population behavior change: a theory-based ... - Semantic Scholar

POPULATION BEHAVIOR CHANGE: A THEORY-BASED APPROACH Alfred

L. McAlister’

Behavior modification is a prime objective in public health (2, 2), both to alter lifestyles which risk individual well-being, and to achieve health-enhancing environmental change when behaviors representing political and/or consumer choice need to be modified so as to influence organizational policy (3). But the social technology for achieving behavioral objectives has remained relatively crude in contrast with the development of biomedical intervention and sanitary engineering. This report illustrates how concepts emerging from advances in behavioral science can be used to define and implement theorybased campaigns to promote selected healthrelated behavior change in populations. In efforts to induce voluntary behavior change, without economic or legal intervention, there are two basic choices: interpersonal and mass communication. The most commonly accepted method is interpersonal communication through face-to-face counseling and education, either in individual or small group sessions which may resemble

psychotherapy, classroom teaching, and other techniques designed to influence the behavior of participants. This is often useful for selfselected persons who can afford or are willing to enter into the role of client or student, but may involve only a small part of the community of interest. If a sizable proportion of a large population does demand direct educational services, the cost of a formal program maybe prohibitive. Volunteer-based self-help programs can fill the gap, but these are usually focused more on coping with immediate problems than on long-term prevention in populations. Communication media are the second major option for influencing behavior change, but mass media messages usually influence only a small proportion of their audience (4). Although mass media are usually less influential than face-to-face contact for a givenperson, they may be more cost-effective if they reach a much larger number of people, i.e., through economy of scale. Although health activists are advised to combine mass media and community programs for greatest impact (5,6), technical options between the extremes of face-to-face services and mass communication campaigns are not well delineated. By applying theoretical concepts concerning the unique and complementary functions of messagesand personal contacts, it is possible to design activities which combine com-

Source: Journal of Public Health Policy 1991; 12(3, autumn): 345-361. Reprinted with permission from the Journal of Public Health Policy, Inc., South Burlington, Vermont, United States of America. ‘Associate Professor and Associate Director, Center for Health Promotion Research and Development, School of Public Health, University of Texas Health Science Center at Houston, Texas, United States of America.

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munication through mass media and through interpersonal networks to produce an interactive influence on behavior. A social agency interested in achieving maximum impact on a minimum budget can use these concepts to implement practical programs that reach large proportions of a population and involve voluntary participation from many diverse subpopulations. Such a system can then be used to promote behavioral objectives that are selected by policy-makers and citizen representatives, e.g., increased appropriate use of preventive health services, smoking cessation, physical fitness, or moderation of eating, drinking, or sexual behaviors. In efforts to influence social policy, the communication system can be used to stimulate specific political behaviors, such as writing letters to representatives, participating in rallies, etc. The participation of volunteers within the community also makes it possible to organize new processes of internal decision-making about the desirable goals of social change, including environmental changes that increase incentives or remove barriers. The communication system can thus play a role in community empowerment and capacitybuilding, and in the acceleration of discourse on topics of controversy. The components of this theoretical system of communication are outlined below. Mass Media Communications: Cognitive/Behavioral Modeling

Planned modeling communication is the presentation of thoughts and behavior with the intent that they be emulated by the audience or observer (7). Interpersonal contact often includes modeling, but massmedia are also well-suited to the display of thoughts and action. For example, portable media, i.e., communication materials that can be carried away and consumed later, enable a learner to repeat and review performances (4). Behavioral models in mass media may become more influential by virtue of the media themselves, which appear to have a status-

