From the Publisher

This fourth edition of the classic book, Health Behavior and Health Education: Theory, Research, and Practice provides a comprehensive, highly accessible, and in-depth analysis of health behavior theories that are most relevant to health education. This essential resource includes the most current information on theory, research, and practice at individual, interpersonal, and community and group levels. This edition includes substantial new content on current and emerging theories of health communication, e-health, culturally diverse communities, health promotion, the impact of stress, the importance of networks and community, social marketing, and evaluation.

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Hoping to aid the health education community understand how theory informs research and practice and vice versa, Glanz (social and behavioral sciences, Cancer Research Center of Hawai'i at the U. of Hawai'i), Rimer (health behavior and health education, U. of North Carolina School of Public Health), and Lewis (nursing, U. of Washington) present 24 papers that look at the application of behavioral theory in a variety of settings. After defining key terms and concepts, four chapters focus on particular bodies of the theory: the health belief model, the theory of reasoned action and planned behavior, the transtheoretical model, and the precaution adoption process plan. Further chapters examine interpersonal theories; social cognitive theory, social networks, and social support; models for the community or aggregate levels of change; and finally, applications of overarching planning and process models. Annotation c. Book News, Inc., Portland, OR

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Offers current information on developments in health behavior theory, research, and practice, drawing on fields such as cognitive and organization psychology, marketing, and communications to explain diverse factors affecting health behavior and exploring the individual, interpersonal, and group or community levels. This revised edition includes information on making health behavior theory useful in populations with varied sociodemographic and cultural backgrounds. For graduate students and professionals in health promotion. Annotation c. by Book News, Inc., Portland, Or.

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Health Behavior and Health Education

John Wiley & Sons

Chapter One

The Editors

The range of health education and health behavior change strategies today is nearly limitless. Health professionals and health education specialists may counsel people at risk for AIDS about safe sex; help children avoid tobacco, alcohol, and drugs; help adults to stop smoking; help patients to manage and cope with their illnesses; and organize communities or advocate policy changes aimed at fostering health improvement. Health education professionals work all over the world in a variety of settings including schools, worksites, voluntary health organizations, medical settings, and communities. They are challenged to disseminate the best of what is known in new situations. They may also forge and test fundamental theories that drive research and practice in public health, health education, and health care. A premise of Health Behavior and Health Education is that a dynamic exchange between theory, research, and practice is most likely to produce effective health education.

Perhaps never before have those concerned with health behavior and health education been faced with more challenges and opportunities than they are today. Kanfer and Schefft (1988) observed that "as science and technology advance, the greatest mystery of the universe and the least conquered force of nature remains thehuman being and his actions and human experiences." The body of research in health behavior and health education has grown rapidly over the past two decades, and health education is recognized increasingly as a way to meet public health objectives and improve the success of public health and medical interventions. Although this increasing literature improves the science base of health behavior and health education, it also challenges those in the field to master and be facile with an almost overwhelming body of knowledge.

The science and art of health behavior and health education are eclectic, rapidly evolving, and reflective of an amalgamation of approaches, methods, and strategies from social and health sciences. They draw on the theoretical perspectives, research, and practice tools of such diverse disciplines as psychology, sociology, anthropology, communications, nursing, and marketing. Health education is also dependent on epidemiology, statistics, and medicine. There is increasing emphasis on identifying evidence-based interventions and disseminating them widely (Rimer, Glanz, and Rasband, 2001). This often requires individual health education and health behavior professionals to synthesize large and diverse literatures.

Many types of professionals contribute to and conduct health education and health behavior (HEHB) programs and research. Health education practice is strengthened by the close collaboration among professionals of different disciplines, each concerned with the behavioral and social intervention process, and each contributing a unique perspective. Psychology brings to health education a rich legacy of over a hundred years of research and practice on individual differences, motivation, learning, persuasion, and attitude and behavior change (Matarazzo, Weiss, Herd, Miller, and Weiss, 1984). Physicians are important collaborators and are in key positions to effect change in health behavior. Likewise, nurses and social workers bring to health education their particular expertise in working with individual patients and patients' families to facilitate learning, adjustment, and behavior change, and to improve quality of life. Other health, education, and human service professionals contribute their special expertise as well. Increasingly, there will be partnerships with genetic counselors and other specialists in this rapidly developing field.

