Health promotion, behaviour change and health communication

In short

Health promotion is the process of enabling people and communities to increase control over the determinants of health, as defined by the WHO Ottawa Charter (1986); health education and health communication are its tools, and behaviour change theory explains why a person acts or does not. It matters because most of India's disease burden - tobacco, alcohol, diet, inactivity, unsafe water, delayed care-seeking, incomplete immunisation - is behaviour-mediated and cannot be fixed by clinical services alone. It is examined in every BPH/MPH paper on health promotion, IEC/BCC and communication, and asked in interviews at NHM state programme management units, UNICEF, WHO-India, PATH, Jhpiego, Population Foundation of India, PSI, Nutrition International, Piramal Swasthya, CSR health teams and market-research/social-marketing firms. Job tasks include writing a BCC strategy, pre-testing IEC material, training ASHAs in interpersonal communication, and measuring message reach and behaviour uptake.

Explained

Definitions, and health promotion versus health education

• Health promotion (Ottawa Charter, 1986): "the process of enabling people to increase control over, and to improve, their health" - it acts on determinants, policy and environments, not only on individual knowledge.
• Health education: planned learning opportunities to improve health literacy, knowledge, attitude and skills. It is a *subset* of health promotion.
• Health protection: legal, fiscal and regulatory action (tobacco law, helmet rules, food standards, taxation).
• Disease prevention levels: primordial (prevent risk factors arising - school nutrition norms), primary (immunisation, condom use), secondary (screening, early treatment), tertiary (rehabilitation, adherence).
• Three WHO Ottawa strategies: *advocate* (make conditions favourable), *enable* (equip people and reduce inequity), *mediate* (coordinate across sectors).
• Five Ottawa action areas: 1) build healthy public policy, 2) create supportive environments, 3) strengthen community action, 4) develop personal skills, 5) reorient health services.
• Later milestones: Adelaide (healthy public policy), Sundsvall (supportive environments), Jakarta, Bangkok, Nairobi, Shanghai Declaration 2016 (health literacy, healthy cities, good governance), Geneva Charter for Well-being 2021.
• Health literacy: the ability to find, understand, appraise and use health information - functional, interactive and critical levels (Nutbeam).
• Empowerment and community participation: Arnstein's ladder from manipulation to citizen control; India's VHSNC and Jan Arogya Samiti are the participation structures in practice.
• Settings approach: health-promoting schools, workplaces, hospitals, cities, prisons - change the setting, not just the person.
• Salutogenesis (Antonovsky): focus on what creates health and on "sense of coherence", not only on pathogens.
• Determinants: proximal (behaviour, biology), intermediate (living and working conditions), distal/structural (income, education, gender, caste, urbanisation) - WHO CSDH framework; equity is the outcome of interest.

