Dietary Guidelines for Americans Discussion

Read the attached files and answer the questions below (150-200 words for each answer):

• Dietary Guidelines for Americans 2015-2020 https://health.gov/dietaryguidelines/2015/guidelines/executive-summaryLinks to an external site.
• Glanz Book on Behavior Change Theory – Chapter 20 (by Sallis et al.)Glanz Book on Theory.pdf (attached)

1. Address all of these parts in your post: what elements of an ecological approach to behavior change strike you as the most important and why? How has your life been personally impacted by an ecological (multi-level) intervention targeting a specific behavior? Name the behavior and describe at least 2 levels of impact.

2. What did you learn about the physical activity guidelines and dietary guidelines so far that surprised you and why? Describe the role you see both sets of guidelines having in the health care sector.

Glanz.ffirs
7/2/08
11:22 AM
Page iii
HEALTH
BEHAVIOR
AND
HEALTH
EDUCATION
Theory, Research,
and Practice
4TH EDITION
KAREN GLANZ
BARBARA K. RIMER
K. VISWANATH
Editors
Foreword by C. Tracy Orleans
Glanz.ffirs
7/2/08
11:22 AM
Page ii
Glanz.ffirs
7/2/08
11:22 AM
Page i
HEALTH
BEHAVIOR
AND
HEALTH
EDUCATION
Glanz.ffirs
7/2/08
11:22 AM
Page ii
Glanz.ffirs
7/2/08
11:22 AM
Page iii
HEALTH
BEHAVIOR
AND
HEALTH
EDUCATION
Theory, Research,
and Practice
4TH EDITION
KAREN GLANZ
BARBARA K. RIMER
K. VISWANATH
Editors
Foreword by C. Tracy Orleans
Glanz.ffirs
7/2/08
11:22 AM
Page iv
Copyright © 2008 by John Wiley & Sons, Inc. All rights reserved.
Published by Jossey-Bass
A Wiley Imprint
989 Market Street, San Francisco, CA 94103-1741—www.josseybass.com
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as
permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior
written permission of the publisher, or authorization through payment of the appropriate per-copy fee
to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400,
fax 978-646-8600, or on the Web at www.copyright.com. Requests to the publisher for permission
should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street,
Hoboken, NJ 07030, 201-748-6011, fax 201-748-6008, or online at www. wiley.com/go/permissions.
Readers should be aware that Internet Web sites offered as citations and/or sources for further information may have changed or disappeared between the time this was written and when it is read. Limit
of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in
preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifi cally disclaim any implied warranties of merchantability or fi tness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for
your situation. You should consult with a professional where appropriate. Neither the publisher nor
author shall be liable for any loss of profi t or any other commercial damages, including but not limited
to special, incidental, consequential, or other damages.
Jossey-Bass books and products are available through most bookstores. To contact Jossey-Bass
directly call our Customer Care Department within the U.S. at 800-956-7739, outside the U.S. at
317-572-3986, or fax 317-572-4002. Jossey-Bass also publishes its books in a variety of electronic
formats. Some content that appears in print may not be available in electronic books.
Library of Congress Cataloging-in-Publication Data
Health behavior and health education : theory, research, and practice / Karen Glanz, Barbara K.
Rimer, and K. Viswanath, editors. — 4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-7879-9614-7 (cloth)
1. Health behavior. 2. Health education. 3. Health promotion. I. Glanz, Karen. II. Rimer, Barbara K.
III. Viswanath, K. (Kasisomayajula)
[DNLM: 1. Health Behavior. 2. Health Education. W 85 H43415 2008]
RA776.9.H434 2008
613—dc22
2008021038
Printed in the United States of America
FOURTH EDITION
HB Printing 10 9 8 7 6 5 4 3 2 1
Glanz.ftoc
7/2/08
11:23 AM
Page v
CONTENTS
Foreword
C. Tracy Orleans
xiii
Tables and Figures
Preface
The Editors
The Contributors
xvii
xxi
xxvii
xxxi
PART ONE: HEALTH EDUCATION AND
HEALTH BEHAVIOR: THE FOUNDATIONS
ONE: THE SCOPE OF HEALTH BEHAVIOR
AND HEALTH EDUCATION
The Editors
Key Points
The Changing Context of Health Behavior
Health Education and Health Behavior in Context
Settings and Audiences for Health Education
Progress in Health Promotion and Health Behavior Research
Summary
TWO: THEORY, RESEARCH, AND PRACTICE
IN HEALTH BEHAVIOR AND HEALTH EDUCATION
The Editors
Key Points
Theory, Research, and Practice: Interrelations
What Is Theory?
