Historical Theoretical Perspectives to Consider in the Application of Community-Based Interventions for African Americans and Communities of Color

Abstract

Using theory as a framework for community-based interventions in African American members provides the principles and guidance needed to generate nursing knowledge. However, choosing an appropriate theoretical framework to guide community-based interventions can be challenging. The aim of this manuscript is to examine the use of three historical models or theories (the Health Belief Model, the Theory of Planned Behavior, and Bandura's Self-Efficacy Theory), which are still being used today, to better understand their applications in community-based interventions.

Keywords

African Americans community-based interventions theory self-efficacy theory of planned behavior health belief model

Community-based interventions have been documented in the literature as being successful, and can have compelling influences on beliefs and health-care behaviors; however, many community-based interventions are not based on theory and are limited in their applicability to different populations (Wu & Chang, 2014). The aim of this manuscript is to examine the use of three historical models or theories: the Health Belief Model, the Theory of Planned Behavior, and Bandura's Self-Efficacy Theory, to better understand their applications in community-based interventions. Understanding historical and theoretical perspectives and assessing their appropriateness for an intervention are important to understanding how the knowledge generated by the theories is to be applied. Historical theoretical models have been supported in the literature as being successful, and their use can positively impact health-care behaviors (Dermott et al., 2015; Kwasnicka et al., 2016; Grandes et al., 2017).

Health Belief Model

The Health Belief Model (HBM) describes and attempts to forecast preventive health behaviors, by focusing on the person's attitudes, values, and behaviors toward health (Rosenstock, 1974). The HBM was developed in the 1950s by a group of social psychologists in the U.S. Public Health Service. The initial intent of the Public Health Service was to provide health promotion and screening services to individuals for disease prevention (Rosenstock, 1960, 1974). Thus, patients ‘illnesses were not a focus. The HBM was developed in response to individuals ‘widespread lack of acceptance of free or low-cost health screening services for early detection of diseases. This lack of utilization of services led the model's users to extend the HBM to include reactions to unpleasant symptoms (Kirscht, 1974), as well as responses of patients receiving medical diagnosis, and adherence to recommended therapies (Becker, 1974).

The model predicts that health behavior is motivated by personal opinions about a disease and the resources available to reduce its manifestations (Hochbaum, 1958). The fundamental premise of the HBM is that changes in behavior are based on how a health threat is interpreted by an individual. The combination of perceived exposure to disease and disease severity forms a perceived threat, and shapes the willingness to change (Rosenstock, 1974). The concepts of the HBM (Rosenstock, 1974) are perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action (Hochbaum, 1958), and self-efficacy (Rosenstock et al., 1988). The HBM is a frequently used framework for attempting to explain and predict health behaviors in community-based settings (Holt et al. 2012; James et al., 2012; Park et al., 2015; Bayat et al. 2013), and is often used in combination with other behavior change models (Kristien et al., 2012).

Understanding historical and theoretical perspectives and assessing their appropriateness for an intervention are important to understanding how the knowledge generated by the theories is to be applied.

Perceived Susceptibility

Within this model, perceived susceptibility may motivate a person to take the necessary acrion(s) to avoid illness. If individuals regard themselves as susceptible to the condition(s), their action(s) may include, but are not limited to, annual health exams, healthy eating, smoking cessation, physical activity, and weight loss.

Perceived Severity

In perceived severity, motivation to take action is based on the seriousness of the condition. For example, will continuation of smoking cause lung cancer? Will failure to monitor blood sugar result in end-stage renal disease? The perceived severity may include physical consequences and social consequences. Persons evaluate the benefits of change to determine the reduced seriousness of the disease threat.

Perceived Benefits

In perceived benefits, options and recommendations are defined, and may include vaccinations and diagnostic testing. Individuals evaluate existing alternatives based on the available information, and select which actions, if any, to take.

Perceived Barriers

Certain factors may prevent persons from performing the proposed actions. For example, in perceived severity, something severe has to occur to stimulate one's readiness to change.

Cues to Action

In cues to action, information about the perceived threat, such as an elevated blood pressure or blood sugar, or loss of a loved one, may trigger a person's readiness to change.