Behaviour change theories and models

• Individual level
  • Health Belief Model (HBM): behaviour follows from perceived *susceptibility*, *severity*, *benefits*, *barriers*, plus *cues to action* and *self-efficacy*. Best for one-off preventive acts (screening, vaccination). Weak on habit and emotion.
  • Transtheoretical Model / Stages of Change (Prochaska & DiClemente): pre-contemplation → contemplation → preparation → action → maintenance (with relapse and sometimes termination). Processes of change (consciousness raising, counter-conditioning, stimulus control) are matched to the stage; relapse is normal, not failure.
  • Theory of Reasoned Action / Theory of Planned Behaviour (Ajzen): intention = attitude + subjective norm + perceived behavioural control; intention plus control predicts behaviour. Explains the *intention-behaviour gap* when control is low.
  • Protection Motivation Theory / Extended Parallel Process Model: fear appeals work only when efficacy is high; high threat with low efficacy produces denial and avoidance.
  • Health Action Process Approach (HAPA): separates motivational phase from volitional phase (action planning, coping planning).
• Interpersonal and social level
  • Social Cognitive Theory (Bandura): reciprocal determinism among person, behaviour and environment; self-efficacy, observational learning/modelling, outcome expectations, reinforcement. Basis of entertainment-education.
  • Social Norms theory: descriptive norms (what others do) and injunctive norms (what others approve); correcting misperceived norms changes behaviour (used in open-defecation-free and alcohol work).
  • Social Network / Diffusion of Innovations (Rogers): innovators, early adopters, early majority, late majority, laggards; attributes that speed adoption - relative advantage, compatibility, low complexity, trialability, observability. Change agents and opinion leaders matter.
• Community and structural level
  • PRECEDE-PROCEED (Green & Kreuter): PRECEDE = social, epidemiological, behavioural/environmental, educational-ecological (predisposing, enabling, reinforcing factors), administrative-policy diagnosis; PROCEED = implementation, process, impact and outcome evaluation. The standard exam answer for "planning a health promotion programme".
  • Socio-ecological model: individual → interpersonal → organisational/community → policy/enabling environment; interventions should act on more than one ring.
  • Social marketing: apply commercial marketing to voluntary behaviour - the 4 Ps (product, price, place, promotion), extended to people, process, partnership, policy; audience segmentation and exchange are central.
  • COM-B and the Behaviour Change Wheel (Michie): behaviour needs Capability (physical, psychological), Opportunity (physical, social) and Motivation (reflective, automatic); nine intervention functions (education, persuasion, incentivisation, coercion, training, restriction, environmental restructuring, modelling, enablement) and seven policy categories. Links to the BCT Taxonomy v1 (93 techniques) and to the SMART / COM-B diagnosis used by donors.
  • Nudge / behavioural economics: default options, framing, loss aversion, present bias, salience, commitment devices, choice architecture - cheap and effective for small frictions, criticised for weak durability and paternalism.
• Choosing a model: one-time clinical act → HBM; addictive or habitual behaviour → TTM plus SCT; behaviour under family or gender control → TPB plus norms; supply-side barrier → socio-ecological plus service redesign; diagnosis before design → COM-B.

Health communication: IEC, BCC and SBCC

• IEC (Information, Education, Communication): awareness-focused, largely one-way; the older NHP/NHM term.
• BCC (Behaviour Change Communication): audience-segmented, theory-based, two-way, aiming at a specific behaviour by a specific group.
• SBCC (Social and Behaviour Change Communication): adds social norms, advocacy and community mobilisation - current donor terminology; NHM state units typically have an "SBCC/IEC-BCC" cell.
• Communication models: Lasswell (who - says what - in which channel - to whom - with what effect); Shannon-Weaver (source, encoder, channel, noise, decoder, receiver); Berlo SMCR; Schramm's two-way field of experience. Noise = language, jargon, literacy, cultural mismatch, poor print, distrust.
• Channels and their trade-off
  • *Mass media* (TV, radio, cinema, print, outdoor, mobile): widest reach, lowest cost per contact, good for awareness and norms; weak at skills and persuasion.
  • *Mid-media / folk media*: nukkad natak, street plays, kalajatha, puppetry, wall painting, video van, haat/mela stalls; good for low-literacy and local idiom.
  • *Interpersonal communication (IPC)*: ASHA, ANM, Anganwadi worker, MAS in urban slums, counsellor; highest persuasion and skill transfer, highest cost per contact, best for stage-matched counselling.
  • *Digital and mobile*: IVR, SMS/WhatsApp, apps, social media, influencers - the Kilkari maternal IVR service and Mobile Academy ASHA training are the standard Indian examples.
• Message design: SMART behavioural objective; one behaviour per message; AIDA / hierarchy of effects (attention, interest, desire, action) or the *knowledge - attitude - intention - practice* chain; positive framing plus efficacy; credible messenger; local language and dialect; 7 Cs of communication - clear, correct, complete, concise, concrete, courteous, coherent; *KISS* for low literacy; pictorial and audio aids where literacy is low.
• Fear appeals and risk communication: pair threat with a doable action; WHO's risk-communication rules - be first, be right, be credible, express empathy, promote action, show respect; infodemic management and pre-bunking of rumours (learnt in COVID-19 vaccine communication and in measles-rubella campaign rumours).
• Pre-testing (compulsory before rollout): test comprehension, attraction, acceptability, persuasion, self-involvement with 8-12 members of the target audience per segment; revise and re-test.
• KAP/KAPB survey: measures knowledge, attitude, practice (and beliefs) before and after; limitation - self-reported practice is inflated by social desirability, and knowledge gain does not prove behaviour change.
• Ethics: informed consent in community work, no stigmatising or shaming imagery (a documented problem in some sanitation and HIV messaging), no coercion, privacy of individuals shown in material, truthful claims, and conflict-of-interest screening for industry-funded promotion.