conferral function for information sources in popular news and entertainment (8, 9). Another advantage of mass communication is that information can be standardized to assure that critical points are made. At the same time, if numerous messages are generated and the audience itself participates in their creation, it is possible to address heterogeneous cultures and diverse behaviors in ways that are directly related to everyday life. Theoretical concepts that might be applied to the design of planned behavioral modeling communication have been thoroughly analyzed (7). Considered as persuasive communication (ZO), key aspects of a modeling message are the identity of the model, the self-attributed reason for a new behavior, and the perceived consequences of that new behavior-particularly with regard to the reactions and perceptions of other people. Enhanced self-efficacy expectations (12, 12), often stated as a greater intention or selfconfidence regarding adoption of a desired new behavior, is another function of modeling: if the model can do it (e.g., perform a new skill), the observer can do it as well. Modeling is also important in conveying norms (23), communicating the idea that “everyone is doing it.” The construction of specific mass media communications, as detailed elsewhere, depends upon analysis of how information is consumed in the different audiences (4). Ethnographic research, focus groups, and quantitative analysis of the structure of verbal cognitions and their relationships to behavior are employed to design the content of modeling messages. The goal is to produce and publicize a few basic messagesin a way that corresponds to the different circumstances, behavioral intentions, and stages of change (24) that currently exist in the study communities. To accomplish this, when possible, behavioral modeling messagesshould be drawn from the community itself, in the form of “role model stories” that publicize positive behavior of actual community members (25).

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Interpersonal Networks: and Distribution

Reinforcement

The limits of masscommunication are wellknown. Audiences may not choose to receive media messages(7). Even if the audience pays attention, communicated models of action may be cognitively acquired but not behaviorally performed unless direct environmental contingencies support the modeling message(2,8). The interpersonal component of the system is specifically designed to supplement mass communication by addressing those issues: Its primary purposes are to urge appropriate community members to give their attention to planned modeling communications and to encourage and reinforce stated intentions to imitate the modeled behavior as well as any actual approximations toward positive change. To accomplish this, a network of interpersonal communication is organized through the recruitment of volunteers whose role is to distribute and promote modeling communications, and to provide positive social reinforcement for desired verbal or behavioral responses. These volunteers can also distribute materials that facilitate behavior change (e.g., condoms for preventing HIV transmission). Volunteers may themselves serve as direct behavioral role models for other community members. They also may be involved in advocacy roles aimed at increasing accessto preventive services, drug treatment, or other entitlements, as described under the next heading. The concept underlying the primary functions of the interpersonal communication network is that some of the content from group or classroom sessionscan also be presented by volunteers in open community settings (26). This is accomplished by combining mass media modeling which is designed to include the knowledge that an expert group or class leader might have-i.e., selection of behavioralobjectives,prioritizationof subobjectives, choices among available behavioral modelswith interpersonal communication that focuses on the less complex task that a group

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leader must also accomplish: providing verbal encouragement for statements of intention and praise for successive approximations of the desired response. Thus the volunteers in the communication network perform a function that does not vary across different behavioral objectives and that also does not require much training beyond the natural social skills that many community members already possess(17). The “expert” content, in statements of fact and in the selection of persuasive messages for behavioral modeling communications, is supplied by portable and other mass media materials primarily in the form of modeling messages, as previously outlined. The supportive media materials may also have a reinforcing function for the members of the volunteer network by increasing the perceived status and credibility of their work, particularly if they use broadcast television or other major channels of communication (4). The organization of networks to provide channels for uniquely interpersonal components of communication has been part of successful campaigns to promote the diffusion of innovations in many areas of cultural and organizational change (28, 29, 20), as well as in campaigns to influence health behaviors such ascigarette smoking (5). In some cases,the most important function of a cornmtmity network may be the distribution of materials, but a significant number are expected to reinforce explicit statements of intention to study and imitate modeled behaviors. Supporting media materials enable volunteers to point to concrete examples of why and how community members can and do make changes in lifestyles or invery specific consumer or politicalbehaviors. For stimulating change in policies and organizations, the function of the participation of community members may be the expression of political or economic interests in ways that might change governmental or private policies that determine key elements of the environment, such aslaw enforcement, housing, etc. With appropriate training, a network of volunteers can be empowered to press for change through political contributions, block