Paradigms for Theory and Research in Health Promotion and Education
Trends in Use of Health Behavior Theories and Models
Selection of Theories for This Book
Fitting a Theory or Theories to Research and Practice
Limitations of This Book
Summary
1
3
3
6
9
12
16
18
23
23
24
26
29
31
33
35
37
38
Glanz.ftoc
7/2/08
vi
11:23 AM
Page vi
Contents
PART TWO: MODELS OF INDIVIDUAL HEALTH BEHAVIOR
41
Barbara K. Rimer
THREE: THE HEALTH BELIEF MODEL
Victoria L. Champion and Celette Sugg Skinner
Key Points
Origins of the Model
Description of HBM and Key Constructs
Evidence for the Model’s Performance
Measurement of HBM Constructs
Applications of the HBM to Mammography
and AIDS-Related Behaviors
Comparison of HBM to Other Theories
Challenges in Future HBM Research
Summary
FOUR: THEORY OF REASONED ACTION, THEORY OF PLANNED
BEHAVIOR, AND THE INTEGRATED BEHAVIORAL MODEL
Daniel E. Montaño and Danuta Kasprzyk
Key Points
Origins and Historical Development
Theory of Reasoned Action and Theory of Planned Behavior
An Integrated Behavioral Model
Elicitation
Application of IBM to HIV Prevention in Zimbabwe
Summary
FIVE: THE TRANSTHEORETICAL MODEL
AND STAGES OF CHANGE
James O. Prochaska, Colleen A. Redding, and Kerry E. Evers
Key Points
Core Constructs
Applications of the Transtheoretical Model
Multiple-Behavior Change Programs
Limitations of the Model
Future Research
Summary
45
45
46
46
50
51
53
60
61
62
67
67
68
70
77
82
82
92
97
97
98
108
114
116
116
117
Glanz.ftoc
7/2/08
11:23 AM
Page vii
Contents
vii
SIX: THE PRECAUTION ADOPTION PROCESS MODEL
123
Neil D. Weinstein, Peter M. Sandman, and Susan J. Blalock
Key Points
123
How Stage Theories Address Explaining and Changing Behavior
124
The Precaution Adoption Process Model
126
Using the PAPM to Develop and Evaluate Behavior Change Interventions 131
How Stage Theories Can Be Tested
134
An Example Using Matched and Mismatched Treatments
134
Review of Research Using the PAPM
140
Criteria for Applying Stage-Based Interventions
143
Future Directions
145
Summary
145
SEVEN: PERSPECTIVES ON HEALTH BEHAVIOR
THEORIES THAT FOCUS ON INDIVIDUALS
Noel T. Brewer and Barbara K. Rimer
Key Points
Why Theory Is Needed
How to Decide Which Theory to Use
A Closer Look at Individual-Level Theories
Commonalities and Differences Across the Theories
New Constructs and Theories
Summary
PART THREE: MODELS OF INTERPERSONAL
HEALTH BEHAVIOR
EIGHT: HOW INDIVIDUALS, ENVIRONMENTS, AND HEALTH
BEHAVIORS INTERACT: SOCIAL COGNITIVE THEORY
Alfred L. McAlister, Cheryl L. Perry, and Guy S. Parcel
Key Points
Concepts of SCT
Applications to Health Promotion
Case Studies
New Applications
Limitations in Research on New SCT Applications
Summary
149
149
150
151
152
157
160
162
167
169
169
170
175
178
182
184
185
Glanz.ftoc
7/2/08
viii
11:23 AM
Page viii
Contents
NINE: SOCIAL NETWORKS AND SOCIAL SUPPORT
Catherine A. Heaney and Barbara A. Israel
Key Points
Definitions and Terminology
Background of the Concepts
Relationship of Social Networks and Social Support to Health
Empirical Evidence on the Influence of Social Relationships
Translating Theory and Research into Practice
Social Network and Social Support Interventions
Health Education and Health Behavior Applications
Future Directions for Research and Practice
Summary
189
TEN: STRESS, COPING, AND HEALTH BEHAVIOR
Karen Glanz and Marc D. Schwartz
Key Points
Historical Concepts of Health, Stress, and Coping
The Transactional Model of Stress and Coping: Overview,
Key Constructs, and Empirical Support
Theoretical Extensions
Applications to Specific Health Behavior Research Areas
Research Gaps and Future Directions
Summary
211
ELEVEN: KEY INTERPERSONAL FUNCTIONS AND HEALTH
OUTCOMES: LESSONS FROM THEORY AND RESEARCH ON
CLINICIAN-PATIENT COMMUNICATION
Richard L. Street Jr. and Ronald M. Epstein
Key Points
Communication Between Health Care Providers and Patients:
Historical Perspective
Pathways Between Clinician-Patient Communication
and Health Outcomes
Key Functions of Clinician-Patient Communication
Moderators of Communication-Outcome Relationships
Clinician-Patient Communication: Application in
Health Education and Health Behavior
Directions for Future Research
Summary
189
189
192
193
195
197
199
203
206
207
211
212
213
220
226
229
230
237
237
239
239
245
255
261
263
Glanz.ftoc
7/2/08
11:23 AM
Page ix
Contents
TWELVE: PERSPECTIVES ON MODELS OF
INTERPERSONAL HEALTH BEHAVIOR
K. Viswanath
Key Points
Some Defining Characteristics of Interpersonal Interaction
Theories and Models at the Interpersonal Level
Summary and Future Directions
PART FOUR: COMMUNITY AND GROUP MODELS
OF HEALTH BEHAVIOR CHANGE
ix
271
271
272
273
279
283
Karen Glanz
THIRTEEN: IMPROVING HEALTH THROUGH COMMUNITY
ORGANIZATION AND COMMUNITY BUILDING
Meredith Minkler, Nina Wallerstein, and Nance Wilson
Key Points
Historical Perspective
The Concept of Community
Models of Community Organization
Concepts in Community Organization and Community-Building Practice
Community Capacity and Social Capital
Issue Selection, Participation, and Relevance
Measurement and Evaluation Issues
Application of Community Organization and Community Building
Community Organizing and Community Building with Youth:
Challenges and Considerations
The Challenge of Community Organization Approaches
Summary
FOURTEEN: DIFFUSION OF INNOVATIONS
Brian Oldenburg and Karen Glanz
Key Points
Development of the Field and Related Research Traditions
Key Concepts
Important Factors in the Diffusion Process
The Role of Settings and Organizations in Diffusion
of Health Behavior Innovations
The Practice of Dissemination and Diffusion of Health
Behavior Interventions
287
287
288
290
291
293
295
296
298
300
307
308
309
313
313
314
317
319
321
322
Glanz.ftoc
7/2/08
x
11:23 AM
Page x
Contents
Applications
Limitations of the Model and Challenges for the Future
Summary
FIFTEEN: MOBILIZING ORGANIZATIONS FOR HEALTH
PROMOTION: THEORIES OF ORGANIZATIONAL CHANGE
Frances Dunn Butterfoss, Michelle C. Kegler, and Vincent T. Francisco
Key Points
Introduction to Theories of Organizational Change
Change Within Organizations
Organizational Development Theory
Change Across Organizations
Applications of Organizational Theory to Health Promotion
Future Research to Inform Organizational Change Theories
Summary
SIXTEEN: COMMUNICATION THEORY AND HEALTH
BEHAVIOR CHANGE: THE MEDIA STUDIES FRAMEWORK
John R. Finnegan Jr. and K. Viswanath
Key Points
Organization of Communication Studies
Message Production and Media Effects
Major Models and Hypotheses at the Individual Level
Theories at the Macro Level
Planned Use of Media
Future Directions
Summary
SEVENTEEN: PERSPECTIVES ON GROUP, ORGANIZATION,
AND COMMUNITY INTERVENTIONS
Michelle C. Kegler and Karen Glanz
Key Points