Planning, implementing and evaluating a health promotion programme

1. Situation analysis: burden and distribution of the problem, determinants, behavioural and non-behavioural causes, existing services, audience research (qualitative FGDs, IDIs plus quantitative KAP), barrier analysis.
2. Audience segmentation: primary (the person who must act), secondary/influencers (husband, mother-in-law, employer, teacher), tertiary (policy makers, media) - a standard exam triad in Indian BCC strategy documents.
3. Objectives: SMART, separated into communication objectives (reach, recall, knowledge) and behavioural objectives (practice).
4. Strategy design: behaviour chosen, barriers to be removed, channel mix, message concept, messenger, frequency and schedule, enabling supply-side action (no demand generation without service readiness).
5. Material development and pre-testing, then production, branding and distribution.
6. Capacity building: train frontline workers in IPC and counselling; job aids such as the Mother and Child Protection (MCP) Card and ASHA module flipbooks.
7. Implementation with a work plan, budget and responsibility matrix; community mobilisation through VHSND, VHSNC, Mahila Arogya Samiti, SHGs, school eco/health clubs.
8. Evaluation: process (outputs, reach, fidelity, dose), impact/outcome (knowledge, attitude, behaviour), and cost (cost per person reached, cost per behaviour adopted). Designs - pre-post with control, quasi-experimental, cluster-randomised; triangulate self-report with observation or records (e.g. HMIS ANC-4 visits, immunisation coverage, tobacco cessation records).
9. Advantages of health promotion: low cost per head, acts upstream, improves equity, sustainable gains, supports every disease programme.
10. Limitations: long lag before measurable outcomes, attribution is hard, needs multi-sector cooperation, risk of victim-blaming if structural causes are ignored, effects decay without reinforcement, and awareness alone rarely changes behaviour.

