Health Behavior Theories

In Chapter 4, we introduced Health Behavior Theories as ways to understand changing human behavior. The Health Belief Model (HBM) is one of the most widely used theories. Its major themes address how people perceive susceptibility, severity, barriers, and benefits. People are likely to change only after cues to action and when they feel enough self-efficacy. With the information we gained from the Needs Assessment (Chapter 3), we can structure our program with insights from the HBM. This is an example of how a theory can help us create the most effective program possible. Without the guiding framework of a theory, we are just guessing that our intervention will bring about change.

Evidence-based Interventions

Also in Chapter 4, we introduced the idea of using evidence-based interventions and best practices for programs that have already been proven to be effective. Once you have identified a program that meets the basic needs of your community, you can adapt it to better fit your needs. Spending the time to find a great program will help ensure improvement and health behavior change.

In this chapter we finish up the planning stage by determining budget, selecting needed personnel to carry out the health promotion program, planning the marketing process, and building the tools for implementation.

Develop a Program Budget

A program budget is vital to ensuring you have resources to carry out the interventions you have developed. Funding for a program can be obtained through a variety of methods, such as grants, participant fees, and sponsorships. The application process for grant funds is a competitive process. Some agencies may go to great lengths to write a grant and still not receive the funding to carry out their proposed program. 

You need to be fiscally responsible with the funds you have received. Having a well-planned and accurate budget will help you be successful. The resources you need may include personnel, supplies, equipment, and space. You need to consider the following:

• Who will implement the program? How many hours a week will they work? What will they be expected to accomplish in that time?

• What personnel will need to be hired, and how can we ensure they have relevant experience?
  

• What supplies and equipment are needed to carry out the program you have planned?

• Where will you hold program activities? Do you need to purchase space or do you have partners who could donate use of their space?

After you have identified your resource needs, you should have a plan in place to monitor the budget to ensure funds are spent appropriately and continue to meet the eligibility requirements of your funding. When you receive funds from a grant, you are required to report on how funds are spent. Monitoring the budget makes you aware of how much of your budget is spent and how the expenses are supporting the program.

In-Kind Contributions  

(Thorne, 2008)

In-kind gifts are non-cash goods or services donated by others. Instead of cash, a group receives a gift that assists in carrying out its mission. Common examples are donated space, office supplies, printing, and shipping. There are generally three categories of contributions.

• Products, supplies, and equipment.

• Use of facilities and services for free or a reduced fee.

• Professional services such as legal, marketing, and tax advice.

Be sure to properly document and account for in-kind contributions. You will need to determine the value of contributions based on fair market value or the cost to the organization if the goods and services were not donated.

The donor should receive a signed receipt that describes the in-kind contribution, its estimated value, the date of donation, and other details. Donors often receive benefits from their in-kind contributions, such as tax deductions and positive recognition.

ELEMENTS OF A  BUDGET

(Rabinowitz, n.d.)

• Projected expenses. The amount of money you expect to spend in the coming fiscal year, broken down into the categories such as salaries, office expenses, and supplies.

• Projected income. The amount of money you expect to take in for the coming fiscal year, broken down by sources.

• The interaction of expenses and income. What gets funded from which sources?

• Adjustments to reflect reality as the year goes on. Budgets usually begin with estimates. As the year progresses, those estimates will be adjusted to keep track of what's really happening.

ANALYZING AND ADJUSTING THE BUDGET

Lay out your figures in a useful format, such as a spreadsheet. Compare your total expenses to your total income.

• If your projected expenses and income are approximately equal then your budget is balanced. Make sure you are able to use your money as planned.

• If your projected expenses are significantly less than your projected income, you have a budget surplus. This gives you the possibility of expanding the project or of putting money away for when you need it, but be aware that it may not show up as cash until the end of the coming fiscal year

• If your projected expenses are significantly greater than your projected income, you have a budget deficit. In this case, you'll either have to find more money or cut expenses. You can explore saving some money by collaborating with another organization to share expenses.