Health, Disease, and Health Behavior: The Changing Context

The major causes of death in the United States and other developed countries are now chronic diseases, such as heart disease, cancer, and stroke (National Center for Health Statistics, 2000). Behavioral factors, particularly tobacco use, diet and activity patterns, alcohol consumption, sexual behavior, and avoidable injuries are among the most prominent contributors to mortality (McGinnis and Foege, 1993). The resurgence of infectious diseases, including foodborne illness and tuberculosis, and the emergence of new infectious diseases such as antibioticresistant infections, HIV/AIDS, Hepatitis C, and human papillomavirus (HPV) are also largely affected by human behaviors (Lederberg, Shope, and Oakes, 1992; Glanz and Yang, 1996). Substantial suffering, premature mortality, and medical costs can be avoided by positive changes in behavior. Most recently, there has been a renewed focus on public health as a result of anthrax exposure due to terrorism.

During the past twenty years, there has been a dramatic increase in public, private, and professional interest in preventing disability and death through changes in lifestyle and participation in screening programs. Much of this interest in disease prevention and early detection has been stimulated by the epidemiologic transition from infectious to chronic diseases as leading causes of death, the aging of the population, rapidly escalating health care costs, and data linking individual behaviors to increased risk of morbidity and mortality. More recent developments, such as the AIDS epidemic, have also contributed. Even as epidemiologists' efforts to better specify the links between diet, lifestyle, genetic predisposition, and environmental factors and disease approach the limits of science, they continue to generate headlines (Taubes, 1995) and influence public policy (Marshall, 1995).

Landmark reports in Canada and the United States during the 1970s and 1980s heralded the commitment of governments to health education and promotion (Lalonde, 1974; U.S. Department of Health, Education, and Welfare, 1979; Epp, 1986). In the United States, federal initiatives for public health education and monitoring populationwide behavior patterns were spurred by the development of the health objectives published in Promoting Health and Preventing Disease: Health Objectives for the Nation (U.S. Department of Health and Human Services, 1980) and their successors, outlined in Healthy People 2000: National Health Promotion and Disease Prevention Objectives and Healthy People 2010 (U.S. Department of Health and Human Services, 1991 and 2000). Increased interest in behavioral and social determinants of health behavior change spawned numerous training programs and public and commercial service programs.

Data systems now make it possible to track trends in risk factors, health behaviors, and healthy environments and policies in the United States and, in some cases, to tie these changes to disease incidence and mortality. Indeed, there have been positive changes in several areas. A major accomplishment has been surpassing the targets for reducing deaths from coronary heart disease and cancer (National Center for Health Statistics, 2001). Blood pressure control has improved and mean population blood cholesterol levels have declined. Alcohol-related motor vehicle deaths and deaths due to automobile crashes and drowning have continued to decrease. Fewer adults are using tobacco products, and more are engaging in moderate physical activity. More adults are meeting dietary guidelines for consumption of fruits, vegetables, and grain products and for dietary fat as a percentage of calories (National Center for Health Statistics, 2001). Rates of HIV/AIDS have leveled off and transfusion-related HIV infections have decreased markedly. The proportion of women age fifty and older who have had breast examinations and mammograms has exceeded the goal of 60 percent in forty-seven states. The United States has made progress toward the goal of reducing health disparities for more than half the objectives identified in Healthy People 2000 (National Center for Health Statistics, 2001). Major litigation against the tobacco industry and a multistate settlement have resulted in increased restrictions on tobacco advertising and enforcement of laws against selling tobacco to minors. The collective efforts of those in health education and public health have indeed made a difference. While this progress is encouraging, much work remains to be done in these areas.

Not all the news is favorable, though. More adults and children are overweight. Diabetes is increasing in near-epidemic proportions. More adolescents are sexually active. After major increases in seatbelt use in the early 1990s, rates have declined slightly and remain at 67 percent, well below the target rate of 85 percent (National Center for Health Statistics, 2001). One-fifth of children under three years old have not received a basic series of vaccinations for polio, measles, diphtheria, and other diseases. Sixteen percent of adults under sixty-five years of age have no health insurance coverage. More than 70 percent of adults over age fifty have not been screened for colorectal cancer (National Center for Health Statistics, 2001). Ethnic minorities and those in poverty still experience a disproportionate burden of preventable disease and disability, and for many conditions the gap between disadvantaged and affluent groups is widening (House and Williams, 2000).