Indian programmes, laws and institutional structure

• NHM funds state IEC/BCC plans through the PIP (Programme Implementation Plan); a share of the NHM budget is earmarked for IEC/BCC - the exact percentage varies by year and state, so quote the state PIP rather than a fixed figure.
• National Health Policy 2017 commits to health promotion, "swasth nagrik abhiyan", and a shift to wellness; Ayushman Bharat Health and Wellness Centres are now renamed Ayushman Arogya Mandir, and deliver health promotion and wellness (including yoga sessions) as part of the 12 comprehensive primary health care packages.
• Frontline cadre: ASHA (ASHA = Accredited Social Health Activist; Mitanin in Chhattisgarh), ANM, AWW, MPW, and Mahila Arogya Samiti in urban areas; ASHA incentives are tied to mobilisation and VHSND attendance.
• Flagship behaviour-change programmes: Swachh Bharat Mission (ODF, with community-led total sanitation triggering), POSHAN Abhiyaan and Poshan Maah/Poshan Pakhwada, Anaemia Mukt Bharat (6×6×6 strategy), Mission Indradhanush/IMI (immunisation), NTEP's Ni-kshay and TB-Mukt Bharat with Ni-kshay Mitra, National Tobacco Control Programme and Tobacco-Free Educational Institutions, Eat Right India and FSSAI's Eat Right Campus/Trans-fat-free labelling, Fit India Movement, Khelo India, Yoga Day, Rashtriya Kishor Swasthya Karyakram with peer educators (Saathiya resource kit), Mental health - Tele-MANAS helpline, and the National Deworming Day.
• Law as a promotion tool: COTPA 2003 (smoking in public places, no sale to minors, ban on advertising, pictorial warnings covering 85% of both principal display areas, and the mandated anti-tobacco health spots/static warning with OTT content disclaimers under the 2023 amendment rules); Cigarettes and Other Tobacco Products (Packaging and Labelling) rules notify the warning images periodically; the Food Safety and Standards Act 2006 with FSSAI labelling and advertising regulations; Infant Milk Substitutes (IMS) Act 1992 as amended 2003 restricting formula promotion; PCPNDT Act 1994 (and "Beti Bachao Beti Padhao" communication); Mental Healthcare Act 2017; Consumer Protection Act 2019 and ASCI's self-regulatory code on misleading health advertisements; a state-level tool is prohibition and alcohol-licensing policy. GST's 40% demerit slab covered aerated and sugary drinks from 22 September 2025, while cigarettes and chewing tobacco stayed at 28% plus compensation cess and moved to the 40% rate only from 1 February 2026, when the GST compensation cess ended - a fiscal health-protection measure.
• Data and reporting: NFHS-5 (2019-21) for behaviour indicators (e.g. tobacco use, breastfeeding, institutional delivery), GATS-2 (2016-17) for tobacco, NFHS/NSSO for sanitation, and HMIS/Ni-kshay/U-WIN for programme records. NFHS-6 fieldwork has been under way; quote NFHS-5 unless the newer round's figures are confirmed.
• Advocacy and partners: Ministry of Health and Family Welfare IEC Division and NIHFW, National Institute of Health and Family Welfare training, state IEC bureaux, Doordarshan/All India Radio for public-service time, UNICEF/WHO/UNFPA, BMGF-funded NGOs, and CSR under the Companies Act 2013 Schedule VII (preventive health care is a permitted CSR activity).

Key points

• Health promotion - enabling control over determinants of health; broader than health education (Ottawa Charter 1986).
• Five Ottawa action areas - healthy public policy, supportive environments, community action, personal skills, reoriented services.
• Three Ottawa strategies - advocate, enable, mediate.
• HBM - susceptibility, severity, benefits, barriers, cues to action, self-efficacy; good for one-off preventive acts.
• Stages of change - pre-contemplation, contemplation, preparation, action, maintenance; match the intervention to the stage.
• TPB - intention from attitude, subjective norm and perceived behavioural control; explains the intention-behaviour gap.
• Self-efficacy - belief in one's ability to perform the behaviour; the strongest single predictor across models (Bandura).
• COM-B - capability, opportunity, motivation produce behaviour; diagnose before designing.
• PRECEDE-PROCEED - predisposing, enabling and reinforcing factors diagnosed first, then implement and evaluate.
• Socio-ecological model - act at individual, interpersonal, community and policy levels together.
• Diffusion of innovations - adoption spreads from innovators to laggards through opinion leaders.
• IEC vs BCC vs SBCC - awareness; targeted behaviour change; behaviour plus social norms and advocacy.
• IPC - highest persuasion per contact, highest cost; mass media is the reverse. Combine them.
• Pre-testing - comprehension, attraction, acceptability, persuasion, self-involvement, before any rollout.
• EPPM/fear appeal rule - high threat works only with high efficacy, else denial.
• Demand without supply fails - never generate demand for a service that is not ready.
• COTPA 2003 - the main Indian tobacco health-protection law; 85% pictorial warnings, advertising ban, no sale to minors.
• Evaluation layers - process (reach, fidelity), outcome (KAP, behaviour), impact (morbidity), cost per behaviour adopted.

Formulas and examples

Example 1 - net effect of a BCC campaign (difference-in-differences). A district BCC campaign promotes exclusive breastfeeding. Intervention block: baseline 46%, endline 63%. Control block: baseline 44%, endline 49%.