New Concepts and Strategies for Macro-Level Change
Multiple Levels of Influence and Action
Models for Change
Approaches to Defining Needs, Problems, and Aims
The Influence of Technology on Macro-Level Theory and Practice
Similarities Between Models
Research Issues
Summary
323
328
330
335
335
336
338
341
345
350
355
357
363
363
364
365
367
371
379
382
384
389
389
390
391
392
395
396
397
399
400
Glanz.ftoc
7/2/08
11:23 AM
Page xi
Contents
PART FIVE: USING THEORY IN RESEARCH AND PRACTICE
EIGHTEEN: USING THE PRECEDE-PROCEED MODEL
TO APPLY HEALTH BEHAVIOR THEORIES
Andrea Carson Gielen, Eileen M. McDonald,
Tiffany L. Gary, and Lee R. Bone
Key Points
Overview of the PRECEDE-PROCEED Model
Issues to Consider in Using PRECEDE-PROCEED
Case Study: The SAFE Home Project
Case Study: Project Sugar 1
Summary
xi
405
407
408
408
417
418
424
429
NINETEEN: SOCIAL MARKETING
J. Douglas Storey, Gary B. Saffitz, and Jose G. Rimón
Key Points
Definition of Social Marketing
Basic Principles of Social Marketing
The Role of Social Marketing Within a Strategic
Communication Framework
The Role of Theory and Research in Social Marketing
International and Domestic (U.S.) Social Marketing Experiences
Summary
435
TWENTY: ECOLOGICAL MODELS OF HEALTH BEHAVIOR
James F. Sallis, Neville Owen, and Edwin B. Fisher
Key Points
Background, History, and Principles of Ecological Models
Application of Ecological Models to Health Behavior
Critical Examination of Ecological Models of Health Behavior
Summary
465
TWENTY-ONE: EVALUATION OF
THEORY-BASED INTERVENTIONS
Russell E. Glasgow and Laura A. Linnan
Key Points
Benefits and Challenges of Evaluating Theory-Based Interventions
Types of Evaluation
Phases of Research
435
436
439
444
448
452
461
465
466
470
479
482
487
487
487
489
490
Glanz.ftoc
7/2/08
xii
11:23 AM
Page xii
Contents
Types of Validity
Intervention Contexts and Intermediate Outcomes
Evaluation Models
The RE-AIM Framework
Evaluation Methods and Analytical Strategies for
Theory-Based Interventions
Cost Issues
Examples of Evaluating Theory-Based Interventions
Challenges to Conducting and Evaluating Theory-Based
Health Behavior Research in Applied Settings
Summary
TWENTY-TWO: PERSPECTIVES ON USING THEORY:
PAST, PRESENT, AND FUTURE
Karen Glanz and Barbara K. Rimer
Key Points
Cross-Cutting Propositions About Using Theory
The PRECEDE-PROCEED Planning Model
Social Marketing
Ecological Models
Evaluation of Theory-Based Health Behavior Interventions
Moving Forward
Name Index
Subject Index
492
493
495
496
498
499
499
503
505
509
509
510
512
513
514
515
516
519
533
Glanz.fbetw
7/2/08
11:21 AM
Page xiii
FOREWORD
C. Tracy Orleans, Ph.D.
Health behavior change is our greatest hope for reducing the burden of preventable
disease and death around the world. Tobacco use, sedentary lifestyle, unhealthy diet,
and alcohol use together account for almost one million deaths each year in the United
States alone. Smoking prevalence in the United States has dropped by half since the
first Surgeon General’s Report on Smoking and Health was published in 1964, but tobacco use still causes over 400,000 premature deaths each year. The World Health Organization has warned that the worldwide spread of the tobacco epidemic could claim
one billion lives by the end of this century. The rising prevalence of childhood obesity could place the United States at risk of raising the first generation of children to
live sicker and die younger than their parents, and the spreading epidemic of obesity
among children and adults threatens staggering global health and economic tolls.
The four leading behavioral risks factors and a great many others (for example,
nonadherence to prescribed medical screening and prevention and disease management practices, risky sexual practices, drug use, family and gun violence, worksite
and motor vehicle injuries) take disproportionate tolls in low-income and disadvantaged racial and ethnic populations, as well as in low-resource communities across
the world. Addressing these behavioral risks and disparities, and the behaviors related to global health threats, such as flu pandemics, water shortages, increasingly
harmful sun exposure, and the need to protect the health of the planet itself, will be
critical to world health in the twenty-first century.
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
extraordinary growth in our knowledge about interventions needed to change health
behaviors at both individual and population levels. This progress can be measured in
the proliferation of science-based recommendations issued by authoritative evidence
review panels, including the U.S. Clinical Preventive Services Task Force, the Centers for Disease Prevention and Control Task Force on Community Preventive Services, and the international Cochrane Collaboration. Today, there are evidence-based
clinical practice guidelines for most major behavioral health risks, including tobacco use, unhealthy diet, sedentary lifestyle, risky drinking, and diabetes management. And there are parallel research-based guidelines for the health care system
changes and policies needed to assure their delivery and use. New community practice guidelines offer additional evidence-based recommendations for a wide array of
population-level school-, worksite-, and community-based programs and public policies to improve vaccination rates and physical activity levels for children and adults,
improve diabetes self-management, reduce harmful sun exposure, reduce secondhand
Glanz.fbetw
7/2/08
xiv
11:21 AM
Page xiv
Foreword
smoke exposure, prevent youth tobacco use and help adult smokers quit, reduce workplace and motor vehicle injuries, and curb drunk driving and family and gun violence.
Another success of the past two decades of theory-based research can be seen in
the evolution of theories and models themselves—a move away from a major focus
only on individual behavior change and toward broader multi-level behavior and social change models. By the late 1980s, the limited reach and staying power of even
our most effective individual health behavior interventions, based on theories emphasizing intrapersonal and interpersonal determinants of health behaviors, made it clear
that an exclusive reliance on individually oriented interventions would be inadequate
to achieve our pressing population health and health care goals. These failures led
to a fundamental “paradigm shift” in our understanding of what the targets of effective interventions needed to be, not just individuals but the broader contexts in which
they live and work. This shift fueled the rise of ecological models of health promotion that have guided the development of powerful interventions in public health and
health care arenas.
