PART TWO
Health-Related Interventions

Recognition of the inequities in health status described in Chapter 4 has led to calls for a focus on an ecologic approach to health-related interventions. An ecologic approach recognizes that people live in social, political, and economic systems that shape behaviors and access to the resources they need to maintain good health (Brown, 1991; Gottlieb and McLeroy, 1994; Krieger, 1994; Krieger et al., 1993; Lantz et al., 1998; McKinlay, 1993; Sorensen et al., 1998; Stokols, 1992, 1996; Susser and Susser, 1996a,b; Williams and Collins, 1995; World Health Organization, 1986). There also is an effort to expand methods for evaluating interventions that incorporate an ecologic approach (Fisher, 1995; Green et al., 1995; Hatch et al., 1993; Israel et al., 1995; James, 1993; Pearce, 1996; Sorensen et al., 1998; Steckler et al., 1992; Susser, 1995).

The ecologic or social-systems perspective places the person in their primary social context and observes how he or she interacts with other important factors to affect and be affected by disease outcomes. The social context with the most immediate effects on disease management and with the greatest implications for intervention is the family, broadly defined (Campbell, 1986; Campbell and Patterson, 1995; Fisher et al., 1998). However, the ecologic perspective also emphasizes the importance of organizations, communities, and society as a whole.

Part Two presents relevant theoretical concepts and models and de-



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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences PART TWO Health-Related Interventions Recognition of the inequities in health status described in Chapter 4 has led to calls for a focus on an ecologic approach to health-related interventions. An ecologic approach recognizes that people live in social, political, and economic systems that shape behaviors and access to the resources they need to maintain good health (Brown, 1991; Gottlieb and McLeroy, 1994; Krieger, 1994; Krieger et al., 1993; Lantz et al., 1998; McKinlay, 1993; Sorensen et al., 1998; Stokols, 1992, 1996; Susser and Susser, 1996a,b; Williams and Collins, 1995; World Health Organization, 1986). There also is an effort to expand methods for evaluating interventions that incorporate an ecologic approach (Fisher, 1995; Green et al., 1995; Hatch et al., 1993; Israel et al., 1995; James, 1993; Pearce, 1996; Sorensen et al., 1998; Steckler et al., 1992; Susser, 1995). The ecologic or social-systems perspective places the person in their primary social context and observes how he or she interacts with other important factors to affect and be affected by disease outcomes. The social context with the most immediate effects on disease management and with the greatest implications for intervention is the family, broadly defined (Campbell, 1986; Campbell and Patterson, 1995; Fisher et al., 1998). However, the ecologic perspective also emphasizes the importance of organizations, communities, and society as a whole. Part Two presents relevant theoretical concepts and models and de-

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences scribes examples of interventions at the principal levels of the ecologic perspective, as described in Table 1–1 (individual, family, social network, organization, community, society). Note that those “levels” can describe either mechanisms that affect health status and disease etiology functioning at that level or the level at which a particular intervention is delivered. Thus, the distinction is made between community-wide interventions (which for the most part define community as a geographic place within which to carry out interventions that address individual-level behavior change relevant to health outcomes) and community-level interventions (which target social and structural changes associated with health status in the community as a whole). Chapter 5 begins by presenting models and interventions relevant to the individual and family levels of the ecologic perspective. Chapter 6 then turns to the organization, community, and society levels. Chapter 7 reviews evaluation of the interventions and dissemination of health messages. REFERENCES Brown, E.R. (1991). Community action for health promotion: A strategy to empower individuals and communities. International Journal of Health Services, 21, 441–456. Campbell, T.L. (1986). Family’s impact on health: A critical review. Family Systems Medicine, 4, 135–328. Campbell, T.L. and Patterson, J.M. (1995). The effectiveness of family interventions in the treatment of physical illness. Journal of Marital and Family Therapy, 21, 545–583. Fisher, E.B.J. (1995). Editorial: The results of the COMMIT trial. American Journal of Public Health, 85, 159–160. Fisher, L., Chesla, C.A., Bartz, R.J., Gilliss, C., Skaff, M.A., Sabogal, F., Kanter, R.A., and Lutz, C.P. (1998). The family and type 2 diabetes: A framework for intervention. Diabetes Educator, 24, 599–607. Gottlieb, N.H. and McLeroy, K.R. (1994). Social health. In M.P.O’Donnell and J.S.Harris (Eds.) Health Promotion in the Workplace, 2nd edition (pp. 459–493). Albany, NY: Delmar. Green, L.W., George, M.A., Daniel, M., Frankish, C.J., Herbert, C.J., Bowie, W.R., and O’Neill, M. (1995). Study of Participatory Research in Health Promotion. University of British Columbia, Vancouver: The Royal Society of Canada. Hatch, J., Moss, N., Saran, A., Presley-Cantrell, L., and Mallory, C. (1993). Community research: partnership in Black communities. American Journal of Preventive Medicine, 9, 27–31. Israel, B.A., Cummings, K.M., Dignan, M.B., Heaney, C.A., Perales, D.P., Simons-Morton, B.G., and Zimmerman, M.A. (1995). Evaluation of health education programs: current assessment and future directions. Health Education Quarterly, 22, 364–389.

