"Health is a state of complete physical, mental and social well-being and not merely the

absence of disease and infirmity" (World Health Organization). Based on this broad
definition of health, total health involves not only physical, but also mental, emotional,
social, intellectual, and spiritual health. These areas of health are interdependent. Genetic
and biological factors, acute and chronic physical illnesses, and environmental conditions
and stressors affect total health status.
Ways to Reduce Risk and Promote Health
Primary prevention involves actions to keep disease from occurring (such as
immunizations). These actions include:
Developing and maintaining a healthy lifestyle
Reducing health risks
Secondary prevention involves actions to detect the presence of disease in its early stages
when it is easier to treat (such as mammography). These actions include:
Accessing professional health services
o Medical examinations
o Medical testing
Conducting self-examinations
Tertiary prevention involves actions to reduce the severity of a disease that has already
occurred, to minimize its complications, or to promote recovery (such as managing
diabetes, cardiac rehabilitation, or alcohol and other drug rehabilitation). These actions
include:
Effectively managing diagnosed disease
Principles for Reducing Risk and Promoting Health
Substitute healthy behaviors for risky behaviors.
Reduce environmental risks, such as infectious diseases, sexually transmitted diseases or
toxic exposure.
Minimize any known hereditary risks. For example, a family history of breast cancer
indicates importance of early onset of self-examination and professional screening.
Effectively use health care resources.
Practical Steps for Reducing Risk and Promoting Health
1. Identify personal risks.
2. Learn about ways to reduce these risks.
Healthy living is a primary means of disease prevention. Healthy living includes a variety of
positive personal actions, such as eating a healthy diet, leading a physically active life,
obtaining adequate rest, dealing effectively with stress, promoting good oral health and
obtaining recommended services, such as immunizations, to prevent disease.
3. Make a plan to improve your health or reduce a specific risk.
Based on the information from Step One and Step Two, prepare a draft statement of a
short-term goal to promote a healthy behavior and/or to reduce your risk for disease.
4. Plan for success.
Certain factors must be in place for behavior change or new learning to occur. They
include:
Motivating or predisposing factors
Enabling factors
Reinforcing factors
Motivating or Predisposing Factors
What does a person need to know and value to want to engage in the new healthy
behavior? Discover these by considering:
Experiences
Perceived benefits (e.g., appearance, sports performance, feeling good)
Perceived threat (e.g., How bad does the adverse impact seem to be?)
Perceived susceptibility (e.g., genetic risks, environmental risks, behavioral risks)
Perceived peer norms (e.g., Everybody does it.)
Enabling Factors
What information and skills does a person need to be able to participate in the new healthy
behavior? Enhance enabling factors by:
Identifying and removing perceived barriers
Identifying available resources
Building confidence (self-efficacy)
Building awareness (e.g., that it matters what you do, eat and smoke)
Reinforcing Factors
What kinds of reinforcement or rewards would help a person continue with the new
healthy behavior?
External rewards (e.g., a star on a chart)
Internal rewards (e.g., pride in achieving)
People who provide positive or negative reinforcement?