Related shifts in the models and strategies of public health and clinical health
promotion opened the way for even broader population models that link health plans
and community public health organizations, communities, clinicians, and public health
practitioners. Examples are the Chronic Care Model promulgated by the Institute of
Medicine and the similar framework promoted by the World Health Organization.
And these frameworks energized efforts to refine and apply models and theories to
translate effective clinical and public health interventions into practice and policy,
including the diffusion of innovations model, community and organizational change
theories, and social marketing and communications theories.
Tremendous parallel gains in what we have learned about the paradigms, processes,
methods, and limitations of public health promotion and health care quality improvement over the past two decades illustrate the fundamental premise of this and previous editions of Health Behavior and Health Education—that a dynamic exchange
between theory, research, and practice is critical to effective health education and
promotion. Just as previous editions of Health Behavior and Health Education have
provided essential stewardship for many of the advances described here, this fourth
edition will help us navigate the new frontiers and challenges that lie ahead.
As this volume makes clear, using theory to craft and evaluate health behavior
change interventions results in more powerful interventions and more robust theories. Like the previous editions, it presents in one place authoritative and highly readable summaries and critiques of the major theories and models of health education at
multiple levels (individual, interpersonal, organizational, community, public policy)
and in a wide variety of settings and populations. Thorough analyses of their strengths
and weaknesses and helpful summaries of how their major constructs have been measured and operationalized—illustrated with clear practical applications and case studies—are features of the book designed to be helpful for researchers, practitioners,
and program planners at all levels of experience, from those new to the field to its
most seasoned leaders. The rigor and accessibility of these reviews reflect the extraordinary knowledge and vision of the editors and authors, who include many of the most
Glanz.fbetw
7/2/08
11:21 AM
Page xv
Foreword
xv
respected and accomplished leaders in the field of health education and health behavior; together, they bring exceptional skill and experience in planning, implementing, and evaluating theory-based interventions for a diverse range of problems, settings,
and populations.
In addition to describing important developments in theory and practice since the
previous edition, this volume gives special attention to cultural and health disparities, global applications, and advances in health communications and e-health. It also
prepares us for the urgent need to identify, extract, and replicate the critical “active”
ingredients of effective interventions through theory-driven reviews and syntheses of
past trials and studies, as well as formative early assessments of promising innovations and rigorous theory-based studies of “natural experiments.” Theory is the essential “divining rod” in new efforts to learn rapidly about “what works” by evaluating
grassroots efforts in schools and communities across the country and the world to implement programs, policies, and environmental changes to curb the rise in childhood
obesity. For example, logic models that reflect lay conceptions of how programs can
work are helping the Robert Wood Johnson Foundation to identify early on the more
and less promising strategies being tried for obesity prevention. The strategies that
align best with theory are often the most promising. This type of practical application of theory makes clear that, in the broadest sense, health education and health behavior encompass the processes of policy development, which are so critical to
understanding and overcoming policy resistance to dissemination of the growing number of evidence-based interventions.
In short, readers will find that the fourth edition of Health Education and Health
Behavior retains and builds on all of the features that have established it as the preeminent text and indispensable reference for our field—the first book we reach for to
help us think about the foundations on which to design an intervention or research
plan, inform a systematic evidence review, write or review an article or grant application, plan a course or presentation, and consult with other practitioners or researchers
both within and outside our own disciplines.
As the editors state in Chapter Two, “the gift of theory” is that it provides the essential conceptual underpinnings for well-crafted research, effective practice, and
healthy public policy. The gift of this volume is that it provides essential guidance
for our efforts to realize the full potential of theory, as we build on our remarkable
past progress in navigating the new frontiers and challenges that lie ahead.
February 2008
C. Tracy Orleans
Distinguished Fellow and Senior Scientist
Robert Wood Johnson Foundation
Princeton, New Jersey
Glanz.fbetw
7/2/08
11:21 AM
Page xvi
In memory of my brother, David Glanz,
who contributed so much and so well to
his family, in his scholarship and
to the lives of older adults.
—K. G.
To my husband, Bernard Glassman, my parents,
Joan and Irving, and my sisters, Liz and Sara,
with gratitude for their unflagging support.
—B.K.R.
To my parents, whose life of hard work
and sacrifice allowed their children to
succeed in their endeavors.
—K. V.
Glanz.fbetw
7/2/08
11:21 AM
Page xvii
TABLES AND FIGURES
TABLES
Table 2.1
Definitions of Theory
27
Table 2.2
Trends in the Most Commonly Used Health Behavior
Theories and Models
32
Table 3.1
Key Concepts and Definitions of the Health Belief Model
48
Table 3.2
Cronbach’s Alpha of Champion’s HBM Scales
Translated into Four Cultures
52
Learning Objectives Used to Change Mammography
Perceptions and Practices Among Urban Minority Women
55
Table 4.1
TRA, TPB, and IBM Constructs and Definitions
74
Table 4.2
Table of Elicitation Questions
83
Table 4.3
Strength of Association of Behavioral, Normative,
and Efficacy Beliefs with Intention to Use Condoms
with Steady Partners
86
Table 5.1
Transtheoretical Model Constructs
98
Table 5.2
Processes of Change That Mediate Progression
Between the Stages of Change
105
Examples of Factors Likely to Determine Progress
Between Stages
129
Precaution Adoption Process Model: Stage Classification
Algorithm
136
Progressed One or More Stage Toward Purchasing
a Radon Test (percentage)
137
Table 6.4
Radon Test Orders (percentage)
137
Table 8.1
Social Cognitive Theory Concepts
171
Table 8.2
Methods for Increasing Self-Efficacy
177
Table 9.1
Characteristics and Functions of Social Networks
191
Table 9.2
Typology of Social Network Interventions
200
Table 10.1
Transactional Model of Stress and Coping
214
Table 11.1
Representative Models of Patient-Centered
Communication Functions
241
Table 3.3
Table 6.1
Table 6.2
Table 6.3
Glanz.fbetw
7/2/08
11:21 AM
xviii
Tables and Figures
Table 11.2
Page xviii
Representative Measures and Coding Systems of
Patient-Centered Communication Functions
246
Key Concepts in Community Organization and
Community Building
294
Table 13.2