CREATING AN ACTUAL BUDGET DOCUMENT

The simplest budget document is one which lists projected expenses by category and projected income by source, with totals for each.

WORKING WITH YOUR BUDGET

Review your budget on a regular schedule, such as once a month, and revise it to keep it accurate. Your budget will tell you if there are gaps in funding and what you need to do to close those gaps. It will also help you keep careful track of your money, be flexible, and not overspend. You will be able to accurately report to funders and to spend their money as you have promised.

Marketing/Communication Plan

(community tool box, n.d.-b, p. 45)

As part of the planning process, you need to decide how you are going to market your program to the target population. The term social marketing is used when, instead of selling a product, you are selling a behavior change which positively impacts health. Social marketing persuades a population to change behavior, while commercial marketing persuades a population to buy a product or service. A social marketing plan involves the marketing mix, sometimes called the 4 P’s: product, price, place, and promotion.

1. The product can be the behavior change you are trying to encourage, a service you are offering such as skin cancer screenings, or a tangible object such as a bike helmet.

2. The price means what the individual has to pay. The price can be non-financial such as the time required to attend a screening.

3. Place is where the product can be accessed. If your product is skin cancer screenings, the place is the location of the screenings.

4. Promotion involves how you will advertise the product to your priority population. To attract the target population to the product, you need to reach them.

To be effective, health communications need to be accurate, consistent, evidence-based, and culturally sensitive. When developing the appropriate messaging for your priority population, keep in mind health literacy: providing health information to your population in a way they can understand it and act on it. Use plain language and refrain from using acronyms and scientific terms that the general population may not understand. Ensure that the material is culturally competent and at a reading level all can understand. Pre-test your content ideas and messages with a sample of the priority population to get their feedback. 

Remember that health literacy refers to both individuals and groups. 

Groups who may have low health literacy include:

• The elderly, due to multiple chronic conditions, aging and possible decline in mental ability.
• Racial/ethnic minorities who may face language or cultural barriers.
• Low income groups, with access to education and health care.
  

(Centers for Disease Control and Prevention, 2023)

• Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

• Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

WHAT IS INVOLVED IN SOCIAL MARKETING?

(community tool box, n.d.-b, p. 45)

At the root of all health promotion is one basic principle: change people’s behavior. The difference between social marketing and commercial marketing is summed up in one key point: commercial marketing tries to change people's behavior for the benefit of the marketer; social marketing tries to change people's behavior for the benefit of the consumer, or of society as a whole.

To begin a social marketing campaign you will need the following: 

• Identify what behavior you want to change.

• Identify your audience: Whose behavior do you want to change? 

• Identify the barriers to change: using interviews, surveys, or focus groups, find out what makes these changes difficult.

• Reduce the barriers to change. Plan ways to make it easier, more accessible, and more attractive.

• Pretest your ideas on a small number of people, then modify your plan according to your results.

• Publicize both the benefits of change, and also your efforts to make change easier in a way that will draw people to take advantage of your efforts. Let people know the benefits of the behavior change.

STAGES OF A SUCCESSFUL SOCIAL MARKETING EFFORT

A social marketing campaign needs to focus on consumers and their motivations. For example, smokers have many motivations to smoke, and they won't go immediately from believing smoking is great to quitting right away. Instead, a social marketing campaign might start them thinking of the health risks, and later another part of the campaign will help them quit, and yet another part will help them remain smoke free.

The following activities need to occur:

• Create awareness and interest

• Change attitudes and conditions

• Motivate people to want to change their behavior

• Empower people to act

• Sustain the change

Implementing the Program with a Logic Model and Gantt Chart

After all the writing and planning, the process of actually implementing a program can be a very different challenge.

The implementation plan shows how your interventions will be carried out in the community. This step details the various tasks and activities that will ensure you can accomplish the goals and objectives you have identified. Two tools that are helpful during implementation are logic models and Gantt Charts. These will both be explained below.

A logic model is a visual representation that displays the resources, planned activities, and outcomes you hope to achieve. This tool provides an overall roadmap of your program elements that can be shared with your stakeholders so they understand how the program will function.

