Limitation of Liability/Disclaimer of Warranty: Although the publisher and author have used their best efforts to prepare this book, they make no representations or warranties as to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. Paradigms for theory and research in health promotion and education 29 Trends in the use of health behavior theories and models 31.
PART FOUR: COMMUNITY AND GROUP MODELS
Approaches to defining needs, problems and goals 395 The influence of technology on theory and practice at the macro level 396.
PART FIVE: USING THEORY IN RESEARCH AND PRACTICE 405
Tracy Orleans, Ph.D
In the past two decades since the publication of the first edition of Health Education and Health Behavior: Theory, Research, and Practice in 1990, there has been tremendous growth in our knowledge about the interventions needed to change health behaviors in both individuals and population. levels. Just as previous editions of Health Behavior and Health Education have provided essential care for many of the advances described here, this fourth edition will help us navigate the new frontiers and challenges that lie ahead.
PREFACE
The Editors
AUDIENCE
OVERVIEW OF THE BOOK
The emphasis of health behavior and health education is on the analysis and application of health behavior theories to health promotion and educational practice. Health behavior and health education has now become established as a widely used text and reference book.
ACKNOWLEDGMENTS
Karen Glanz would like to acknowledge partial funding support from the Georgia Cancer Coalition for the technical editing and production of this volume.
THE EDITORS
Fisher is professor and chair of the Department of Health Behavior and Health Education at the University of North Carolina School of Public Health at Chapel Hill. Andrea Carson Gielen is a professor and director of the Center for Injury Research and Policy at the Johns Hopkins Bloomberg School of Public Health in Baltimore.
THE CONTRIBUTORS
Francisco is an associate professor in the Department of Public Health Education at the University of North Carolina at Greensboro. Israel is a professor in the Department of Health Behavior and Health Education in the School of Public Health at the University of Michigan.
HEALTH BEHAVIOR
HEALTH
EDUCATION
HEALTH EDUCATION
HEALTH BEHAVIOR The Foundations
THE SCOPE OF
HEALTH BEHAVIOR AND HEALTH EDUCATION
KEY POINTS
This often requires individual health education and health behavior professionals to synthesize large and diverse literature. Many kinds of professionals contribute to and conduct health education and health behavior (HEHB) programs and research.
THE CHANGING CONTEXT OF HEALTH AND BEHAVIOR
A major achievement in the United States has been exceeding targets for reducing deaths from coronary heart disease and cancer (National Center for Health Statistics, 2001). Rates of HIV/AIDS in the United States have leveled off, and transfusion-related HIV infections have declined markedly.
HEALTH EDUCATION AND HEALTH BEHAVIOR
In this context, the definitions of health education and health promotion can be recognized and discussed as overlapping and intertwined. In fact, the terms health promotion and health education are often used interchangeably in the United States.
SETTINGS AND AUDIENCES FOR HEALTH EDUCATION
Health education for high-risk individuals, patients, their families and the surrounding community, as well as continuing education for health care providers, are all part of healthcare today. For health education to be effective, it must be designed with an understanding of the health and social characteristics, beliefs, attitudes, values, skills and past behaviors of the recipients – the target groups.
PROGRESS IN HEALTH PROMOTION AND HEALTH BEHAVIOR RESEARCH
Overall, there is a growing trend towards evidence-based health education and health behavior (HEHB) as the findings of numerous large health behavior intervention studies have been published (Rimer, Glanz, and Rasband, 2001). The challenge of understanding and improving health behaviors is central to current health policy and is “one of the most complex tasks facing science to date.
SUMMARY
Concerted and focused efforts will be essential to solving many of the most vexing health issues facing our society (Smedley and Syme, 2000). Integrating the best available knowledge from theory, research and health promotion and educational practice can advance this agenda over the next decade.
Have the focus and sophistication of research in health education changed?” Health education and behavior. Search for evidence on health education and health behavior interventions.” Health education and behavior.