Examples of YES! Group Social Action Projects
306
Table 14.1
Key Concepts and Stages of Diffusion
317
Table 14.2
Characteristics of Innovations That Affect Diffusion
319
Table 15.1
Organizational Change: Stage Theory
340
Table 15.2
Summary of Organizational Change Concepts
342
Table 15.3
Constructs of the Community Coalition Action Theory
349
Table 16.1
Selected Communication Theories and Levels of Analysis
368
Table 16.2
Knowledge Gap Concepts, Definitions, Applications
372
Table 16.3
Agenda-Setting Concepts, Definitions, Applications
376
Table 18.1
PRECEDE-PROCEED Model as an Organizing
Framework for Application of Theory and Principles
413
Table 18.2
Main Results of Project Sugar 1 Interventions
428
Table 19.1
Comparisons Between Social Marketing, Commercial
Marketing, and Health Education
437
Applications of Major Theories and Research
in Social Marketing
449
Table 20.1
Historical and Contemporary Ecological Models
468
Table 21.1
Model of Phases of Research (Greenwald and Cullen, 1985)
491
Table 21.2
RE-AIM Dimensions and Questions in Evaluating
Health Education and Health Behavior Programs
496
Common Challenges Encountered in Evaluating
Health Behavior Interventions
504
Figure 3.1
Key Concepts and Definitions of the Health Belief Model
49
Figure 4.1
Theory of Reasoned Action and Theory of Planned Behavior
70
Figure 4.2
Integrated Behavior Model
77
Figure 5.1
Point Prevalence Abstinence Rates Over Time
for Smokers Recruited by Reactive Versus Proactive
Strategies and Treated with TTM-Tailored
Home-Based Expert System Interventions
113
Table 13.1
Table 19.2
Table 21.3
FIGURES
Glanz.fbetw
7/2/08
11:21 AM
Page xix
Tables and Figures
xix
Figure 6.1
Stages of the Precaution Adoption Process Model
127
Figure 6.2
Two Examples of the Stages of the Precaution
Adoption Process Model: Home Radon Testing and
Taking Calcium to Prevent Osteoporosis
127
AIDS Community Demonstration Projects: Exposure
and Behavior Change in Carrying Condoms
182
Conceptual Model for the Relationship of Social
Networks and Social Support to Health
194
Figure 10.1
Transactional Model of Stress and Coping
216
Figure 11.1
Direct and Indirect Pathways from Communication
to Health Outcomes
240
Examples of Potential Moderators of Clinician-Patient
Communications
256
Community Organization and Community-Building
Typology
293
Figure 13.2
Conceptual Risk Model
302
Figure 13.3
YES! Intervention Model
303
Figure 15.1
Community Coalition Action Theory (CCAT)
348
Figure 18.1
PRECEDE-PROCEED Planning Model
410
Figure 18.2
Application of PRECEDE-PROCEED to Injury Prevention
419
Figure 18.3
Safe Home Case Study Design and Results
423
Figure 18.4
Application of PRECEDE-PROCEED to Diabetes Care
and Self-Management Interventions
425
Figure 19.1
The Blue Circle (Indonesia)
446
Figure 19.2
Communication for Healthy Living (Egypt)
455
Figure 19.3
Red Ribbon Question Mark Campaign (Baltimore, Md.)
460
Figure 20.1
Ecological Model of Four Domains of Active Living
472
Figure 20.2
Illustrative Model of Relationships among Organizational
Factors and Supports for Diabetes Self-Management
477
Figure 21.1
BEAUTY Conceptual Model
489
Figure 21.2
Hypothetical Worksite Intervention Participation
Flow Diagram
494
Figure 8.1
Figure 9.1
Figure 11.2
Figure 13.1
Glanz.fbetw
7/2/08
11:21 AM
Page xx
Glanz.fpref
7/2/08
11:23 AM
Page xxi
PREFACE
The Editors
Programs to influence health behavior, including health promotion and education programs and interventions, are most likely to benefit participants and communities when
the program or intervention is guided by a theory of health behavior. Theories of
health behavior identify the targets for change and the methods for accomplishing
these changes. Theories also inform the evaluation of change efforts by helping to
identify the outcomes to be measured, as well as the timing and methods of study to
be used. Such theory-driven health promotion and education efforts stand in contrast
to programs based primarily on precedent, tradition, intuition, or general principles.
Theory-driven health behavior change interventions and programs require an understanding of the components of health behavior theory, as well as the operational
or practical forms of the theory. The first edition of Health Behavior and Health
Education: Theory, Research, and Practice, published in 1990, was the first text to
provide an in-depth analysis of a variety of theories of health behavior relevant to
health education in a single volume. It brought together dominant health behavior
theories, research based on those theories, and examples of health education practice
derived from theory that had been tested through evaluation and research. The second (1996) and third (2002) editions of Health Behavior and Health Education updated and improved on the earlier volume. People around the world are using this
book, and it has been translated into multiple languages, including recent Japanese
and Korean editions.
It has been over five years since the release of the third edition; the fourth edition of Health Behavior and Health Education once again updates and improves on
the preceding edition. Its main purpose is the same: to advance the science and
practice of health behavior and health education through the informed application of
theories of health behavior. Likewise, this book serves as the definitive text for students, practitioners, and scientists in these areas and education in three ways: by (1)
analyzing the key components of theories of health behavior that are relevant to health
education, (2) evaluating current applications of these theories in selected health promotion programs and interventions, and (3) identifying important future directions
for research and practice in health promotion and health education.
The fourth edition responds to new developments in health behavior theory and
the application of theory in new settings, to new populations, and in new ways. This
edition includes (1) an enhanced focus on the application of theories in diverse populations and settings, (2) an expanded section on using theory, including its translation for program planning, and (3) chapters on additional theories of health behavior.
Glanz.fpref
7/2/08
xxii
11:23 AM
Page xxii
Preface
More global applications from both developing and developed countries are included.
As new communication and information technologies have opened up an unprecedented range of strategies for health behavior change, this edition integrates coverage
of e-health into health communications examples throughout the book. Issues of culture and health disparities are also integrated into many chapters, rather than covered
as a separate chapter. These issues are of broad and growing importance across many
theories and models.
AUDIENCE
Health Behavior and Health Education speaks to graduate students, practitioners,
and scientists who spend part or all of their time in the broad arenas of health behavior change, health promotion, and health education; the text will help them both understand the theories and apply them in practical settings. Practitioners, as well as
students, will find this text a major reference for the development and evaluation of
theory-driven health promotion and education programs and interventions. Researchers
should emerge with a recognition of areas in which empirical support is deficient and
theory testing is required, thus helping to set the research agenda for health behavior and health education.