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences James, S.A. (1993). Racial and ethnic differences in infant mortality and low birth weight: A psychosocial critique. Annals of Epidemiology, 3, 130–136. Krieger, N. (1994). Epidemiology and the web of causation: Has anyone seen the spider. Social Science and Medicine, 39, 887–903. Krieger, N., Rowley, D.L., Herman, A.A., Avery, B. and Phillips, M.T. (1993). Racism, sexism and social class: Implications for studies of health, disease and well-being. American Journal of Preventive Medicine, 9, 82–122. Lantz, P.M., House, J.S., Lepkowski, J.M., Williams. D.R., Mero, R.P. and Chen, J. (1998). Socioeconomic factors, health behaviors, and mortality. Journal of the American Medical Association, 279, 1703–1708. McKinlay, J.B. (1993). The promotion of health through planned sociopolitical change: Challenges for research and policy. Social Science and Medicine, 36, 109–117. Pearce, N. (1996). Traditional epidemiology, modern epidemiology and public health. American Journal of Public Health, 86, 678–683. Sorensen, G., Emmons, K., Hunt, M.K., and Johnston, D. (1998). Implications of the results of community intervention trials. Annual Review of Public Health, 19, 379– 416. Steckler, A.B., McLeroy, K.R., Goodman, R.M., Bird, S.T., and McCormick, L. (1992). Integrating qualitative and quantitative methods. Health Education Quarterly, 19, 1– 8. Stokols, D. (1992). Establishing and maintaining healthy environments: toward a social ecology of health promotion. American Psychologist, 47, 6–22. Stokols, D. (1996). Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion, 10, 282–298. Susser, M. (1995). Editorial: The tribulations of trials—interventions in communities. American Journal of Public Health, 85, 156–58. Susser, M. and Susser, E. (1996a). Choosing a future for epidemiology. I.Eras and paradigms. American Journal of Public Health, 86, 668–673. Susser, M. and Susser, E. (1996b). From black box to Chinese boxes and eco-epidemiology. American Journal of Public Health, 86, 674–677. Williams, D.R. and Collins, C. (1995). US socioeconomic and racial differences in health: patterns and explanations. Annual Review of Sociology, 21, 349–386. World Health Organization (WHO). (1986). Ottawa Charter for Health Promotion. Copenhagen: WHO.