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voting, boycotts, publicity-seeking events, and direct expression of constituent or consumer opinion (21-26). From the practical standpoint of a Department of Health or other publicly-funded program to prevent disease through behavior modification, controversial issues of public policy or social change are often difficult to address because a consensus does not exist. If opposing forces can reach a consensus on policy or environmental change objectives, the communication media and interpersonal network can include directive modeling and encouragement of economic or political behaviors. Where a consensus is absent, behavioral role modeling content can present different points of view in a balanced fashion that accelerates public dialogue on the issue at hand, without offense to persons with different points of view. As a news or human interest story, rather than propaganda, role modeling of advocacy behaviors can be an acceptable part of a community effort to stimulate consideration of options for environmental change. The application of these concepts has been demonstrated and documented in the North Karelia Project for the prevention of cardiovascular disease in Finland (27). A behavioral modeling television series (28), entitled Keys to Health, has been produced seven times (16, 29,30,31). Anetwork of several hundred community volunteers was recruited and mobilized to promote imitation of the televised role models (30). Although there are many factors which may be responsible for the positive changes in lifestyle and health that have occurred in North Karelia, it is reasonable to attribute a significant portion to the media programs and community network. The network of volunteers in North Karelia also served as the basis for the organized mobilization of political sentiment and economic choice with regard to several issues of public policy, promoting smoke-free environments, advising food outlets with regard to product requests, and encouraging conversion of dairy farms to produce fish and berries. The following sections describe how the media

modeling/community networking approach can be applied to diverse public health objectives in U.S. populations.

STD PREVENTION AS PART OF AN “INTEGRATED” PROGRAM OF DISEASE PREVENTION: PROCRAMA A SU SALUD Begun in 1985, with support from the U.S. National Cancer Institute, the Programa A Su Saltlu! demonstrates theory-based, communitywide systems to promote smoking cessation and other health-related changes in lifestyle in Eagle Pass, an economically disadvantaged area on the Mexican border in South Texas. The project was expressly designed to follow the model provided by the North Karelia Project with regard to mass media behavioral modeling and community reinforcement networks, and is part of a global network of demonstration projects for the integrated prevention and control of noncommunicable diseases (32). The methods and preliminary findings are more thoroughly reported elsewhere (15,17). The project included volunteer mobilization and empowerment which successfully supported local legislation on smoke-free environments, and the key community network participants have been involved in other policy issues related to dietary practices (restaurants and supermarkets) and alcohol abuse (bars and law enforcement). Because the media /community behavior change system is adaptable to any supportable public health objective, it was possible to include public education related to STD, AIDS, and prevention of HIV transmission in connection with a national emphasis on that problem during the spring of 1988.

Behavioral

Modeling

in Mass Media

As part of our ongoing health promotion campaign in South Texas, brief behavioral modeling messages are included weekly in

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widely viewed television news broadcasts (25). In Eagle Pass, weekly news stories are also carried on two local Spanish-language television channels, as well as on two regional channels, one Englishand one Spanish-language, both with large shares of the audience. Weekly behavioral modeling stories are also placed at two Spanishlanguage radio stations and in three Spanishand one English-language newspaper. During April and May of 1988, each of these presented several behavioral modeling stories concerning reduction in risk of HIV and other STD (e.g., a sexually active young woman who insists on condom use because of fears of infertility from sexually transmitted disease). The Surgeon General’s Report on AIDS, which contained behavioral modeling stories, was also made available; the network of volunteers distributed 10,000 copies in Eagle Pass. A bilingual comic book was designed for low-literacy persons, presenting a modeling story with fear-reducing information about routes of HIV transmission, and promoting behavior change among persons who are at risk. The volunteer network distributed 5,000 copies of the comic book.