This book is intended to assist all professionals who value the need to influence
health behavior positively. Their fields include health promotion and education, medicine, nursing, health psychology, behavioral medicine, health communications, nutrition and dietetics, dentistry, pharmacy, social work, exercise science, clinical
psychology, and occupational and physical therapy.
OVERVIEW OF THE BOOK
The authors of this text bring to their chapters an understanding of both theory and
its application in a variety of settings that characterize the diverse practice of public
health education—for example, worksites, hospitals, ambulatory care settings, schools,
and communities. The chapters, written expressly for the fourth edition of this book,
address theories and models of health behavior at the level of the individual, dyad,
group, organization, and community.
This book is organized into five parts. Part One defines key terms and concepts.
The next three parts reflect important units of health behavior and education practice: the individual, the interpersonal or group level, and the community or aggregate
level. Each of these parts has several chapters, and ends with a perspectives chapter
that synthesizes the preceding chapters.
Part Two focuses on theories of individual health behavior, and its chapters focus
on variables within individuals that influence their health behavior and response to
health promotion and education interventions. Four bodies of theory are reviewed in
separate chapters: the Health Belief Model, the Transtheoretical Model, the Theory
of Reasoned Action/Theory of Planned Behavior/Integrated Behavioral Model, and
the Precaution Adoption Process Model.
Glanz.fpref
7/2/08
11:23 AM
Page xxiii
Preface
xxiii
Part Three examines interpersonal theories, which emphasize elements in the interpersonal environment that affect individuals’ health behavior. Three chapters focus
on Social Cognitive Theory: social support and social networks, clinical-patient and
interpersonal communication, and stress and coping.
Part Four covers models for the community or aggregate level of change and includes chapters on community organization, diffusion of innovations, organizational
change, and media communications.
Part Five explores “Using Theory,” which presents the key components and applications of overarching planning and process models, and a discussion of the application of theory in culturally unique and other unique populations. It includes
chapters on the PRECEDE-PROCEED Model of health promotion planning, social
marketing, ecological models, and evaluation of theory-based interventions.
The major emphasis of Health Behavior and Health Education is on the analysis and application of health behavior theories to health promotion and education
practice. Each core chapter in Parts Two, Three, and Four begins with a discussion
of the background of the theory or model and a presentation of the theory, reviews
empirical support for it, and concludes with one or two applications. Synthesis chapters review related theories and summarize their potential application to the development of health education interventions. Strengths, weaknesses, areas for future
development and research, and promising strategies are highlighted.
Chapter authors are established researchers and practitioners who draw on their
experience in state-of-the-art research to critically analyze and apply the theories to
health education. This text makes otherwise lofty theories accessible and practical,
and advances health education in the process.
No single book can be truly comprehensive and still be concise and readable. Decisions about which theories to include were made with both an appreciation of the
evolution of the study of health behavior and a vision of its future (see Chapter Two).
We purposely chose to emphasize theories and conceptual frameworks that encompass a range from the individual to the societal level. We acknowledge that there is
substantial variability in the extent to which various theories and models have been
codified, tested, and supported by empirical evidence. Of necessity, some promising
emerging theories were not included.
The first three editions of Health Behavior and Health Education grew out of the
editors’ own experiences, frustrations, and needs, as well as their desire to synthesize the diverse literatures and to draw clearly the linkages between theory, research,
and practice in health behavior and education. We have sought to show how theory,
research, and practice interrelate and to make each accessible and practical. In this
edition we have attempted to respond to changes in the science and practice of public health and health promotion, and to update the coverage of these areas in a rapidly evolving field. Substantial efforts have been taken to present findings from health
behavior change interventions, based on the theories that are described, and to illustrate the adaptations needed to successfully reach diverse and unique populations.
Health Behavior and Health Education has now been established as a widely used
text and reference book. We hope the fourth edition will continue to be relevant and
Glanz.fpref
7/2/08
11:23 AM
xxiv
Preface
Page xxiv
useful, and to stimulate readers’ interest in theory-based health behavior and health
education. We aspire to provide readers with the information and skills to ask critical questions, think conceptually, and stretch their thinking beyond using formulaic
strategies to improve health.
ACKNOWLEDGMENTS
We owe deep gratitude to all the authors whose work is represented in this book. They
worked diligently with us to produce an integrated volume, and we greatly appreciate their willingness to tailor their contributions to realize the vision of the book.
Their collective depth of knowledge and experience across the broad range of theories and topics far exceeds the expertise that the editors can claim.
We pay special tribute to Dr. Everett Rogers, a luminary in our broad field, whose
work in the area of diffusion of innovations has taught and inspired us, and whose
body of work cuts across several chapters in this book. Along with many colleagues,
we were saddened by Ev’s death in the fall of 2005 and know his work will continue
to be influential in using theory to improve research and practice.
We also wish to acknowledge authors who contributed to the first three editions
of this text. Although some of them did not write chapters for this edition, their intellectual contributions form an important foundation for the present volume. We especially appreciate the contributions of Frances Marcus Lewis, an editor for the
first three editions. And we welcome K. “Vish” Viswanath, an internationally recognized health communication scholar, to the editorial team.
The staff at Jossey-Bass Publishers provided valuable support to us for development, production, and marketing from the time that the first edition was released
through completion of this edition. Our editors at Jossey-Bass—Andy Pasternack and
Seth Schwartz—provided encouragement and assistance throughout. Kate Harris provided exceptional technical editing support for this edition.
The editors are indebted to their colleagues and students who, over the years,
have taught them the importance of both health behavior theories and their cogent
and precise representation. They have challenged us to stretch, adapt, and continue
to learn through our years of work at the University of Michigan, University of North
Carolina at Chapel Hill, Emory University, Harvard University, the University of Minnesota, Ohio State University, The Johns Hopkins University, Temple University, Fox
Chase Cancer Center, Duke University, the University of Hawai’i, and the National
Cancer Institute (NCI). The updated review of theory use for this edition was completed by doctoral students at Emory University—Julia Painter, Michelle Hynes,
Christina Borba, and Darren Mays.
