Public Health Enabling Factors
by
Gary D. Gilmore
  • LAST REVIEWED: 15 June 2015
  • LAST MODIFIED: 28 May 2013
  • DOI: 10.1093/obo/9780199756797-0081

Introduction

The concept and the implementation of enabling factors emerged from the behavioral sciences. Enabling factors are forces that facilitate or impede individual, collective, or environmental change based on their level of availability. Overall, it is helpful to view an enabling factor as a component of a combination of the following forces that, taken together, influence the degree of initiation and continuation of some type of action. First, predisposing factors are more inherent motivational forces (e.g., values and attitudes) that provide reasons for taking a given action; second, enabling factors facilitate or impede such action based on their degree of availability (e.g., health insurance coverage), while reinforcing factors support and potentially reward the action taken (e.g., family encouragement). Such factors are particularly important to consider when behavioral changes are sought for health enhancement. Health-related actions do not occur in a vacuum; rather, they result from an array of inherent behavioral influences interfaced with external environmental forces. Sorting out the behavioral influences provides the public health practitioner with insight to assist in taking the next appropriate steps. The planning models described in this article take these factors and forces into consideration. Of note, enabling factors can be considered intrinsic or extrinsic. Individual perceptions and positive internal perspectives relate to the more internal, or intrinsic, types of enabling factors. Options of choice regarding types of engagement activities, along with experiencing supportive environments, individuals, and incentives, represent the more external, or extrinsic, types of enabling factors.

Introductory Works

The following works not only describe enabling factors, but also provide examples of their use in context. They include reviews in which enabling factors make up part of planning models, theoretical frameworks, and case studies. An historical perspective over time, Last 2005 explores the role of environmental and lifestyle influences on health outcomes, while clear examples are provided in Doyle and Ward 2001, particularly with regard to the development of objectives used in health program development. Within this context, one of the most highly regarded and widely used models, the PRECEDE–PROCEED approach, is explained in Green and Kreuter 2005. The PRECEDE–PROCEED model was first developed by Lawrence W. Green in Green 1974 as PRECEDE, and relatively more recently with the addition of PROCEED by Lawrence W. Green and Marshall W. Kreuter (Green and Kreuter 2005). The first three letters in PRECEDE refer to predisposing, reinforcing, and enabling factors influencing behavioral activity. Green and Kreuter 2005 describes enabling factors as “those skills, resources, or barriers that can help or hinder the desired behavioral changes as well as environmental changes. One can view them as vehicles or barriers, created mainly by societal forces or systems” (p. 15). The authors point out that skills that are required for the intended behavior also can be considered enabling factors. A helpful example of such a skill would be a person knowing how to properly use a sphygmomanometer for a hypertension self-care program. Overall, the authors explain that it is helpful “to think of enabling factors as those that make possible a change that people want in behavior or in the environment” (p. 15). Applications of enabling factors as inherent elements in practical planning models are clarified in Gielen, et al. 2008 and Ramirez, et al. 2007 from the community and interpersonal perspectives, and in Parker and Sommer 2011 from more global vantage points. From a health promotion vantage point, Well-Being Concepts from the Centers for Disease Control and Prevention (CDC) provides an overview of the determinants of individual-level well-being from an array of study findings.

  • Doyle, E., and S. Ward. 2001. The process of community health education and promotion. Mountain View, CA: Mayfield.

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    Helpful practical examples of enabling factors are provided by these authors, in one instance citing that “regular exercise will be easier to maintain if exercise resources, such as a safe and convenient place to jog or engage in recreational sports, are available and accessible. Because improper exercise can cause needless muscle soreness and injury, adolescents also need training in appropriate exercise skills” (p. 135).

  • Gielen, A. C., E. M. McDonald, T. L. Gary, and L. R. Bone. 2008. Using the PRECEDE-PROCEED model to apply health behavior theories. In Health behavior and health education: Theory, research, and practice. 4th ed. Edited by K. Glanz, B. K. Rimer, and K. Viswanath, 405–433. San Francisco: Jossey-Bass.

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    Using a definition of “model” as drawing on several theories to advance understanding, the authors address enabling factors as an inherent part of the educational and ecological assessment phase in the PRECEDE–PROCEED model. Careful attention is given to the application of the model at the community, interpersonal, and individual levels. In particular, the educational and ecological assessment phase is aligned with key theories and models.

  • Green, L. W. 1974. Toward cost-benefit evaluations of health education: Some concepts, methods, and examples. Health Education Monographs 2 (Suppl. 1): 34–65.

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    This article serves as a grounding document that includes reference to enabling factors as derived from the work of Ronald Andersen (R. M. Andersen, A Behavioral Model of Families’ Use of Health Services. Research Series 25 [Chicago: Center for Health Administration Studies, Univ. of Chicago, 1968]), who addressed enabling resources from the behavioral model of families’ use of health services.

  • Green, L. W., and M. W. Kreuter. 2005. Health program planning: An educational and ecological approach. 4th ed. Boston: McGraw-Hill.

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    Green and Kreuter formally define an enabling factor as “any characteristic of the environment that facilitates action and any skill or resource required to attain a specific behavior,” (p. G-3). In a preliminary manner, enabling factors are many times described and addressed within the context of facilitation and what are known as predisposing factors, which motivate behaviors to take place. Enabling factors are related to the “process” of behavioral activity.

  • Last, J. 2005. A brief history of advances toward health. In Understanding the global dimensions of health. Edited by S. W. A. Gunn, P. B. Mansourian, A. M. Davies, A. Piel, and B. M. Sayers, 3–14. New York: Springer.

    DOI: 10.1007/b104427E-mail Citation »

    Last uses the context of the broad sweep of health and history. Along the way, he reminds us that our “new” perspectives on health-related influences are not limited solely to present-day issues (e.g., Hippocrates in 460–370 BCE addressed epidemics using case records of diseases such as tetanus, rabies, and mumps, coupled with the influences of airs, waters, and places related to environmental health). Lifestyle influences are included.

  • Parker, R., and M. Sommer. 2011. Routledge handbook of global public health. New York: Routledge.

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    The editors provide a useful overview of current and emerging public health issues that are influenced by a myriad of factors. Ten sections guide the discussion, covering the emergence of global health issues (as distinguished from international health, which involves sovereign states and their boundaries). All of the sections explore the influences on specific health issues to include the outcomes.

  • Ramirez, A. G., P. Chalela, K. Gallion, and L. F. Velez. 2007. Energy balance feasibility study for Latinas in Texas: A qualitative assessment. Preventing Chronic Disease 4.4.

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    Ramirez, et al. address the health issue of the nearly two-thirds of the population in the United States considered to be overweight or obese. They investigate the knowledge, attitudes, and behaviors about nutrition and exercise of Latinas aged forty years or older who were living in a low-income area of Houston, Texas. Enabling factors related to physical activity included learning about the benefits of exercise.

  • Well-Being Concepts.

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    This Centers for Disease Control and Prevention review addresses the determinants of individual-level well-being (meaningful positive outcomes to include social, economic, and personal development) using multiple study findings. Included in the review are the impacts of genetic factors and personality factors, paid employment, and supportive relationships (one of the strongest predictors of well-being), among others.

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