ENABLING FACTORS
In the public health arena, the term "enabling factors" is recognized most widely as part of
Lawrence W. Green's PRECEDE Model and Green and Kreuter's PRECEDE-PROCEED Model
of Community Health Promotion Planning and Evaluation. These models provide a series of
steps to guide the assessment of the health and quality-of-life needs of individuals and
populations, and the planning, implementation, and evaluation of strategies and programs
designed to meet those needs. Once a particular health problem has been identified, the
process of designing effective strategies to address it involves determining which
behaviors lead to, or are otherwise associated with, that health problem. The next step
involves ascertaining which factors have the ability to cause each of these behaviors to
occur or to inhibit their occurrence. These factors are themselves grouped into three types:
predisposing, reinforcing, and enabling factors.
Green originally adapted the term "enabling factor" in 1974 from the concept of "enabling
resources" found in Ronald Andersen's Behavioral Model of Families' Use of Health
Services (1968). Andersen's model, still used widely in the fields of health services research
and health administration, suggests that among the factors that influence use of health
services are two categories of enabling resources: community enabling resources (e.g.,
health personnel and facilities must be available), and personal/family enabling resources
(e.g., people must know how to access and use the services and have the means to get to
them).
Within the PRECEDE-PROCEED Model, enabling factors are defined as factors that make it
possible (or easier) for individuals or populations to change their behavior or their
environment. Enabling factors include resources, conditions of living, societal supports, and
skills that facilitate a behavior's occurrence.
SKILLS
A person or population may need to employ a number of skills to carry out successfully all
of the tasks involved in changing behavior. Skills that people already possess may serve as
predisposing factors insofar as they motivate the behavior. In contrast, any skills that still
need to be developed are considered to be enabling factors.
New skills may include those involved with determining how to identify, access, and use
medical care procedures, facilities, and programs. For example, women who are
comfortable using the Internet may be able to follow a number of links to access
information about where to receive a screening mammogram, whereas women who are not
able to use the Internet may have a harder time tracking down available services. Women
who have never been shown how to perform breast self-examination may feel that they
would do it wrong and may therefore not try at all. Similarly, older women who have
traditionally let their doctor guide the discussion during office visits may not know how to
effectively ask questions about becoming involved in preventive health maneuvers related
to breast cancer.
Other skills of importance are those that allow an individual or population to undertake
personal action to reduce their risk of disease. For instance, women may not know how to
decrease the fat content of their diet or to increase the amount of vegetables they eat so as
to reduce their risk of cancer and heart disease. They may not know how to change their
cooking patterns to create meals that are healthful while also being tasty enough that their
families will eat them.
Finally, skills in changing the environment may be important for behavior change. As an
example, women who receive training in advocacy may be effective in securing funding for
comprehensive breast cancer screening programs for low-income recipients. Women who
are shown how to participate in community development initiatives may gain credibility
with ethnic populations and be able to share with them the importance of breast-cancer
screening.
HEALTH CARE RESOURCES
A number of health care resources may be implicated if an individual or population is to
make a behavior change. These include such things as health care providers, hospitals,
public health programs and classes, clinics for those who are sick, and programs for healthy
people who are trying to maintain or improve their health. The relative availability,
accessibility, and affordability of these resources may either enable or hinder undertaking
a particular behavior.
For example, overweight people may need to reduce their risk of heart
disease anddiabetes by decreasing the amount of fat and sugar in their diet. Toward this
end, health care providers or clinics might agree to making themselves available to people
who need to be informed about, and who need periodic monitoring of their blood
pressure and the levels of sugar and fat in their blood. Accessibility depends on such things
as whether people can secure transportation to clinics and doctors' offices and whether the
design of these facilities is user friendly for people with physical limitations. Similarly, the
affordability of visits to health care providers for testing, and possibly for lifestyle
counseling, is influenced by whether people have health-insurance coverage and
whether preventive health care procedures such as lifestyles counseling are covered.
COMMUNITY AND OTHER ENVIRONMENTAL CONDITIONS AND RESOURCES
Changing behavior may be easier if aspects of one's environment are supportive of that
change. Community resources include such things as the availability of referral services
and of centers that sponsor or provide space for public health initiatives or activities. Other
important conditions and resources include policy initiatives, the availability of healthful
products and alternatives to unhealthful behaviors, and the existence and enforcement of
legislation.
As an example, public health practitioners may want people to increase their levels of
physical activity. Individuals may have a greater likelihood of becoming involved inregular
exercise if such things as parks, recreation centers, and swimming pools are available in
their community. They might be more likely to take up regular walking, jogging,
rollerblading, or bike riding if their neighborhood is safe and relatively clean. Furthermore,
user fees for recreation centers and other sports facilities, and having to pay for child care
while exercising, will influence the affordability of exercise options.
If the aim is to reduce tobacco use, people may be encouraged to quit, or at least to reduce
their smoking, if there is a ban on smoking in workplaces and in other public spaces.
Levying taxes on cigarettes increases their cost and acts as a disincentive to smoking,
especially among youth. Laws that prohibit tobacco sales to minors and that eliminate the
placing of tobacco vending machines where minors can access them can combine to
decrease access to tobacco among youth, and may serve to discourage their
experimentation with tobacco. Making nicotine replacement therapy and other smoking
cessation aids available, accessible, and relatively low cost may also increase the likelihood
that smokers will attempt to quit.