We particularly want to acknowledge Kelly Blake and Jenny Lewis for their editorial and substantive contributions. Completion of this manuscript would not have
been possible without the dedicated assistance of Kristen Burgess, Johanna Hinman,
Jenifer Brents, Kat Peters, Terri Whitehead, Mae Beale, Suzanne Bodeen, Dave Potenziani, Elizabeth Eichel, Lisa Lowery, Shoba Ramanadhan, and Josephine Crisistomo.
Glanz.fpref
7/2/08
11:23 AM
Page xxv
Preface
xxv
Karen Glanz would like to acknowledge partial funding support from the Georgia Cancer Coalition for technical editing and production of this volume.
We also wish to express our thanks to our colleagues, staffs, friends, and families, whose patience, good humor, and encouragement sustained us through our work
on this book.
Karen Glanz
Atlanta, Georgia
Barbara K. Rimer
Chapel Hill, North Carolina
K. Viswanath
Boston, Massachusetts
Glanz.fpref
7/2/08
11:23 AM
Page xxvi
Glanz.flast
7/2/08
11:22 AM
Page xxvii
THE EDITORS
Karen Glanz is a professor and a Georgia Cancer Coalition Distinguished Research
Scholar in the Rollins School of Public Health at Emory University, where she holds
appointments in the Departments of Behavioral Sciences and Health Education and
Epidemiology. She is also the founding director of the Emory Prevention Research
Center. Prior to coming to Emory, Karen Glanz was professor and director of the Social and Behavioral Sciences Program at the Cancer Research Center of Hawai’i at
the University of Hawai’i from 1993 to 2004. From 1979 to 1993, she was a professor in the Department of Health Education at Temple University in Philadelphia. She
received her M.P.H. (1977) and Ph.D. (1979) degrees in health behavior and health
education from the University of Michigan.
Glanz’s research and academic interests have been in the area of health behavior change program development and evaluation, community nutrition environments,
cancer prevention and control, ethnic differences in health behavior, and risk communication. She is currently principal investigator on five federally funded research
grants that test health behavior change interventions for skin cancer prevention, colorectal cancer risk counseling, and chronic disease prevention; and on several grants
that focus on translation and dissemination of effective interventions and measurement tools. Glanz’s scholarly contributions consist of more than 270 journal articles
and book chapters, and she serves on the editorial boards of several journals. She was
recognized in 2006 as a Highly Cited Author by ISIHighlyCited.com, in the top 0.5
percent of authors in her field over a twenty-year period.
Glanz has been recognized with several national awards and was the 2007 recipient of the Elizabeth Fries Health Education Award from the James and Sarah Fries
Foundation. She was honored by the Public Health Education and Health Promotion
Section of the American Public Health Association (APHA) with the Early Career
Award (1984), the Mayhew Derryberry Award for outstanding contributions to theory and research in health education (1992; with Barbara Rimer and Frances Lewis),
and the Mohan Singh Award for contributions to humor in health education (1996).
Her recent health education programs in skin cancer and underage drinking prevention have received national awards for innovation and program excellence. Glanz
serves on numerous advisory boards and committees for scientific and health organizations in the United States and abroad, including the Task Force on Community Preventive Services at the Centers for Disease Control and Prevention.
䊏 䊏 䊏
Barbara K. Rimer is dean and Alumni Distinguished Professor of Health Behavior and Health Education in the School of Public Health at the University of North
Carolina at Chapel Hill. Rimer received an M.P.H. (1973) from the University of
Michigan, with joint majors in health education and medical care organization, and
Glanz.flast
7/2/08
11:22 AM
Page xxviii
xxviii
The Editors
a Dr.P.H. (1981) in health education from The Johns Hopkins School of Hygiene and
Public Health. Previously, she served as deputy director for Population Sciences at
UNC Lineberger Comprehensive Cancer Center at UNC-Chapel Hill (2003–2005),
as director of the Division of Cancer Control and Population Sciences at the National
Cancer Institute (part of the National Institutes of Health), from 1997–2002, as Professor of Community and Family Medicine at Duke University (1991–1997), and as
director of behavioral research and a full member at the Fox Chase Cancer Center in
Philadelphia (1987–1991).
Rimer has conducted research in a number of areas, including informed decision
making, long-term maintenance of behavior changes (such as diet, cancer screening, and tobacco use), interventions to increase adherence to cancer prevention and
early detection, dissemination of evidence-based interventions, and use of new technologies for information, support, and behavior change.
Rimer is the author of over 280 publications and serves on several journal editorial boards. She is the recipient of numerous awards and honors, including the Healthtrac Foundation Award for Health Education (2004), the Secretary’s Award for
Distinguished Service from the U.S. Department of Health and Human Services (2000),
the Director’s Award from the National Institutes of Health (2000), and the American
Cancer Society Distinguished Service Award (2000). Rimer was the first woman and
behavioral scientist to lead the National Cancer Institute’s National Cancer Advisory
Board—a presidential appointment. She currently is vice chair for the Task Force on
Community Preventive Services at the Centers for Disease Control and Prevention.
䊏 䊏 䊏
K. “Vish” Viswanath is an associate professor in the Department of Society, Human
Development and Health at the Harvard School of Public Health (HSPH) and associate professor of population sciences at Harvard’s Dana-Farber Cancer Institute
(DFCI). He is also the director of the Dana-Farber Harvard Cancer Center’s Health
Communication Core and chair of the steering committee of the Health Communication Concentration of HSPH. Before coming to Harvard, Viswanath was the acting associate director of the Behavioral Research Program, Division of Cancer Control and
Population Sciences, at the National Cancer Institute. He was also a senior scientist
in the Health Communication and Informatics Research Branch. He came to the National Cancer Institute from Ohio State University where he was a tenured faculty
member in the School of Journalism and Communication. He also held an adjunct appointment in the School of Public Health and was a Center Scholar with Ohio State’s
Center for Health Outcomes, Policy, and Evaluation Studies. Viswanath received his
doctoral degree in mass communication from the University of Minnesota (1990).