Reinforcement

Network

The effort to recruit a volunteer health promotion network in Eagle Pass began in 1986 and yielded a peak enrollment of more than 800 persons who were systematically recruited in health care settings, neighborhoods, retail businesses, worksites, government agencies, and social clubs (2 7). The volunteers were trained to distribute monthly calendars that listed the modeling messagesand useful information about smoking cessation, HIV risk reduction, preventive health services, et cetera. Supervised by two community workers, the volunteers were recruited personally and in group presentations. Initial training sessions of one hour include modeling and role play practice of positive social reinforce-

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ment, using praise and avoidance of negative reactions. In continuing monthly meetings, the volunteers shared experiences, learned about health promotion topics, and picked up calendars and other print materials for distribution within their network.

Evaluation

One hundred and sixty-six volunteers responded to a detailed survey in the summer of 1987(33). Among these, 120represented geographically defined parts of the community (neighborhoods). They reported making an average of 20 monthly contacts and estimated that the persons they were contacting had seen an average of approximately nine models. Only 21 casesof smoking cessation were reported. Follow-up surveys in 1989 found that four-fifths of the Eagle Passrespondents had seen the modeling messagesand that one in five have been contacted by a volunteer or community worker. A 10% reduction in smoking was observed in a panel of smokers in Eagle Pass, with little or no long-term smoking cessation observed in a reference panel in a comparable nearby border city (34). With regard to HIV risk and risk reduction, a telephone survey conducted two months after that part of the campaign in 1988 (N = 166) found greater reported AIDS fear reduction in Eagle Passthan in the comparisoncommunity (33). One-third of the respondents in Eagle Passreported a risk-reducing change in sexual behavior, e.g., reducing the number of sexual partners or using condoms. Television and other mass media were the most frequently cited sources of influence on behavior change.

Further

Application

In connection with U.S. Centers for Disease Control (CDC) Community HIV Prevention Projects (3.5), the theoretical principles described here are being applied with narrowly

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defined, high-risk behavior populations. Modeling messages are being prepared in the form of cartoon-like handouts, video and audio tapes, recorded telephone messages, and other specialized channels of communication. Although it is necessary to protect model identity in most stories about sexual and drug using behaviors, many at-risk persons are willing to share their skills and techniques for risk reduction (e.g., prostitutes who can eroticize condom use). By using role models, it is possible to present behavioral alternatives that may be unacceptable to some parts of the community without appearing to directly advocate those behaviors. For example, a person who continues to inject drugs but who avoids needle sharing may be presented as a useful model for some persons, while the greater long-term goal of avoiding all drug abuse is also acknowledged. Other stories can be provided to model abstinence. Depending upon journalistic decisions, behavioral models may include persons engaged in political or other advocacy efforts to, for example, increase drug or AIDS treatment services. To reach narrowly-defined groups with covert and often illegal behaviors, reinforcement networks must be highly specialized and may include direct street contact by community outreach workers and volunteers at strategic locations, such as in sexually-oriented businesses. The principles of social reinforcement are the same, whatever the unique nature of the network that must be organized. For some groups at risk of sexually-transmitted disease, a network of communication may serve as a vehicle for empowerment and improvement of other living conditions that threaten wellbeing.

CONSTITUENCY EMPOWERMENT: THE “SWING DISTRICT” PROJECTS TEXAS AND MISSISSIPPI

IN

An illustration of how the principles of behavioral modeling and community networking can be applied for the purpose of

influencing nuclear weapons policy (36) is provided by an advocacy project organized by the Harvard-Radcliffe Students for Social Responsibility (HRSSR) in Cambridge, Massachusetts (37). In cooperation with the Public Interest Video Network in Washington, D.C., a coordinated effort was made to influence citizen participation in congressional decisions about nuclear weapons (38). Specifically, the project sought to influence votes on MX or Peace Keeper Missile appropriations among selected members of the U.S. House of Representatives, particularly the undecided leadership and members of the Defense Appropriations Subcommittee. For Congressmen “Jim” Wright (Democrat of Fort Worth, Texas; Majority Leader) (39), and “Jamie” Whitten (Democrat of Tupelo, Mississippi; Chairman of the Appropriations Committee) (39), a particularly intensive campaign of constituent mobilization was organized according to the concepts of media modeling and community reinforcement networks that have been presented here (38). The goal was to encourage citizens to register disapproval of the MX missile procurement bills that were considered in 1982.

