
implementation, as it is usually carried out on a large scale, can be costly and take a long time
to design, implement and evaluate.

Stage theory of Organisational Change

One of the most important skills that should distinguish a professional who is active in the
promotion of health, is the one that allows to understand the function of organisation and
therefore to implement appropriate interventions that promote the desired changes for health.
Organisations are multidimensional social formations and are characterised by a stratification
in their structure. By understanding and applying theories that promote change at the
organisational level, professionals can develop environments that support health practices and
can address and resolve problems. In the field of promotion, two specific theories have
proven effective in the design of interventions, the Stage Theory, and the Organisational
Development Theory.

Stage theory of Organisational Change

This theory explains how different organisation go through certain stages as they change in
order to adopt an innovation. These stages are recognised and the characteristics that

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distinguish them can be developed at each stage of interventions that promote change. The
theory consists of four stages (various textbooks and publication give different names to these
stages and even include additional stages) (Glanz et al., 2008)

1. Identification of deficiencies, analysis, and evaluation in order to follow an action plan

2. Initiation of action

3. Implementation of the change

4. Ownership of the change

This model has been modified by various studies. However, the core is always common.
Some studies suggest the addition of another stage, after that of ownership, called 'renewal',
during which a successful program is developed to address potential new emerging
requirements (Glanz et al., 2008).

Organisational Development Theory

The main application of this theory is in the workplace, as it emerged from studies
concerning the recognition that the organisational structure of an organisation and the
procedures that follow which affect both the behaviour and the engagement of employees
(Glanz et al., 2008).

This theory is more concerned with identifying problems that hinder the functioning of an
organisation, than with introducing innovation and therefore a change. A strategy developed
on the basis of this theory, consists of consultation at the level of process, external experts
who specialize in this field, and help to identify a problem and then facilitate in finding
solutions, by developing the appropriate strategic plan.

In any case, both Stage theory of Organisational Change and Organisational Development
theory can have better results, if used in combination. Also useful is a third theory that can be
applied at the level of organisations which is called Interorganisational Relation theory and
concerns the way in which different organisations work together (Butterfoss et al., 2003;
Wickizer et al., 1993).

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Organisations often adopt and implement new health promotion programs (e.g., a school
canteen program to sell fruits and vegetables). The health professionals themselves work
within organisations that should also be able to innovate and adopt change, while
collaborating between different organisations and health care providers is an excellent
practice for promoting and protecting health.

Ecological approaches to health

As mentioned, the theories developed to explain and predict behaviour and therefore to be
used for the design, implementation and evaluation of education and health promotion
interventions are not only for the individual, but also for larger social formations, such as the
community and other organised formations. This approach, which illustrates a broad
implementation of health promotion at more than one level, is called the 'ecological
approach'. The term refers to the nature of the interactive relationship an individual has with
their physical, social and cultural environments. The term environment in ecological models
includes anything external to that person (Glanz et al., 2008; Green et al., 2019; Stokols, at
al., 1996).

In order to develop and adopt a healthy behaviour, an environment is needed that will support
it. People are not isolated from the place where they live, work, use their free time and
socialize. The ecological approach (figure 1) highlights that the factors that affect health are
not one-dimensional, but, on the contrary, have a complexity that arises from the constant
interaction between the individual, the natural and the social environment.

Ecological models have an advantage over others as they do not limit health as a biological,
social or psychological phenomenon. On the contrary, by utilising basic features and
principles of other models, they integrate them, helping essentially in the better and holistic
understanding of the bio-psychosocial phenomenon of health. In this way, they provide a
solid foundation for the development of more successful interventions and health promotion
strategies aimed at individuals and groups living in complex environments.

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 Figure 1: Ecological Health Promotion model

Source: American College Health Association

Concluding comment: Exploiting the cumulative action of behavioural theories

The theories and models that have been developed for the better application of health
promotion and education are not exhausted in the presentation and analysis of this weekly
overview. The dynamics that characterise the science of health promotion have led to a
continuous evolution of theories, their critical analysis and the creation of new ones. Nothing
restricts a professional from leveraging and combining more than one theory and model and
many times this is the most effective way. Most importantly, however, no theory or model
can replace the strategic plan that every health promotion professional must develop.

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 Source: WHO

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