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences 5 Individuals and Families: Models and Interventions Human behavior plays a central role in the maintenance of health, and the prevention of disease. With an eye to lowering the substantial morbidity and mortality associated with health-related behavior, health professionals have turned to models of behavior change to guide the development of strategies that foster self-protective action, reduce behaviors that increase health risk, and facilitate effective adaptation to and coping with illness. Several decades of concerted effort to promote health and decrease risk through individual behavior change have produced successes, failures, and lessons learned. This chapter addresses the models of behavior change and interventions designed to influence individual behaviors. It continues to explore the influence of family relationships on the management and outcomes of chronic disease. MODELS OF BEHAVIOR CHANGE Human behavior plays a central role in the maintenance of health and the prevention of disease. Growing evidence suggests that effective programs to change individual health behavior require a multifaceted approach to helping people adopt, change, and maintain behavior. For example, strategies for establishing healthy eating habits in children and adolescents might be quite ineffective for changing maladaptive eating

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences behaviors—that is, when they are used to substitute one pattern for another—in the same population (e.g., Jeffery et al., 2000). Similarly, maintaining a particular behavior over time might require different strategies than will establishing that behavior in the first place (e.g., Ockene et al., 2000). Models of behavior change have been developed to guide strategies to promote healthy behaviors and facilitate effective adaptation to and coping with illness. Several models for individual behavior change are reviewed here. Learning and Conditioning Among the oldest, most widely researched, and yet most often misunderstood models of individual behavior applied to behavior change are those that deal with fundamental associative or classical conditioning and the related models of operant conditioning. Classical conditioning, pioneered by Pavlov, modifies behavior by repeatedly pairing a neutral stimulus with an unconditioned stimulus that elicits the desired response. Operant-conditioning builds on classical conditioning and focuses on the hypothesis that the frequency of a behavior is determined by its consequences (or reinforcements; Skinner, 1938). Although learning theory has been criticized for treating behavior in simplistic and mechanistic stimulus response terms, modern learning theory addresses complex components, including environmental cues and contexts, memory, expectancies, and underlying neurological processes related to learning (Rescorla, 1988). As Kehoe and Macrae (1998) note, today classical conditioning integrates cognition, brain science, associative learning, and adaptive behavior. Classical conditioning introduced concepts that have been particularly important in the design of health-related interventions, such as reinforcement, stimulus—response relationships, modeling, cues to action, and expectancies. However, given the particular difficulty in maintaining behavior changes, the relapse of behaviors that have been eliminated (or “extinguished”) by an intervention is of particular interest. Relapse of extinguished behaviors is a major problem in health-related behavior change interventions, especially those that target alcohol use, smoking, and diet (Dimeff and Marlatt, 1998; Marlatt and George, 1998; Perri et al., 1992; Wadden et al., 1998). Extinction initially was conceptualized as a process in which original learning, and therefore behavior, was unlearned or destroyed. That is, it was assumed that extinguished behavior would no

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences longer be elicited by the environmental cues that originally evoked it. However, extensive research shows that extinction does not involve unlearning, but rather new learning that does not overwrite the original learning. Furthermore, the physical environment and social context in which extinction takes place, as well as such internal states as emotions, drug-related states, and time, will influence the process of extinction (Bouton, 1998, 2000). Those findings have important implications for health-related behavior change. Specifically, the effectiveness of an intervention to reduce or eliminate a health risk, such as cigarette-smoking, will be limited to the extent that it is bound to the context in which it is delivered. As noted by Bouton (2000, p. 58), “the reformed smoker who once habitually smoked in a particular setting at work, or under the influence of a particular drug or alcohol, or in the presence of negative affect will be ready to lapse when cigarettes are made available in one of those contexts again. We now think of extinction as inherently context-specific, with the term ‘context’ being broadly defined.” One important implication of those findings is the importance of eliciting extinction in different contexts, including various physical environments, times, and emotional states. For example, extinction trials that are more widely spaced and in separate locations are more likely to be effective than core sessions that occur within short periods or in similar physical circumstances. Behavior change efforts should recognize the possible influence of contextual cues, identify the cues that might be involved, and help people avoid (or cope with) the contexts connected with the original health-compromising behavior, whether physical environments, interpersonal relationships, or negative emotional states. The learning of the new behavior (or extinction of the old) should take place in the contexts in which the person will need it the most. There is another important difference between original learning and extinction, namely, that original learning of a behavior readily generalizes across contexts, whereas extinction does not (Bouton, 2000, p. 61): [F]irst-learned things seem much more likely to generalize over place and time. One implication of this is that if we really want to reduce cardiovascular risk, we should arrange a world in which healthy behaviors are the first things, not the second things, learned. One way of thinking about research on behavior change is that the organism seems to treat the second thing learned about a stimulus as a kind of exception to a rule. It is as if the learning and memory system is organized with a default assumption that the first-learned thing is correct, and everything else is conditional on the current context, place, or time.