Mass Media and Community

Networks

The Public Interest Video Network produced a one-hour public television program entitled Thinking Twice About Nuclear War. The program began by following a southern family as they studied trends in defense policy and responded fearfully to the growing threat of nuclear war. The broadcast then depicted citizens working in diverse ways to prevent nuclear war, including models for grass roots political action. It was carried at 10:00 p.m. on a weeknight by most PBS affiliates. With the cooperation of national offices of the Campaign for a Nuclear Weapons Freeze, Physicians for Social Responsibility, and the “Ground Zero” organization, HRSSR worked to identify representatives of local citizens‘ groups opposed to escalating nuclear

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arms production. One individual was identified in each district and served as the contact point for volunteer outreach activities. Initial telephone conversations informed these individuals six weeks in advance of the Thinking Twice broadcast. Promotional materials to be distributed by volunteers were mailed as requested, and advice was given on how to persuade local television outlets to accept the Thinking Twice program. In continuing telephone contact following the April 1982 broadcast, the volunteers were encouraged to promote letter-writing and other persuasive communications with members of Congress. Within the networks they had organized, advice was given on how to track the upcoming votes on the Nuclear Weapons Freeze and MX missile appropriations, along with suggestions on how to organize a “phone tree” for rapidly alerting fellow citizens to critical times for communications to Congress. Depending upon their requests, the local contacts were mailed sets of printed materials by the Friends Committee on National Legislation (all undated): How to Write to Members of Congress (40), How to Organize an Action Network (41), and The Nuclear War Prmention Kit (42). These materials contained detailed instructions for effectively expressing opinions to elected officials, including models for writing letters to and visiting congressional representatives, writing letters to the editor of local newspapers, etc. Continuing encouragement of the local contacts was maintained by the Harvard-Radcliffe Students for Social Responsibility

Experiences

at the Grass Roots

In Fort Worth, Texas a community network was available through linkage with an organization named Citizens for Education on Nuclear Arms (CENA) and identified by the National Clearinghouse for a Nuclear Weapons Freeze. Leaders of CENA were very interested in the upcomingbroadcast of Thinking Twice, but a check with the local public televi-

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sion outlet found that the program would not be aired in the Fort Worth area. After repeated requests from CENA the station management agreed to tape the program for a late rebroadcast. Over 100 promotional posters were distributed in advance of the broadcasts. As part of their participation in “Ground Zero Week,” CENA solicited new members, and interested citizens were urged to write letters and to sign petitions at tables set up outside lecture halls and meeting rooms. Citizens were explicitly urged to communicate their concerns to Representative Wright and to state their support of the Nuclear Freeze Resolution and opposition to the MX procurement. About 500 sets of educational materials were distributed. Methods for communicating to Congress were presented and discussed at a group meeting in May. About 300 names and phone numbers of supporters identified at that time were listed by the organization and distributed among the 19 most active members, who telephoned appeals for letter-writing. The Fort Worth arms control group also worked to ensure that the local newspaper provided balanced coverage of the arms race and related issues. On the editorial page, the Freeze proposal was criticized and the MX defended. To counter that expression of opinion, members of the group wrote frequent letters to the editor. CENA also organized media events to portray citizens’ fears regarding nuclear war, and their support for strong initiatives toward arms control. A chapter of Physicians for Social Responsibility was listed in Tupelo, Mississippi. The contact person was a local physician who reported that there was a small group opposed to the nuclear arms buildup, but that interest was not focused on a specific issue. Representative Whitten was believed to be unlikely to support arms control measuresin Congress, and Mississippi’s public broadcasting network did not plan to carry Thinking Twice. After requests from the Tupelo physician and some of his associates, a tape of the program was broadcast. Approximately 50 posters were distributed in advance of the program.