THEORY, RESEARCH, AND PRACTICE IN
HEALTH BEHAVIOR AND HEALTH EDUCATION
THEORY, RESEARCH, AND PRACTICE: INTERRELATIONSHIPS
The purpose of Health Behavior and Health Education is to – broadly speaking – help educators, regardless of their background or discipline, understand some of the key theoretical underpinnings of health education and health behavior and use theory to inform research and practice. The healthcare professional in a healthcare organization who understands the relevance of the Transtheoretical Model (TTM) or the Social Cognitive Theory (SCT) may be able to design better interventions to help patients lose weight or quit smoking.
WHAT IS THEORY?
In advanced disciplines, theories integrate laws; in less advanced fields, theories specify the determinants that determine the phenomena of interest.” In Health Behavior and Health Education, the term theory is used in the latter sense, because the field is still relatively young. The term subjective normative belief is an example of a construct within the Theory of Reasoned Action (TRA) by Ajzen and Fishbein (1980; see Chapter Four); the particular construct has a precise definition in the context of that theory.
PARADIGMS FOR THEORY AND RESEARCH IN HEALTH PROMOTION AND EDUCATION
Health behavior and the guiding concepts to influence it are far too complex to be explained by a single, unified theory. Although the paradigms described here focus on the basic scheme for developing and applying knowledge, health education and health behavior are also concerned with approaches to solving social problems – in other words, how to bring about change.
TRENDS IN USE OF HEALTH BEHAVIOR THEORIES AND MODELS
䊏 Theory-based: in which a theoretical framework was identified, but application of the theory was not or limited to specific components and measures of the study.䊏 Applied theory: in which a theoretical framework was identified and multiple constructs were used in the components studies.
SELECTION OF THEORIES FOR THIS BOOK
Each of the most cited theories and models is the focus of a chapter in this fourth edition of Health Behavior and Health Education. Second, there must be evidence that the theory is being used in current health behavior and health education research.
FITTING A THEORY OR THEORIES TO RESEARCH AND PRACTICE
Furthermore, both research and practice communities within health education and health behavior greatly need more rigor and precision in theory development and testing – in measurements, assessment of mediating variables and specification of theoretical elements (Rejeski, Brawley, McAuley and Rapp, 2000) . As this chapter and the previous one show, health education and health behavior are concerns of increasing importance to human well-being worldwide.
LIMITATIONS OF THIS BOOK
Therefore, health behavior and health education should be considered as a starting point and not as an end. Health behavior theory and cumulative health behavior knowledge: Are we heading in the right direction?” Health Education Research.
MODELS OF INDIVIDUAL
Barbara K. Rimer
Behavioral Health Education helps the reader to gain a better understanding of theories that focus primarily on an individual's health behavior. Together, these four chapters provide both researchers and practitioners with an introduction to widely used theories of health education and health behavior.
THE HEALTH BELIEF MODEL
Victoria L. Champion Celette Sugg Skinner
ORIGINS OF THE MODEL
DESCRIPTION OF HBM AND KEY CONSTRUCTS
Various early formulations of HBM included the concept of cues that can trigger actions. Health beliefs include the main constructs of the HBM: susceptibility, severity, benefits, barriers, and self-efficacy.
EVIDENCE FOR THE MODEL’S PERFORMANCE
Although HBM identifies constructs that lead to outcome behaviors, relationships between and among these constructs are not defined. Analytical approaches to identify these relationships are needed to advance the utility of HBM in predicting behavior.
MEASUREMENT OF HBM CONSTRUCTS
Reliability and validity were tested among a sample of 1,233 women, 54 percent of whom were African American; Cronbach's alpha coefficient was 0.87 and confirmatory factor analysis supported construct validity. Development of HBM scales for colorectal cancer (CRC) screening has been guided by the same measurement principles as those for mammography and breast self-examination.
APPLICATIONS OF THE HBM TO MAMMOGRAPHY AND AIDS-RELATED BEHAVIORS
The intervention also included personal counseling that addressed each woman's perceived receptivity, benefits, and barriers to mammography screening. Among women who had never had mammograms, adherence was significantly higher in the HBM-based interactive intervention group (50 percent) than in the comparison group (18 percent) (Champion et al., 2006).