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences That perspective provides support for the importance of preventive interventions that promote health-enhancing behaviors, as opposed to interventions designed to treat or change health-compromising behaviors. The evidence that extinction depends on context is but one of several important results from basic research on learning and conditioning with important implications for explaining health-related behavior change. Closer ties between intervention research and basic learning theory and research could contribute to what O’Donohue (1998) called “third-generation behavior therapy,” behavioral interventions that are informed by recent developments in learning theory and other fields of basic behavioral science. Cognitive Social Learning Cognitive social-learning theory (e.g., Bandura, 1977, 1986, 1997) proposes that reinforcements are not the sole determinants of behavior, but that behavior changes with observations of others. According to cognitive social-learning theory, the most important prerequisite for behavior change is a person’s sense of self-efficacy or the conviction that one is able successfully to execute the behavior required to produce the desired outcome. People can feel susceptible to an illness, expect to benefit if they change their behavior, and perceive their social environment as encouraging the change, but if they lack a belief that they can indeed change, their efforts are not likely to succeed. Substantial empirical evidence suggests that self-efficacy beliefs (and the related concept of optimism) are reliable predictors of behavior, and that they mediate the effects of intervention on behavior change, including a number of health-related behaviors (e.g., Bandura et al., 1987; Ewart, 1995; Kaplan et al., 1994; Scheier et al., 1989; Wiedenfeld et al., 1990). A growing body of literature supports the importance of self-efficacy in initiation and maintenance of behavioral change (Bandura, 1977, 1986; Marlatt and Gordon, 1985; Strecher et al., 1986). Self-regulation is a concept that derives from cognitive social learning theory (see Bandura, 1986; Baumeister et al., 1998; Carver and Scheier, 1998; Compas et al., 1999; Eisenberg et al., 1997), and it includes what many people call “will power.” Self-regulation includes cognitive and behavioral processes that involve the initiation, termination, delay, modulation, modification, or redirection of a person’s emotions, thoughts,

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences behaviors, physiological responses, or environment (Compas et al., 1999). Self-regulation can be critical in such health-protective and health-maintaining behaviors as eating a healthy diet, engaging in regular exercise, and managing stress. Conversely, the failure or breakdown of self-regulatory efforts can be crucial in some risky behaviors, such as smoking, poor dietary management, and a sedentary lifestyle. Although much research supports the utility of Social Learning Theory, limitations have been noted. It is difficult to evaluate the efficacy of theory-based interventions because the studies have involved only small numbers of subjects and the intervention designs have been very complex. In addition it is difficult to quantify and measure the conceptual elements of Social Learning Theory: self-efficacy, influence of observational learning, and emotional arousal. Health Belief Model One of the earliest theoretical models developed for understanding health behaviors was the health belief model (HBM; Hochbaum, 1958). The model was developed in the 1950s to explain why people did not engage in behaviors to prevent or detect disease early. It integrates elements of operant-conditioning and Cognitive Theory. Operant-conditioning theory focused on the hypothesis that the frequency of a behavior is determined by its consequences while Cognitive Theory gave more emphasis to expectations to explain behavior. For example, the desire to avoid becoming ill is a value, and belief that a specific health behavior can prevent an illness is an expectancy. Perceived susceptibility is the perception of personal risk of developing a particular condition, and it involves a subjective evaluation of risk rather than a rigorously derived level of risk. Perceived severity is the degree to which the person attributes negative medical, clinical, or social consequences to being diagnosed with an illness. Together, perceived susceptibility and perceived severity provide motivation for reducing or eliminating such threats. The type of action taken depends on perceived benefits (beliefs about the effectiveness of different actions) and perceived barriers (potential negative aspects of particular actions). People are thought to weigh an action’s effectiveness in reducing a health threat against possible negative outcomes associated with that action. The HBM has been applied, among other things, to influenza inoculation, screening for Tay-Sachs disease, exercise programs, nutrition pro-