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Thirty sets of follow-up instructional materials were mailed and distributed among interested citizens in northern Mississippi. Because of Representative Whitten’s important position in funding decisions, the group in Tupelo was urged to concentrate on opposition to the appropriation of funds for the MX missile system. In May 1982, a group of colleagues wrote to Representative Whitten to express their viewpoint and to request an invitation to testify before the House Subcommittee on Defense Appropriations. The physician volunteer from Tupelo testified before the subcommittee in August 1982, expressing opposition to the MX and citing evidence that it would destabilize the nuclear balance. Aprivate meeting with Representative Whitten was also obtained. In addition to those direct efforts to express opinions to Congress, the physician leading the Tupelo organization encouraged like-minded citizens to write to Whitten and was locally visible as a role model for like-minded persons. InDecember 1982 the Tupelo Journal published his letter thanking Representative Whitten for his House Appropriations Committee vote against the production of the MX missile system.

Evaluation

Legislative assistants in touch with the home district and/or specializing in the Freeze and MX issues were interviewed in June, September, and December 1982 (38). On the Nuclear Freeze Resolution, Wright’s office reported receiving about 60 pieces of mail in the summer of 1982, including two petitions of 26 and 32 names. Fewer than five of the letters opposed the Freeze, with the rest supporting the Resolution. Media reports of small community demonstrations favoring the peace initiative were also noted. Regarding correspondence in autumn 1982 on the MX appropriation issue, Wright’s office reported 40 to 50 pieces of correspondence, including a petition with 35 names. Fewer than 10 of the letters were in support of the MX, with the rest

voicing opposition. It is reasonable to assume that at least 100 persons wrote directly or signed a petition as part of the volunteer networking activities. Whitten’s office reported fewer than 10 letters on the issue, saying that “what there was, was against it (the MX).” Most, if not all, of those letters came as a result of the networking and reinforcement provided by the local volunteer. The appearance of the physician volunteer at the subcommittee hearing to consider the MX was mentioned by Whitten’s assistant, as was a letter to the editor of the local paper. Two other congressional offices were studied for comparison, and their staff reported markedly less mail opposing the MX missile. Assistants to representatives in the program and those in comparison districts had distinctly different impressions of constituent interest, with those in the offices of Wright and Whitten clearly perceiving an organized and locally meaningful expression of constituent opinion that corresponded to the behavioral modeling in media communications and the community networking activities of local volunteers. Of the 94 House members with consistently “hawkish” voting records for the first half of 1982, Representative Wright of Fort Worth, Texas, was among only three who chose to support the Nuclear Freeze Resolution. Representative Whitten of Mississippi was able to vote on the MX appropriation twice in November 1982 in the Defense Appropriations Subcommittee and in the full Appropriations Committee and again on the House floor in early December. Whitten voted to cut production funds on all three occasions. Wright also voted against MX production funds on the floor vote, in the first congressional defeat of a major presidential request for nuclear weapons. Legislative assistants believed that the local expressions of opinion were only a facilitating influence. The primary influence on these unusual votes was the partisan Democratic caucus which favored arms control and had the power to reappoint Wright and Whitten to their leadership assignments when the next Congress was orga-

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nized. Comments from legislative assistants evaluated the impact of local lobbying: made it easier for him (to vote against the MX). Public opinion had a lot to do with (the voting decisions). We realized that a good portion of the mail was generated. But still they were opinions voiced and we listened. It

