MPH 520 Week 1 Theories of Health Behavior Applied to a Public Health Problem Example

Why Knowing About Prediabetes Is Not Enough: Using the Health Belief Model and Social Cognitive Theory to Explain Low Enrollment in a Diabetes Prevention Program

[Student Name]

University of Phoenix

MPH/520: Social and Behavioral Aspects of Public Health

Week 1 Assignment

[Instructor Name]

[Date]

The county health department, its program and enrollment figures are composites written for a model paper; county estimates and research findings come from the sources cited.

The diabetes prevention coordinator at a composite southern Colorado county health department had a program that worked and almost nobody in it. Clinics had referred 620 adults with prediabetes in the past year to the department's year-long lifestyle program. Fifty-six enrolled, 9%. She asked why, and turned to theories of health behavior for an answer. This paper applies two of them.

The Size of the Opportunity

Preventing type 2 diabetes is one of public health's clearest opportunities. In a landmark randomized trial of adults with elevated blood glucose, an intensive program of modest weight reduction plus regular brisk activity cut the incidence of diabetes by 58%, and metformin reduced it by 31%, compared with placebo (Diabetes Prevention Program Research Group, 2002). County estimates for adults in Pueblo County, the model for this composite county, show age-adjusted diagnosed diabetes at 10.4%, obesity at 32.3% and no leisure-time physical activity at 25.7%.

Who Was Referred

The 620 referred adults were mostly between 40 and 64, about half Hispanic, and many worked in hospitals, warehouses, schools and the steel mill. About a third were covered by Medicaid. Understanding who they were mattered because each theory's constructs play out differently across work schedules, cultures and incomes.

The Behavior in Question

The behavior to explain is specific: enrolling in and attending a year-long lifestyle change program after a clinician's referral. General statements about why people do not exercise are less useful than understanding this decision.

Listening First

The coordinator interviewed 24 referred adults who had not enrolled. Their words guided the application of both theories.

The Health Belief Model

Under the health belief model, a person acts to protect their health when convinced they could get the condition, that it is serious, that action will benefit them and that the barriers are outweighed, with cues to action prompting the decision and, in later versions, self-efficacy supporting it. Janz and Becker's ten-year review of studies using the model concluded that perceived barriers were the most powerful single dimension across studies, with perceived susceptibility and benefits also important (Janz & Becker, 1984).

Perceived Susceptibility

Many interviewees did not believe prediabetes meant much. One man said his doctor called it borderline, so he figured he was fine. Low perceived susceptibility undermined motivation from the start.

Perceived Severity

Most knew diabetes was serious, often from relatives who had lost toes or sight or needed dialysis in their fifties. Severity was high; susceptibility was the weak link.

Perceived Benefits

Few knew that a modest weight loss could cut their risk by more than half. Several thought only medication would help, and none had heard of the national trial behind the program.

Perceived Barriers

Barriers were the strongest theme. The program met on weekday evenings at the health department, across town for many. Shift workers could not attend. Some worried about cost, though the program was free. Several said a year felt too long.

Cues to Action

Referral was a cue, but often weak: a line on a visit summary rather than a conversation. Those who had enrolled usually recalled a clinician who explained the risk and urged them to go.

Self-Efficacy

Several doubted they could change. A woman who had tried diets said she always failed, so why try again.

What the Health Belief Model Explains

The model explains much of the gap: low perceived susceptibility, unclear benefits and high barriers. People who thought borderline meant safe had no reason to spend a year in a program.

Social Cognitive Theory

Social cognitive theory explains behavior through interactions among personal factors, behavior and the environment. It emphasizes knowledge of risks and benefits, perceived self-efficacy, outcome expectations, goals and perceived facilitators and impediments, and argues that self-efficacy is a foundation of health behavior change (Bandura, 2004).

Outcome Expectations

Interviewees expected a program to mean hard diets and gym workouts they disliked. They did not expect it to be manageable or enjoyable.

Self-Efficacy Revisited

Self-efficacy grows through mastery, seeing similar people succeed, encouragement and managing stress. Few interviewees knew anyone who had completed the program.

The Environment

Social cognitive theory also points to the environment. Many interviewees lived where fresh food was costly and parks felt unsafe. Their families ate together, and changing meals meant changing the household.

What Enrollees Said

The coordinator also interviewed eight people who had enrolled. Most described a clinician who took time to explain the risk and a friend or relative who came with them. Several said the first session surprised them: it was about small changes in familiar meals and walking with others, not strict diets. Their experience confirmed the importance of cues, social support and realistic outcome expectations.

Comparing the Theories

The health belief model explains the decision to enroll: whether people see enough risk and benefit to outweigh barriers. Social cognitive theory explains whether people believe they can succeed and how their environment helps or hinders. Together they explain more than either alone.

What Neither Explains Well

Neither theory fully addresses shift schedules, transportation or household food budgets, which are structural. Later weeks in this course will add social ecological and social determinants perspectives.

Why Two Theories Rather Than One

Using two theories reduced the risk of forcing the evidence into one framework. Where they agreed, such as on self-efficacy, the coordinator had more confidence. Where they differed, the comparison revealed gaps, especially the environmental and structural barriers the health belief model tends to treat as individual perceptions rather than real constraints.

Testing the Explanation

Before redesigning the program, the coordinator checked her interpretation with a focus group of referred adults. They agreed that the word borderline had reassured them and that evening sessions across town were the biggest barrier, which confirmed the priorities for change.

Recommendation for Susceptibility

Clinicians will explain prediabetes as a warning sign, not a borderline result, using a script tested with patients.

Recommendation for Benefits and Outcome Expectations

Referral materials will state the program's evidence plainly and show what sessions actually involve.

Recommendation for Barriers

The program will add weekend and lunchtime groups at clinics and churches and a virtual option.

Recommendation for Self-Efficacy

Graduates will co-lead sessions and share their stories, providing models similar to participants.

Measures

The department will track enrollment among referred adults, session attendance and changes in perceived susceptibility and self-efficacy measured at intake and at six months, comparing clinics that adopt the new referral conversation with those that have not yet adopted it.

Conclusion

A program that works cannot help people who do not enroll. The health belief model showed that low perceived susceptibility, unclear benefits and high barriers kept referred adults away; social cognitive theory added low self-efficacy, discouraging expectations and a difficult environment. Recommendations tied to specific constructs give the department a theory-based plan to close the gap between referral and enrollment.

References

Bandura, A. (2004). Health promotion by social cognitive means. Health Education & Behavior, 31(2), 143-164. https://doi.org/10.1177/1090198104263660

Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346(6), 393-403. https://doi.org/10.1056/NEJMoa012512

Janz, N. K., & Becker, M. H. (1984). The health belief model: A decade later. Health Education Quarterly, 11(1), 1-47. https://doi.org/10.1177/109019818401100101