COMPARISON OF HBM TO OTHER THEORIES
Self-efficacy training for condom use has been the target of several other interventions. Although results have varied, most attempted to use interventions to increase perceived risk and self-efficacy and target condom use.
CHALLENGES IN FUTURE HBM RESEARCH
A Tailored Intervention for Mammography Among Low-Income African American Women." Journal of Psychosocial Oncology. Using the Health Belief Model to Examine Differences in Mammography Adherence Among African American and Caucasian Women." Journal of Psychosocial Oncology.
THEORY OF REASONED ACTION, THEORY OF
BEHAVIORAL MODEL
Daniel E. Montaño Danuta Kasprzyk
TPB is an extension of ART and includes an additional construct: perceived control over behavioral performance. Although TRA and TPB have been criticized, based on whether correlational outcomes can explain behavior (Weinstein, 2007), many published intervention study reports show that changing TRA or TPB constructs lead to subsequent changes in behavior (Albarracin and others Jemmott, Jemmott, and Fong, 1992; Kamb et al., 1998; Rhodes et al., 2007; Kalichman, 2007).
ORIGINS AND HISTORICAL DEVELOPMENT
In recent years, Fishbein and colleagues have further expanded TRA and TPB to include components from other major behav- ioral theories and have proposed use of an Integrated Behavioral Model (IBM). The TRA and TPB, which focus on the constructs of attitude, subjective norm, and perceived control, explain a large proportion of the variance in behavioral intention and predict a number of different behaviors, including health behaviors.
THEORY OF REASONED ACTION AND THEORY OF PLANNED BEHAVIOR
The theory's success in explaining behavior depends on the extent to which the behavior is under voluntary control (that is, individuals can exert a high degree of control over the behavior). A person's behavioral beliefs about the likelihood that performance of the behavior will lead to certain outcomes are measured on bipolar "unlikely-probable" or "agree-agree" scales.
AN INTEGRATED BEHAVIORAL MODEL
For example, by changing normative beliefs, someone can be motivated enough to perform the behavior once. It is the specific beliefs underlying these constructs that must be specific to the behavior and population under investigation.
APPLICATION OF IBM TO HIV PREVENTION IN ZIMBABWE
Predicting Leisure Participation from Behavioral, Normative, and Control Beliefs: An Application of the Theory of Planned Behavior." Leisure Science. Predicting Intentions to Use Condoms: A Meta-Analysis and Comparison of the Theories of Reasoned Action and Planned Behavior." Journal of Applied Social Psychology.
THE TRANSTHEORETICAL MODEL AND STAGES
OF CHANGE
Kerry E. Evers
Precontemplation No intention to take action within the next six months. Contemplation Plans to take action within the next six months. Preparation Plans to take action within the next 30 days and has taken some behavioral steps in this direction.
CORE CONSTRUCTS
The measurement structure of higher-order processes (experiential and behavioral) was replicated in problem behaviors better than specific processes (Rossi, 1992b). But the measurement structure of the processes was not as consistent across studies as the mathematical relationships between the stages and the pros and cons of change.
APPLICATIONS OF THE TRANSTHEORETICAL MODEL TO SMOKING CESSATION
Pretreatment stage-related measures correctly classified 93 percent of the three groups (Brogan, Prochaska, & Prochaska, 1999). Participants in the personal condition may have become somewhat dependent on the social support and social control of the counselor caller.
MULTIPLE-BEHAVIOR CHANGE PROGRAMS
For sun exposure, 29.7 percent of at-risk parents in the baseline group achieved action or maintenance levels in the treatment group, compared with 18.1 percent of controls. In sun exposure, 23.4 percent of the treatment group were active or maintained compared to 14.4 percent of the control group.
LIMITATIONS OF THE MODEL
FUTURE RESEARCH
Smoking cessation processes: An analysis of precontemplation, contemplation, and preparatory stages of change.” Journal of Counseling and Clinical Psychology. Stages of Change and Smoking Cessation: A Computer-Guided Intervention Program for Young Adults.” American Journal of Health Promotion.