Changes in the health care system provide new supports and opportunities for health education. Respect for patients' rights is now recognized as fundamental to the practice of medicine (Levinsky, 1996). Moreover, there is increased attention to issues of shared decision making (Edwards and Elwyn, 1999). At the same time, patients' access to information about their health care institutions and providers remains limited. Insurance carriers and managed care systems can impose barriers that impede patients' exercise of their rights to make treatment decisions (Weston and Lauria, 1996; Levinsky, 1996). The advent of managed health care and health care financing reform pose new challenges as the drive for cost containment affects the entire health care system. While increased accountability often results in cost savings and fewer unnecessary services, little is known about its effects on the health of patients and the overall quality of care (Iglehart, 1996). Clinical prevention and behavioral interventions may grow in importance under managed care when their cost-effectiveness is demonstrated and recognized (Center for the Advancement of Health, 2000; Rimer, Glanz, and Rasband, 2001), but the climate of fiscal constraint will probably slow adoption of efficacious behavioral strategies in the short run.

The rapid emergence of new communication technologies and new uses of older technologies, such as the telephone, also provide new opportunities and dilemmas. A new chapter has been added to Health Behavior and Health Education to reflect the importance of new communication technologies (see Chapter Twenty- Two). A variety of electronic media for interactive health communication (for example, the internet, CD-ROMs, personal digital assistants) can serve as sources of both general and individualized health information, reminders, and social support for health behavior change.

Since the last edition of this book, use of the Internet has grown dramatically. E-health strategies are becoming an important part of the armamentarium of strategies for those in health education and health behavior. Internet and computer-based applications can support many of the strategies that evolve naturally from the theories presented in this book. It is important that use of the new technologies be based and evaluated on theories of health behavior. Otherwise, we risk being technology driven instead of outcomes driven.

New technologies have the potential to cause harm through misleading or deceptive information, promotion of inappropriate self-care, and interference in the patient-provider relationship (Science Panel on Interactive Communication and Health, 1999). Interactive health communications provide new options for behavioral medicine and preventive medicine (Noell and Glasgow, 1999; Fotheringham, Owies, Leslie, and Owen, 2000) and are altering the context of health behavior and health education as they unfold and as their effects are studied.

Health Education and Health Behavior

The Scope and Evolution of Health Education

In the fields of health education and health behavior, the emphasis during the 1970s and 1980s on individuals' behaviors as determinants of health status eclipsed attention to the broader social determinants of health. Advocates of system-level changes to improve health called for renewal of a broad vision of health education and promotion (Minkler, 1989; see Chapter Twenty). These calls for moving health education toward social action heralded a renewed enthusiasm for holistic approaches rather than an entirely new worldview. They are well within the tradition of health education and are consistent with its long-standing concern with the impact of social, economic, and political forces on health.

Over the past fifty years, outstanding leaders in health education repeatedly stressed the importance of political, economic, and social factors as determinants of health. Mayhew Derryberry (1960) noted that "health education ... requires careful and thorough consideration of the present knowledge, attitudes, goals, perceptions, social status, power structure, cultural traditions, and other aspects of whatever public is to be addressed." In 1966, Dorothy Nyswander spoke of the importance of attending to social justice and individuals' sense of control and self-determination (Nyswander, 1966). These ideas were reiterated later when William Griffiths (1972) stressed that "health education is concerned not only with individuals and their families, but also with the institutions and social conditions that impede or facilitate individuals toward achieving optimum health" (emphasis added).

The view of health education as an instrument of social change has been renewed and invigorated during the past decade. Policy, advocacy, and organizational change have been adopted as central activities of public health and health education. Most recently, experts have explicitly recommended that interventions on social and behavioral factors related to health should link multiple levels of in- fluence, including the individual, interpersonal, institutional, community, and policy levels (Smedley and Syme, 2000). This volume purposefully includes chapters on community and societal influences on health behavior and strategies to effect community and social policy changes. In this context, definitions of health education and health promotion can be recognized and discussed as overlapping and intertwined.

Continues...

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