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Georgetown UniversityNCEMCH

NAPPSS Social-Ecological Model

NAPPSS uses three evidence-based approaches to bring about behavior change with safe sleep and breastfeeding: Ajzen's Theory of Planned Behavior 1, the Social-Ecological Model 2, and the Diffusion of Innovations approach. 3

1. Ajzen's Theory of Planned Behavior

The theory of planned behavior provides a context for addressing barriers to breastfeeding and safe sleep implementation. Behavior change theory provides context and focus for addressing barriers and challenges to adopting safe sleep behaviors and breastfeeding as the national norm. To effectively address such barriers, it is essential to understand the factors that influence behavior change of parents, family members, and other caregivers. In Ajzen’s Theory of Planned Behavior (TPB), intention correlates strongly with behavior change, with three major factors influencing intention to perform or change a specific behavior:

  • Positive perceptions of the behavior, the actions required, and the advantages (e.g., placing my baby to sleep on his back in his own safe crib with only a tight-fitting sheet will keep him safer during sleep; breastfeeding will help keep my baby healthier now and in the future).
  • Others’ beliefs about the behavior (“normative beliefs” held by others who are important to the individual, such as friends, family members, colleagues, even societal pressures).
  • Personal perceptions of one’s own ability, level of control, and self-efficacy to perform or change the behavior.

Image of model showing Conceptual Framework for Increasing Adoption of Breastfeeding and Safe Sleep Behaviors by Infant Caregivers, based on Ajzens Theory of Planned Behavior

2. Social-Ecological Model

Who provides the influence and support needed in Ajzen's second step? This social-ecological model shows the dynamic interrelations among various personal and environmental factors. The model bridges the gap between behavioral theories that focus on small settings and anthropological theories that analyze larger settings. 2 As detailed in the diagram below, every system exerts influence on the infant caregivers – truly safe sleep and breastfeeding are everyone's business, and every group detailed below is needed for NAPPSS to be effective in making safe sleep and breastfeeding a national norm.

Layers of the Social-Ecological Model


Social-Ecological Model

Influences in the Social-Ecological Model

A problem in promoting and supporting safe sleep and breastfeeding is that caregivers receive inconsistent messages from important sources.

Click on a thumbnail to see how each social level can positively influence the others levels
with the goal of providing consistent safe infant sleep and breastfeeding messages to infant caregivers.

3. Diffusion of Innovations

Diffusion is the process in which an innovation is communicated through certain channels over time among members of a social system. This is a two-way communication that leads to diffusion. Rogers proposes that four main elements affect the spread of a new idea: the innovation itself, communication channels, time, and a social system. The innovation must be widely adopted in order to self-sustain. Within the rate of adoption, there is a point at which an innovation reaches critical mass. The categories of adopters are: innovators, early adopters, early majority, late majority, and laggards. 3

How Do We Get People to Accept New Things?

A. Knowledge Stage: Letting people know it exists

  • Mass media
  • Brochures
  • Presentations
  • Dissemination of materials/resources

B. Reinforcement and Persuasion Stage: Communication within individual’s social network (people they see/talk to regularly)

  • Hearing about it from trusted, usual sources
  • People who are “like me” or who I trust accept it and think I should try it

C. Decision/Adoption Stage: Overcoming the Barriers

  • Is the innovation better, easier, more convenient, more effective, less expensive?
  • Is the innovation consistent with existing values, past experiences and needs?
  • Is the innovation perceived as easy to understand?
  • Can people try it out? Any long term commitments?
  • Is the innovation and its benefits visible? Do adopters know someone who has used and liked the innovation?
  • Can the innovation be changed to suit the adapters needs?



1. Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. Springer Berlin Heidelberg.

2. Bronfenbrenner, U (1999). Friedman SL and Wachs TD, ed. Measuring environment across the life span: Emerging methods and concepts. Washington, DC: American Psychological Association Press.

3. Rogers, E (2003). Diffusion of Innovations, 5th Edition. New York: NY. Simon and Schuster.

Author: Suzanne Bronheim, PhD, National Center for Cultural Competence
October 2014; Updated November 2016