• Intervention change = 63 − 46 = +17 pp; relative change = 17/46 = +37.0%.
• Control change = 49 − 44 = +5 pp (secular trend).
• Net effect attributable to the campaign = 17 − 5 = +12 pp.
• Target group = 8,500 mothers → additional adopters = 0.12 × 8,500 = 1,020 mothers.
• Campaign cost ₹18,70,000 → cost per additional adopter = 18,70,000/1,020 = ₹1,833.

Example 2 - reach, frequency and cost per contact. A radio plus mid-media campaign: target population 6,00,000; 3,90,000 persons exposed at least once; average 4 exposures each; total cost ₹46,80,000.

• Reach = 3,90,000/6,00,000 = 65%; GRP = 65 × 4 = 260.
• Total impressions = 3,90,000 × 4 = 15,60,000.
• Cost per person reached = 46,80,000/3,90,000 = ₹12.00; cost per impression = 46,80,000/15,60,000 = ₹3.00.

Example 3 - stage-of-change audience profile and targeting. In 1,200 adult male tobacco users surveyed: pre-contemplation 480, contemplation 300, preparation 180, action 150, maintenance 90.

• Shares = 40%, 25%, 15%, 12.5%, 7.5% (sums to 100%).
• Ready to act now (preparation + action) = 180 + 150 = 330 = 27.5% - the group to route to cessation services (National Tobacco Quitline/cessation centre).
• 65% are in pre-contemplation or contemplation → mass-media consciousness-raising and risk messaging, not cessation logistics.
• If cessation counselling converts 30% of the 330 to quitting, quitters = 99; at ₹850 per counselled person, cost = 330 × 850 = ₹2,80,500 → cost per quitter = ₹2,833.

Example 4 - intention-behaviour gap and PAF. A survey finds 72% of adolescents intend to use a helmet but 41% actually do.

• Gap = 72 − 41 = 31 pp - a perceived-behavioural-control/opportunity problem (helmet cost, carrying it, enforcement), so COM-B points to *opportunity* and *enablement*, not more awareness.
• Separately, for the same population's smoking: exposure prevalence P(E) = 0.30 and RR = 2.5 for a disease, PAF = 0.30 × 1.5 / (1 + 0.30 × 1.5) = 0.45/1.45 = 31.0% - that fraction of cases would be averted if the exposure were eliminated.

Example 5 - choosing a channel mix on a fixed budget. Budget ₹30,00,000, target 1,00,000 people, objective = both awareness and skill (correct ORS preparation).

• Mixed plan reaches awareness through TV/radio and skill through natak plus ASHA demonstration; weighted cost per person for the whole plan = 30,00,000 / 1,00,000 planned contacts = ₹30 per person.
• Allocation lesson: judge a channel by cost per *objective achieved*, not cost per contact - ASHA IPC at ₹66.67 is the only line that teaches the skill.

Where it is used

• NHM state and district programme management units: IEC/BCC officers write the communication chapter of the PIP, commission material, run Poshan Maah and immunisation campaign communication, and report reach against the HMIS.
• Development and global health organisations: UNICEF, WHO-India, UNFPA, PATH, Jhpiego, PSI, Nutrition International, Population Foundation of India, Piramal Swasthya - roles titled SBCC Specialist, Demand Generation Officer, Community Mobilisation Coordinator.
• Hospitals and insurers: patient education and counselling units, discharge adherence counselling, NABH-required patient-rights and education standards, Ayushman Arogya Mandir wellness sessions.
• Corporate and CSR: workplace wellness (NCD screening, Fit India challenges, employee assistance programmes), CSR preventive-health projects under Schedule VII of the Companies Act 2013.
• Regulators and advocacy: FSSAI Eat Right India campus and labelling work, National Tobacco Control Cell and tobacco-free institution certification, Voluntary Health Association and consumer groups filing ASCI complaints on misleading health claims.
• Market and social research: agencies running KAP surveys, message pre-testing, media monitoring and campaign evaluation for government and donors - a common entry role for public health graduates.