Self-Efficacy

Making effective action changes requires a set of beliefs about oneself. The HBM eventually added the construct self-efficacy which was defined as a person's confidence in their ability to perform a given task (Rosenstock et al., 1988). In addition, the HBM indicated that other variables such as demographic, social, and/or psychological factors may affect people's perceptions, and therefore may indirectly influence health-promoting behaviors (Rosenstock et al., 1988).

Limitations of the Model

There are several limitations to the Health Belief Model, particularly in community-based interventions. The model does not account for behaviors that are habit forming (Egede, 2002). Value in adherence-enhancing interventions is weak, with no consistent relationships between the various HBM constructs (Jones et al., 2013). The model predicts participants ‘beliefs at one specific time only, with an inability to predict future behaviors (Davis et al., 2013). And, the model does not account for environmental or economic factors that may exclude or encourage the suggested action (Tanner-Smith & Brown, 2010; Davis et al., 2013). The remaining limitations refer to aspects of applicability of the model in African American populations. The HBM constructs do not measure external cultural factors nor ethnicity, which may also influence an individual's belief. Finally, the HBM does not account for participants who express feelings of uncertainty and/or ambivalence.

Theory of Planned Behavior

The Theory of Planned Behavior (TPB; Ajzen & Fishbein, 1980) is another frequently used model for community-based interventions. The TPB was developed from the Theory of Reasoned Action (TRA) framework (Fishbein & Ajzen, 1975). Both theories focus on concepts that may explain and predict motivational factors responsible for the probability of performing a particular behavior (Montano & Kasprzyk, 2002).

The transformation of the TRA to the TPB involved the addition of the perceived behavior control construct, which directly and indirectly impacts behavior intention (Ajzen, 1991). The greater the availability of resources, the greater a person's perceived behavior control over the behavior (Ajzen, 1991). When individuals feel they have little or no control over performing a behavior due to lack of resources and opportunities, their intentions to perform the behavior may be decreased, in spite of a positive attitude toward the behavior (Ajzen, 1991).

Advantages of the Theory of Planned Behavior Model

A strength of the TPB is that findings are interpreted as an association among the constructs, with attitudes and perceived behavioral control being dominant determinants of behavior intention (Spink et al., 2012; McGuckin et al., 2012; Lino et al., 2014). The TPB provides a framework for designing interventions that facilitate self-monitoring and performance behaviors (Peters & Templin, 2010; Spink et al., 2012; Peters et al., 2015).

Limitations of the Theory of Planned Behavior Model

Several limitations to the TPB model should be considered when developing community-based interventions. Interpretations of TPB findings indicate an association, not a causal inference, among the constructs (Spink et al., 2012). Studies have demonstrated limited support for the utility of the TPB constructs as outcome measures (Peters & Templin, 2010; White et al., 2012). Applicability of the TPB is limited, particularly in the African American population. Variables such as ethnicity, cultural differences, and situational and environmental factors influence factors such as physical activity and diet (Peters & Templin, 2010).

Bandura's Self-Efficacy Theory

Albert Bandura's (1977) self-efficacy theory was founded on social cognitive theory (SCT), which originated in the discipline of psychology and focuses on human behaviors. The initial study that led to the development of the self-efficacy theory (Bandura, 1977) involved participants with ophidiophobia (fear of snakes) who were randomly assigned to three different treatments: (1) enactive attainment, actually touching the snakes; (2) seeing others touch the snakes; and (3) a control group. The findings suggested that self-efficacy was a predictor of behavior; greater degrees of enactive attainment resulted in stronger self-efficacy expectations. The theory claims that behavior can be explained by how confident a person feels about their ability to perform a given task (Bandura, 1977).

Bandura's self-efficacy theory conceptualizes person-behavior-environment interactions as mutual influences. Self-efficacy expectations and outcome expectations involve opinions about one's capability to perform a given assignment; if individuals do not believe they are capable of carrying out a specific task, they are less likely to complete it (Bandura, 1977).

When individuals feel they have little or no control over performing a behavior due to lack of resources and opportunities, their intentions to perform the behavior may be low, in spite of a positive attitude toward the behavior.