A Gantt Chart can help you visually display program activities and the anticipated timeline

for each activity. It allows you to predict when and how long each activity should take to complete. While an activity is being implemented, you can track the actual time it took to complete each task. This process can help to better prepare for future years of the program and plan more effectively for how the program is delivered.

Implementation Plan

(community tool box, n.d.-a, p. 8)

Developing an Action Plan

Developing an action plan can help turn your vision into reality and increase efficiency within your organization. An action plan describes the way your organization will meet its objectives through detailed action steps. It describes what actions will occur, who will carry them out, time limits, needed resources, and communication plans.

A good action plan for your initiative needs to be complete, clear, and current. It will bring many advantages to your program:

• An action plan shows members of the community (including grantmakers) that your organization is organized and dedicated to getting things done.

• Helps you know you didn't overlook any of the details.

• Saves time, energy, and resources in the long run.

 HOW TO WRITE AN ACTION PLAN

1. Bring together influential people from all the parts of the community.

2. Review your group’s vision, mission, objectives, and strategies.

3. Develop action steps that address all proposed changes.

4. Review your plan and check for completeness.

5. Follow through. Remember the 80-20 rule: successful efforts depend 20% on planning and 80% on follow through.

6. Keep everyone informed about what's going on. Communicate to everyone involved how their input was incorporated.

7. Keep track of what is done. Document the work carefully so it can be evaluated and reported.

8. Celebrate a job well done! This helps keep everyone excited and interested in the work they are doing.

Logic Models

(Chapter 2, Section 1. Developing a Logic Model or Theory of Change, n.d., p. 1)

A logic model presents a picture of how your effort or initiative is supposed to work. It explains why your strategy is a good solution to the problem at hand. Effective logic models make a visual statement of the activities that will bring about change and the results you expect to see.

The form that a logic model takes is flexible. Flow charts, maps, or tables are the most common formats. Components of a typical logic model include:

• Purpose, or mission.

• Context, or conditions. What is the political climate?

• Inputs, including resources or infrastructure. What raw materials will be used?

• Activities, or interventions.

• Outputs. Example: number of youth trained or number of classes held.

• Effects. Results or outcomes. What was changed because of the activities? 

In a logic model, columns are in a specific order showing how one factor leads to the next. However, it is likely to often move forward and backward between columns to execute a logic model, and go back to a previous column if needed.

Gantt Chart

 (Tague, 2022)

(Agency for Healthcare Research and Quality, n.d.)

A Gantt chart is a bar chart that shows the tasks of a project, when each must take place, and how long each will take. As the project progresses, bars are shaded to show which tasks have been completed. Gantt charts are helpful at the following times:

• When scheduling and monitoring tasks within a project

• When communicating plans or status of a project

• To show the steps of a project, their sequence and their duration

• To show how tasks or phases of a project overlap  

Gantt chart example (Centers for Disease Control and Prevention, n.d.)

How to create and use a Gantt chart

1. Identify the tasks needed to complete the project.

2. Identify key milestones in the project by brainstorming a list or a flowchart.

3. Identify the time required for each task and the correct sequence.

4. Draw time axis (horizontal) with a scale for the length of the tasks (days, weeks, months, and so on).

5. Draw task axis (vertical). For events that happen at a point in time, draw a diamond under the time the event must happen. For activities that occur over a period of time, draw a bar that spans the times.

6. Review to ensure that every task of the project is on the chart.

7. Use the Gantt chart. You can start with only outlines of the diamonds and bars, and fill them in as the project proceeds. For tasks in progress, you can fill in an estimate of how far along you are on the bar. You can also place a vertical marker to show where you are on the timeline.

You can draw the chart manually or use software such as Excel to draw the Gantt chart.

Vocabulary

GLOSSARY

This glossary covers some of the basic accounting terminology used in the section.