SUMMARY These case studies show that the illustrated principles of behavioral change are practical in their application and that they may help meet diverse objectives of concern to public health. The basic approach, combining media-delivered behavioral modeling, with locally oriented interpersonal contact to support that modeling has been applied to other forms of social change, such as product sales and agrarian reform (28). Modeling is central to many legends and children’s stories, and family/community reinforcement for imitation of behavioral models is part of child-rearing (7). Although principles of behavioral modeling and social reinforcement can be used to further the goals of an already empowered group, they are not necessarily one-way in their conceptualization of change. The direction of social change can be determined by the behavioral models that are selected. If they are selected from the audience itself and the behaviors that are portrayed are real, the media presentation may amplify naturally occurring social change processes, as when role models and networks of imitators emerge spontaneously within a specific community. If the network of volunteers represents the community and agrees with the objectives of behavioral modeling, participation in the system described here may be considered as a kind of aggregate skill for social selfchange in behavior and policy. If the modeling messages are popularly selected by the audience rather than by central planners attempting to dictate behavior, they may rep-

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resent reasons for empowerment and aspirations for social change. Communication networks may thus become sources of community self-determination and foster internal leadership to set new goals and policies. Nonscientific issues are involved in the selection of behavioral objectives for programs of social change. At the most rational level, behavioral objectives might be selected and emphasized according to their impact on health. For example, if a limited number of modeling messages are to be presented by a television program, the distribution of topics might be chosen according to an analysis of population-attributable risk related to major risk factors such as cigarette smoking and alcohol abuse (17, 32). In the Programa A Su Salud in Texas, that analysis was presented to the community to justify and gain support for the initial focus on cigarette smoking (1.5). Mechanisms that select goals for the socialbehavioral technology described here may include political processes, citizens’ panels, or simply the informed decision of a public health authority. However its objectives are selected, this theory-based approach to behavior change should be considered by any agency interested in accelerating the diffusion of innovations in health.

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6. Mass Communication and Public Health: Complexities and Conflicts. Charles Atkin &Lawrence Wallack, eds. Sage Publications, Newbury Park, CA, 1990. 7. Bandura, A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NY Prentice-Hall, 1986. 8. McGuire, W. J. “Attitudes and Attitude Change,” in The Handbook of Social Psychology Vol. II. G. Lindzey and E. Aronson, eds. New York: Random House, 1985. 9. McGuire, W. J. “Public Communication as a Strategy for Inducing Health Promotions Behavioral Change,” Preventive Medicine 13 (1984): 299-319. 10. McGuire, W. J. “Theoretical Foundations of Campaigns,” in R. E. Rice & W. J. Paisley, eds. Public Communication Campaigns. Beverly Hills, CA: Sage Publications, 1981. 11. Bandura,A. “Self-efficacy: Toward a Unifying Theory of Behavioral Change,” Psychological Reviezo 84 (1977): 191-215. 12. Bandura, A. “Self-Efficacy Mechanism in Human Agency,” American Psychologist 37 (1982): 122-47. 13. Ajzen, I., and Fishbem, M. Belief, Attitude, Intention and Behavior: An introduction to Theory and Research. Reading, Mass: Addison-Wesley, 1975. 14. Prochaska, J. O., Velicer, W. F., DiClemente, C. C. and Fava, J. “Measuring Processes of Change: Application to the Cessation of Smoking,” Journal of Consulting and Clinical Psychology 56 (1988): 520-28. 15. Ramirez, A., and McAlister, A. “Mass Media Campaign: A Su Salud,” PreventiveMedicine 17 (1988): 608-21. 16. McAlister,A., Puska,l?,Koskela, K.,Pallonen,U.,and Maccoby, N. “Mass Communication and Community Organization for Public Health Education,” American Psychologist 35 (1980): 37579. 17. Amezcua, C., McAlister, A., Ramirez, A., and Espinoza, R. “Health Promotion in a MexicanAmerican Border Community: Program a Su Salud in Eagle Pass, Texas,” in N. Bracht, ed. Organizing for Community Health Promotion: A Handbook. Sage Publications, 1990. 18. Rogers, E. Diffusion of Innovations. Third Edition. New York: The Free Press, 1983. 19. Parcel, G., Taylor, W. C., Brink, S. G., Gottlieb, N. H., Engquist, K. E., and Eriksen, M. I? “Translating Theory into Practice: Intervention Strategies for the Diffusion of a Health Promotion Innovation,” Family and Community Health 12 (1989): l-13. 20. Israel, B. “Social Networks and Social Support: Implications for Natural Helper and Community Level Interventions,” Health Education Quarterly 12 (1985): 65-80. 21. Olson, M. The Logic of Collective Action. Cambridge, Harvard University Press, 1965. 22. Rappaport, J. “Terms of Empowerment/Exemplars of Prevention: Toward a Theory for Community Psychology,” American ]ournal of Community Psychology 15 (1987): 12148.