EFFECTIVE USE OF INFORMATION COLLECTED ABOUT ENABLING FACTORS
Key to the success of health-promotion and disease-prevention programs is a
determination of which of the requisite skills and resources for changing behavior and the
environment people already possess, and which ones are lacking. This involves an
organizational assessment of resources and an educational assessment of the necessary
skills. Public health practitioners should then consider adding components to their
programs or tapping into other sources that teach the necessary skills or that provide the
missing resources. They should further identify what organizational actions need to be
taken to modify the environment.
To continue with the examples provided above, if the availability of health care providers
in a geographical area is minimal or if their business hours are limited,blood pressure as
well as blood lipid and sugar testing can be offered periodically during evening and
weekend hours in local shopping malls or in mobile units. Providing child care while
individuals undergo testing and any follow-up counselingcould further increase
accessibility. Follow-up counseling could include the provision of information about, and
samples of, low-fat cooking, along with referrals for low-cost classes on healthful cooking. If
neighborhoods are not adequately safe or clean, or during winter months, walking clubs
could be established in shopping malls before stores opened. If vendors are
selling tobacco products to youth in the community, interested citizens could be trained to
advocate for consistent enforcement of minors' access laws. In all cases, the aim is to
render the environment more supportive of and more conducive to behavior change.

Brief Talk on PRECEDE Framework

Explain to participants that in health education there are ways of organizing our
knowledge about why people behave the way they do in order to help us design better
educational methods. This way of organizing factors that influence behavior is called the
PRECEDE Framework. Define the three sets of factors in the PRECEDE Framework as
follows
(display these on a flipchart or PowerPoint slide for all to see):

PREDISPOSING FACTORS: Predisposing factors are those things
that are already inside peoples heads, for example their
knowledge, beliefs, values, confidence and attitudes.

REINFORCING FACTORS: Reinforcing factors include those things
that encourage us to repeat the behavior again and again and
include the advice or pressure we receive from other people or
the positive or negative experiences we have after trying the
behavior.

ENABLING FACTORS: Enabling factors consist resources needed to
carry out the behavior and include time, money, skills, materials,
transport, etc.


Provide a handout as seen on next page and review how these factors affect whether
people each a high fat and carbohydrate diet or not. Encourage group members to ask why
factors are categorized the way they are. Ask group members if they have other factors to
add to
the chart.

Ask the participants to look again at the flipcharts from group work posted on the walls.
Go through the lists of reasons for each behavior one-by-one. Ask the participants to say
whether they think the reason is a predisposing, reinforcing or enabling factor, and then
place a
different color P, R, or E next to the factor accordingly.

Finally, examine the items on the flipcharts and handouts closely. Ask how the local
cultural and social setting contributes to these factors that influence behavior. Ask whether
there
are belief HE about foods and how traditional family structure reinforces certain behaviors.
FHE Module on Health Education 13
Handout on Factors that Influence Behavior (PRECEDE FRAMEWORK)

Behavioral Antecedents Behavior Health Status
Predisposing Factors:
Believe original diet with beans,
corn, etc., is old fashioned
Lack knowledge of recipes for
vegetables
Lack knowledge of health
implications of diet
Believe diabetes is something other
people get, not me
(add other ideas from trainees)


Reinforcing Factors:
Grandmother prepares and
encouraged eating
Friends eat these foods together
These Foods are highly advertised
These foods make one feel full,
satisfied
See relatives cope with diabetes so
feel it is normal
(add)

Eating Anglo diet high in
fat and carbohydrates
Developing Type II
Diabetes
Enabling Factors:
These foods are readily available
They are less expensive than meat
and vegetables
Many are ready to eat needing little
preparation