Accounting: The method by which one keeps track of and manages money. There are various accounting systems that an organization can use, but the goals of all of them are to assure accurate records, and to give the organization the ability to know exactly how its money is being spent and how its financial position compares to its budget at any given moment.

Audit: A CPA (Certified Public Accountant) checks the organization's financial records to make sure they are accurate. They also work with the organization to correct any errors and solve problems. The CPA then prepares financial statements using the organization's books, and either certifies that the organization follows acceptable accounting practices and that its financial records are in order, or explains any problems with the financial records and suggests corrective measures.

Balanced Budget: Projected expenses and projected income are approximately equal.

Budget Deficit: Projected expenses are significantly greater than projected income.

Budget Surplus: Projected income is significantly greater than projected expenses.

Conservative Estimation: Using the highest reasonable figures when estimating expenses and the lowest reasonable figures when estimating income. Doing this, you will be more likely to create a budget that will keep you from overspending.

CPA: Certified Public Accountant. A certified audit, which is what most funders require, must be conducted by a CPA.

Fiscal Year: This term means financial year, and is the calendar which you use to figure your yearly budget (July 1 to June 30, for example) and which determines when you file tax forms, get audited, and close your books.

Fund Accounting: The practice of keeping a separate record of the expenditures for each separate grant or contract administered by an organization. Thus, a grass roots AIDS prevention initiative might keep separate records for funds they receive from the Department of Health, the Department of Social Services, the Department of Welfare, a local community foundation, and the AIDS Action Committee.

Line-Item: An expense category (salaries, telephone, office supplies).

Line-Item Budget: A budget agreed upon with a funder that specifies how much of the funder's money will be spent on each line-item. It could also refer to any budget that is broken out by line-item.

Projected expenses: The amount of money you expect to spend in the coming fiscal year, broken down into the categories you expect to spend it in -- salaries, office expenses, and so on.

Projected income: The amount of money you know or can reasonably expect to take in for the coming fiscal year, broken down by sources -- that is, the amount you expect from each funding source, including grants, contracts, your own fundraising efforts, memberships, interest and investment income, and sales of, or fees for, goods or services.

Spreadsheet: A grid format for setting out a budget in order to see expenses, income, and the ways they interact all in one place. In a budget spreadsheet, each vertical column represents a funding source, and each horizontal row represents an expense category. In the space where a column and row meet (called a cell) a number represents the amount of money from that column's funding source spent on that row's expense category.

Contributor 

Phil Rabinowitz

References

Agency for Healthcare Research and Quality. (n.d.). Gantt Chart. Agency for Healthcare Research and Quality. https://digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/gantt-chart

Centers for Disease Control and Prevention. (n.d.). Gantt Chart. https://www.cdc.gov/dhdsp/programs/spha/roadmap/docs/gantt_chart_ac.pdf

Centers for Disease Control and Prevention. (2023, March 31). What Is Health Literacy? Centers for Disease Control and Prevention. https://www.cdc.gov/healthliteracy/learn/index.html

Chapter 2, Section 1. Developing a Logic Model or Theory of Change. (n.d.). Community Tool Box. https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/logic-model-development/main

community tool box. (n.d.-a). Chapter 8, Section 5. Developing an Action Plan. Community Tool Box. https://ctb.ku.edu/en/table-of-contents/structure/strategic-planning/develop-action-plans/main

community tool box. (n.d.-b). Chapter 45, Section 1. Understanding Social Marketing: Encouraging Adoption and Use of Valued Products and Practices. Community Tool Box. https://ctb.ku.edu/en/sustain/social-marketing/overview/main

Rabinowitz, P. (n.d.). Chapter 43, Section 1. Planning and Writing an Annual Budget. Community Tool Box. https://ctb.ku.edu/en/table-of-contents/finances/managing-finances/annual-budget/main

Tague, N. R. (2022, October 3). Gantt Chart. Department of Health. https://www.health.state.mn.us/communities/practice/resources/phqitoolbox/gantt.html

Thorne, D. M. (2008). In-Kind Contributions. Encyclopedia of Business Ethics and Society, 3, 1134–1135.