23. Zimmerman, M. A., and Rappaport, J. “Citizen Participation, Perceived Control, and Psychological Empowerment,” American Journal of Community Psychology 16 (1988): 725-50. 24. Minkler, M. “Improving Health Through Community Organization,” in K. Glanz, F. M. Lewis, and 8. Rimer, eds. Health Behavior and Health Education. San Francisco, CA: Jossey-Bass, 1990. 25. Wallerstein, N., and Bernstein, E. “Empowerment Education: Freire’s Ideas Adapted to Health Education,” Health Education Quarterly 15 (1988): 379-94. 26. Freire, I? Education for Critical Consciousness. New York: Continuum Press, 1983. 27. Puska, P., Salonen, J. T., Koskela, K., McAlister, A., Kottke, T. E., Maccoby, W., and Farquhar, J. W. “The Community-Based Strategy to Prevent Coronary Heart Disease: Conclusions From Ten Years of the North Karelia Project.” See page 89 of this book. 28. McAlister, A. Toward the Mass Communication of Behavioral Counseling. Unpublished doctoral dissertation, Stanford University, 1976. 29. Puska, l?, Koskela, K., McAlister, A. L., Pallonen, U., Vartiainen, E., and Homan, K. “A Comprehensive Television Smoking Cessation Programme in Finland,” international Journal of Health Education 22 (suppl.) (1979): l-15. 30. Puska, I?, Koskela, K., McAlister, A., Mayranen, H., Smolander, A., Moisio, S., Viri, L., Korpelainen, V., and Rogers, E. M. “Use of Lay Opinion Leaders to Promote Diffusion of Health Innovations in a Community Programme: Lessons Learned from the North Karelia Project,” Bulletin of the World Health Organization 64 (1986): 43746. 31. Puska, I?, McAlister, A., Niemensivu, H., Piha, T., Wiio, J., and Koskela, K. “A Television Format for National Health Promotion: Finland’s ‘Keys to Health’,” Public Health Reports 102 (1987): 26569. 32. McAlister, A., Nissinen, A., Berrios, X., Alberti, K. G. M. M., and Khaltaev, N. “Demonstration Projects for the Integrated Prevention and Control of Noncommunicable Disease (INTERHEALTH Programme): Epidemiological Background and Rationale,” World Health Organization Quarterly, in press, 1991. 33. Amezcua, C., Ramirez, A., McAlister, A., McCuan, R. A., Galavotti, C., and Reed, C. “Effects of a Spanishlanguage Community Intervention in Southwest Texas on Reported HIV Infection Knowledge, Attitudes and Behavior,” Paper presented at the V International Conference on AIDS, Montreal, Canada, 1989. 34. McAlister, A., Ramirez, A., Amezcua, C., Stern, M., Mercado, S., Galavotti, C., and Pulley, L. “TheoryBased Systems to Promote Smoking Cessation on the Texas-Mexico Border,” American Journal of Health Promotion, in press, 1991. 35. Goldsmith, M. “Target: Sexually Transmitted Diseases,” Journal of the American Medical Association 264 (1990): 2179-80.

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