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences grams, and smoking cessation (Strecher and Rosenstock, 1997). An important contribution of the model is the recognition that prevention requires people to take action in the absence of illness. This continues to be useful, for example, in explaining women’s reluctance to perform breast self-examination or obtain mammograms (Rimer, 1990). The limitations of the HBM are reviewed by Janz and Becker (1984). Perhaps the most critical of these is the lack of predictive value for some of its central tenets. For example, the perceived severity of a risk does not reliably predict protective health behaviors (Rimer, 1990). Moreover, the HBM is more descriptive than explanatory and does not presuppose or imply a strategy for change (Rosenstock and Kirscht, 1974). The predictive utility of the HBM and its applicability to behavior change can be improved by adding variables, such as self-efficacy, or by integrating it with other models. Theory of Reasoned Action The Theory of Reasoned Action was first proposed by Ajzen and Fishbein (1980) to predict an individual’s intention to engage in a behavior at a specific time and place. The theory was intended to explain virtually all behaviors over which people have the ability to exert self-control. Factors that influence behavioral choices are mediated through the variable of behavioral intent. In order to maximize the predictive ability of an intention to perform a specific behavior, it is critical that measures of the intent closely reflect the measures of the behavior, corresponding in terms of action, target, context, and time. Behavioral intentions are influenced by the attitude about the likelihood that the behavior will have the expected outcome and the subjective evaluation of the risks and benefits of that outcome. The predictive power of the model depends significantly on the identification of most or all of the salient outcomes associated with a given behavior for any particular target population. Stages-of-Change Model/Transtheoretical Model Beginning with the first formulation of the HBM, Hochbaum (1958) assessed the “readiness” of adults to participate in screening. The inclusion of beliefs about susceptibility to illness and the personal benefits of screening was seen as an essential element in “readiness.” The concept

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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences was expanded into more elaborate models, such as the Transtheoretical Model (also known as the Stages-of-Change Model) first proposed by Prochaska and DiClemente (1983). This model characterizes the continuum of steps that people take toward change and includes the activities or processes to move people from one stage to another. The earliest stage of behavior change starts with moving from being uninterested, unaware, or unwilling to change (precontemplation) to considering a change (contemplation). This is followed by the decision to take action (preparation) and the first steps toward the behavioral change (action). With determined action, the requirement for maintenance and relapses are recognized as part of the process. In addition to these temporal stages, the Transtheoretical Model encompassed the concepts of decision criteria, self-efficacy, and change processes (consciousness-raising, relief from negative emotions associated with unhealthy behavior, self-reevaluation, environmental reevaluation, committing to change, seeking support, substituting healthier alternative behaviors, contingency management, stimulus control, and recognizing supportive social norms; Prochaska et al., 1997). The Transtheoretical Model has been influential in research on smoking and was recently extended to other health risk behaviors (Prochaska et al., 1994). The theoretical validity of the Stages-of-Change Model for behavior change is a matter of controversy (Budd and Rollnick, 1997; Sutton, 1996). Although early cross-sectional studies provided support for the theory (DiClemente et al., 1991; Fava et al., 1995), recent longitudinal studies did not support the Transtheoretical Model (Herzog et al., 1999; Sutton, 1996). Furthermore, multivariate analyses of several behavioral predictors demonstrate that the stages are weak predictors of cessation (Farkas et al., 1996; Pierce et al., 1998). Variables from cognitive social learning—such as outcome expectancy, self-efficacy, and behavioral self-control—appear to be better predictors of change than are the stages and associated processes (Bandura, 1997; Herzog et al., 1999). Despite questions about its theoretical validity, the model has contributed to the recognition that most potential recipients of health-related behavior change efforts are not motivated to change. Population surveys show 80% of the target group in the “precontemplation” or “contemplation” stages. That result draws attention to the potential of approaches that increase motivation for health promotion and illness prevention. The development of innovative motivational programs to encourage less interested people to consider healthier lifestyles represents

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