Interview questions

• Q: How is health promotion different from health education? A: Health education builds knowledge and skills in individuals; health promotion also changes policy, environments and services so that the healthy choice is the easy choice. Education is one component of promotion.
• Q: Name the five action areas of the Ottawa Charter. A: Build healthy public policy, create supportive environments, strengthen community action, develop personal skills, reorient health services.
• Q: A campaign raised awareness of ORS from 40% to 85% but diarrhoea deaths did not fall. What went wrong? A: Knowledge is not practice - the barriers were probably opportunity and skill (availability of ORS, correct preparation, caregiver confidence), so the design needed IPC demonstration and supply-side assurance, not more awareness.
• Q: Which model would you use to design a cervical cancer screening drive, and why? A: The Health Belief Model, because screening is a one-off preventive act driven by perceived susceptibility and severity against perceived barriers such as fear, cost, travel and embarrassment, with a cue to action from an ASHA invitation.
• Q: What is the difference between IEC, BCC and SBCC? A: IEC is awareness-led and largely one-way; BCC targets a specific behaviour in a segmented audience using theory; SBCC adds social norms, advocacy and community mobilisation.
• Q: Why must IEC material be pre-tested? A: To check comprehension, attraction, acceptability, persuasion and self-involvement with the actual audience - untested material routinely fails on dialect, imagery and literacy, and printing before testing wastes the budget.
• Q: When do fear appeals backfire? A: When perceived threat is high but efficacy is low - people respond with denial, avoidance or fatalism (EPPM); always pair the threat with a specific doable action.
• Q: How do you measure whether a behaviour change campaign worked? A: Separate process indicators (reach, frequency, fidelity, materials distributed) from outcome indicators (knowledge, attitude, self-reported and observed practice) and use a control area or difference-in-differences, triangulating self-report with service records.
• Q: What is COM-B and why do practitioners prefer it? A: Behaviour requires capability, opportunity and motivation; it is a diagnostic tool - you identify which component is deficient and then pick the matching intervention function from the Behaviour Change Wheel, so the design follows evidence rather than habit.
• Q: Give an Indian example where law, not communication, drove behaviour change. A: COTPA 2003 with pictorial warnings covering 85% of the pack face, the advertising ban and the 40% GST demerit slab on tobacco - fiscal and legal measures that reduce consumption irrespective of individual persuasion.
• Q: Who are primary, secondary and tertiary audiences in a maternal health BCC plan? A: Primary - pregnant women; secondary - husbands, mothers-in-law, ASHA/ANM; tertiary - panchayat leaders, media and district officials whose policy and support decisions enable the behaviour.
• Q: A community rejects a vaccine because of a WhatsApp rumour. What is your response? A: Risk-communication practice - respond fast with accurate, empathetic information through a locally credible messenger (religious leader, doctor, ASHA), pre-bunk the specific claim, and address the underlying grievance rather than only debunking.

Common mistakes

• Treating health promotion as only awareness-raising and forgetting policy, environment and service-side action.
• Equating knowledge gain with behaviour change, and reporting a KAP knowledge rise as programme success.
• Confusing the Health Belief Model with the Theory of Planned Behaviour constructs, or listing "stages of change" without matching an intervention to each stage.
• Designing for an "average" audience - no segmentation, no primary/secondary/influencer split, no pre-testing.
• Generating demand without checking supply readiness (no vaccine, no ORS, no counsellor at the facility).
• Using fear or shame imagery without an efficacy message - stigmatising and often counter-productive.
• Quoting a baseline-to-endline rise as the campaign effect without a control or secular-trend adjustment.

Related topics

Monitoring and evaluation of development projects · Project proposal writing · Epidemiology: measures of association and attributable risk · National health programmes and NHM · Social and behavioural determinants of health · Hospital information systems and digital health (ABDM and ABHA)