THE PRECAUTION ADOPTION PROCESS
MODEL
Susan J. Blalock
At the time, some young people might have been aware that AIDS is a fatal disease, but few would have known anything more. However, neither their actual behavior nor subsequent changes in their behavior would have been explained or predicted by their beliefs about AIDS.
HOW STAGE THEORIES APPROACH THE ISSUE OF EXPLAINING AND CHANGING BEHAVIOR
Some young adults would have many sexual partners, while others would have few or none; some would use condoms and others would not. Stage theories assume that people usually go through all the stages in order before acting.
THE PRECAUTION ADOPTION PROCESS MODEL
The media is often very influential in moving people from PAPM Level 1 to Level 2 and from Level 2 to Level 3, but much less influence after that. One of the values of PAPM is its recognition of differences between people who neither act nor intend to act.
USING THE PAPM TO DEVELOP AND EVALUATE BEHAVIOR CHANGE INTERVENTIONS
The intensity of the intervention required will depend on the behavior of interest and what barriers need to be overcome. Among smokers who are already interested in quitting, for example, the early stages of the PAPM may be ignored.
HOW STAGE THEORIES, INCLUDING THE PAPM, CAN BE TESTED
Intervention-induced changes in beliefs and behavior may be transitory, so intervention effects may be missed if only long-term follow-up assessments are used. Although long-term behavior change is generally desired, a stage model perspective raises the possibility that even transitory changes can be steps in the right direction, helping us understand barriers at different stages and increasing the success of subsequent change efforts. of behavior.
AN EXAMPLE USING MATCHED AND MISMATCHED TREATMENTS TO TEST THE PAPM
Participants in the High-Probability condition received a five-minute video, Radon Risk in Columbus Area Homes, and an accompanying cover letter. Participants in the low-effort condition received a five-minute video, How to Test Your Home for Radon, an accompanying cover letter, and a form to order test kits through the ALA.
REVIEW OF RESEARCH USING THE PAPM
Variables in the table are those that the creators of the model believe may be important. Another difficult question for users of the PAPM is whether to add stages that differentiate people based on their past actions.
CRITERIA FOR APPLYING STAGE-BASED INTERVENTIONS
Within print channels, pamphlets and magazines offer more opportunities for stage targeting than newspapers;. A final measure of importance concerns the difficulty of the action being advocated and the expected resistance of the audience to the behavior change recommendation.
FUTURE DIRECTIONS
Effects of Osteoporosis Prevention Program Including Tailored Educational Materials.” American Journal of Health Promotion. Reasoned action and social responsiveness: willingness and intention as independent predictors of health risk. Journal of Personality and Social Psychology.
PERSPECTIVES ON HEALTH BEHAVIOR
ON INDIVIDUALS
WHY THEORY?
Theories that focus on individuals' beliefs and actions were among the first theories of health behavior developed and are still the most widely used. Despite the many potential benefits of using theory, one theory is unlikely to be sufficient for all, if not most, health behavior problems.
WHICH THEORY TO USE?
A systematic review of counseling interventions to increase healthy eating habits drew similar conclusions about the benefits of targeting theorized mediating variables (Pignone et al., 2003). Readers should consider integrating theories from more than one level and using these theories to design and evaluate health behavior interventions.
A CLOSER LOOK AT INDIVIDUAL-LEVEL THEORIES
Some apparent limitations of TTM may result not from shortcomings of the model, but from the way researchers operationalize stages of change and design interventions. TTM's numerous reviews no doubt reflect the enthusiasm and considerable attention the model has received.
COMMONALITIES AND DIFFERENCES ACROSS THE THEORIES
Self-efficacy is embodied in three of the theories (TTM and included in modifications of the HBM and TPB). Recognizing this fact, Fishbein (2000) recommended the use of an integrated model (see Chapter Four) that incorporates key variables from several of the theories in this section as well as Social Cognitive Theory.
NEW CONSTRUCTS AND THEORIES
Of the nineteen studies that compared health behavior theories, none involved theory developers (Nigg and Jordan, 2005). Although emotions play a prominent role in many theories of health behavior, they deserve more attention than they receive in the four theories in this section of the book.