People are capable of altering their thought processes by rejecting or accepting truth; Bandura calls this process self-regulation. It is subjective beliefs that produce motivation and capability to perform tasks (Bandura, 1977). There are two main components of self-efficacy theory: self-efficacy expectations and outcome expectations.

Self-Efficacy Expectations

Self-efficacy expectations refers to a process in which individuals carefully evaluate information to determine whether they have the capability to carry out activities. A key aspect of SCT is that humans have the ability to examine their mental and emotional thoughts and decide how to process information. They may accept the information as truth, or modify the information based on their beliefs. It is the examining of the information (repeated thoughts) that determines the level of self-efficacy. The processing of information includes meditating on one's beliefs, which influence one's confidence about and response to a given task. The stronger the belief, the greater the feelings of self-efficacy in performing the task. Feelings of uncertainty about performing a task make one less likely to perform it; the greater the level of confidence, the greater the self-efficacy (Bandura, 1977).

Outcome Expectations

Outcome expectations refer to successful completion of the given task. People's thoughts are based on their level of confidence in performing a given task, and are determined by four factors: (1) mastery experiences, (2) vicarious experiences, (3) social persuasion, and (4) physiological and emotional states (Bandura, 1995).

Mastery Experiences. These are the most influential determinant of self-efficacy. When individuals successfully perform repeated actions, it strengthens their self-efficacy beliefs. Conversely, repeated failures weaken one's self-efficacy. Mastery experiences involve obtaining the cognitive, behavioral, and self-regulatory skills for performing recommended behavioral actions (Bandura, 1995).

Vicarious Experiences. When a person observes others similar to themselves perform the same activity, it influences the person's belief that they, too, have the capability to perform the same activities. Observing others fail at performing the same activities lowers a person's belief in their own efficacy (Bandura, 1995).

Social Persuasion. People who are persuaded verbally that they have the capabilities to master activities are more likely to use intense effort than if they are doubtful about personal adequacies. Social persuasion influences one's self-efficacy and leads one to push toward success (Bandura, 1995).

Physiological and Emotional States. Individuals evaluate information from their physiological and emotional states to judge their capabilities in behavioral performances. High emotions may enhance self-efficacy, and low emotions may diminish self-efficacy (Bandura, 1995). The strength of the self-efficacy model is its ability to demonstrate positive associations between outcome variables and the self-efficacy constructs. For example, diabetes knowledge and self-efficacy were factors that influence participation in diabetes self-care activities (McCleary-Jones, 2011).

Limitations to Bandura's Self-Efficacy Theory

Limitations to the applicability of Bandura's Self-Efficacy Theory include that only correlations, not causation, have been identified between self-efficacy, depression, and adherence; the mechanism by which each are related is unknown. Also, self-efficacy theory focuses on knowledge and skills, and does not take into consideration biological factors that may prohibit a person from carrying out a task (Kamimura et al., 2014).

Conclusion

Bandura's self-efficacy theory would be an appropriate theory to guide community-based interventions for African Americans and communities of color. The model considers several factors that may directly and indirectly influence self-efficacy, including the person's surroundings and the impact they have on self-management behaviors.

The Health Belief Model may not be an appropriate model for community-based intervention because it does not account for habit-forming behaviors, shows no consistent relationship between the interventions and the constructs, predicts behavior only at specific times with no follow-up for sustainability, and does not consider socioeconomic factors. The Theory of Planned Behavior may not be an appropriate model for community-based interventions for African Americans and communities of color because it does not consider ethnicity, cultural differences, situational, and/or environmental factors and how these factors influence self-care activities, and does not take into account other health-care behaviors and how they may be related.

Community-based interventions guided by historical theoretical models that are still in use today continue to be necessary in the African American community and communities of color to determine the best way to educate the population about health and wellness, diseases, and disease self-management (Dermott et al., 2015; Grandes et al., 2017; Kwasnicka et al., 2016).

Footnotes

Pandora Goode, PhD, DNR CNE, FNP, is an Assistant Professor at Winston-Salem State University. She is credentialed as a Certified Nurse Educator (CNE) by the National League for Nursing and as a Family Nurse Practitioner (FNP) by the American Academy of Nurse Practitioners. Her research interest is diabetes self-management.

Disclosure. The author(s) have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

Funding. The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.

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