Viswanath’s research interest is studying how macro-social factors influence
health communication, particularly strategic communication campaigns. His scholarly work focuses on health communication and social change in both national and
international contexts, with a particular focus on communication inequities and health
disparities and sociology of health journalism. He has been involved with planned
social change projects in India and the United States. His current research examines
Glanz.flast
7/2/08
11:22 AM
Page xxix
The Editors
xxix
the use of new communication technologies for health among urban poor, medical
and health reporters and the conditions of their work, and social capital and health
communications. Viswanath has published more than sixty-three journal articles and
book chapters and coedited three books and monographs, including Mass Media, Social Control and Social Change with David Demers (Iowa State University Press,
1999) and The Role of the Media in Promoting and Discouraging Tobacco Use, a monograph to be published by the National Cancer Institute. He was also the editor of the
Social Behavioral Research section of the International Encyclopedia of Communication, a ten-volume series to be published by the Blackwell Press.
An internationally recognized health communications expert, Viswanath holds
leadership roles in professional organizations. He was chair of the Mass Communication Division of the International Communication Association, head of the Theory and Methodology Division of the Association for Education in Journalism and
Mass Communication, and secretary and president of the Midwest Association for
Public Opinion Research (MAPOR). He was recently elected a Fellow of MAPOR.
Glanz.flast
7/2/08
11:22 AM
Page xxx
Glanz.flast
7/2/08
11:22 AM
Page xxxi
THE CONTRIBUTORS
Susan J. Blalock is associate professor of Pharmaceutical Outcomes and Policy in
the School of Pharmacy at the University of North Carolina in Chapel Hill.
Lee R. Bone is associate professor at The Johns Hopkins University Bloomberg School
of Public Health.
Noel T. Brewer is assistant professor in the Department of Health Behavior and Health
Education at the University of North Carolina School of Public Health in Chapel Hill.
Frances Dunn Butterfoss is professor and director of the Division of Behavioral Research and Community Health in the Department of Pediatrics at Eastern Virginia
Medical School, Norfolk, Virginia.
Victoria L. Champion is the Mary Margaret Walther Distinguished Professor and
associate dean for research at the Indiana University School of Nursing.
Ronald M. Epstein is professor of Family Medicine, Psychiatry and Oncology and
director of the Rochester Center to Improve Communication in Health Care at the
University of Rochester School of Medicine and Dentistry.
Kerry E. Evers is director of health behavior change projects Pro-Change Behavior
Systems, Inc., in Rhode Island.
John R. Finnegan Jr. is professor and dean of the School of Public Health at the
University of Minnesota.
Edwin B. Fisher is professor and chair of the Department of Health Behavior and
Health Education at the School of Public Health, University of North Carolina at
Chapel Hill.
Vincent T. Francisco is associate professor in the Department of Public Health Education at the University of North Carolina in Greensboro.
Tiffany L. Gary is assistant professor of epidemiology at The Johns Hopkins
Bloomberg School of Public Health in Baltimore.
Andrea Carson Gielen is professor and director of the Center for Injury Research
and Policy at The Johns Hopkins Bloomberg School of Public Health in Baltimore.
Russell E. Glasgow is senior scientist at the Center for Health Dissemination & Implementation at the Institute for Health Research, Kaiser Permanente, Colorado.
Glanz.flast
7/2/08
11:22 AM
Page xxxii
xxxii
The Contributors
Catherine A. Heaney is with the Stanford Prevention Research Center at Stanford
University.
Barbara A. Israel is professor in the Department of Health Behavior and Health Education in the School of Public Health at the University of Michigan.
Danuta Kasprzyk is research leader at the Centers for Public Health Research and
Evaluation, Battelle Memorial Institute, in Seattle.
Michelle C. Kegler is associate professor in the Department of Behavioral Sciences
and Health Education in the Rollins School of Public Health at Emory University in
Atlanta.
Laura A. Linnan is associate professor in the Department of Health Behavior
and Health Education at the University of North Carolina, Chapel Hill, School of Public Health.
Alfred L. McAlister is professor of behavioral sciences at the University of Texas
School of Public Health regional campus in Austin.
Eileen M. McDonald is associate scientist and MHS program codirector at The Johns
Hopkins Bloomberg School of Public Health in Baltimore.
Meredith Minkler is professor of Health and Social Behavior in the School of Public Health at the University of California, Berkeley.
Daniel E. Montaño is research leader at the Centers for Public Health Research
and Evaluation, Battelle Memorial Institute, in Seattle.
Brian Oldenburg is professor and chair of International Public Health at Monash
University in Melbourne, Australia.
Neville Owen is professor and director of the Cancer Prevention Research Centre at
the University of Queensland in Brisbane, Australia.
Guy S. Parcel is the John P. McGovern Professor in Health Promotion in the School
of Public Health at the University of Texas Health Science Center, Houston.
Cheryl L. Perry is professor and regional dean at the University of Texas School of
Public Health regional campus in Austin.
James O. Prochaska is professor and director of the Cancer Prevention Research
Center at the University of Rhode Island.
Colleen A. Redding is a research professor in the Cancer Prevention Research Center at the University of Rhode Island.
Glanz.flast
7/2/08
11:22 AM
Page xxxiii
The Contributors
xxxiii
Jose G. Rimón is at the Center for Communication Programs at The Johns Hopkins
Bloomberg School of Public Health in Baltimore.
Gary B. Saffitz is deputy director of the Center for Communication Programs and
senior associate faculty at The Johns Hopkins University Bloomberg School of Public Health.
James F. Sallis is professor of psychology at San Diego State University and director of the Active Living Research program in San Diego.
Peter M. Sandman is a risk communication consultant in Princeton, New Jersey.
Marc D. Schwartz is associate professor of oncology at the Lombardi Cancer Center at Georgetown University in Washington, D.C.
Celette Sugg Skinner is professor and chief of the Division of Behavioral and Communication Sciences at UT Southwestern Medical Center in Dallas.
J. Douglas Storey is associate director of the Center for Communication Programs
at the Johns Hopkins Bloomberg School of Public Health in Baltimore.
Richard L. Street Jr. is professor and head of the Department of Communication
at Texas A&M University and Baylor College of Medicine.
Nina Wallerstein is professor in the Masters in Public Health Program at the University of New Mexico in Albuquerque.
Neil D. Weinstein is research professor in the Department of Family and Community Medicine at the University of Arizona College of Medicine in Tucson.
Nance Wilson is a principal investigator with the Public Health Institute in Oakland,
California.
Glanz.flast
7/2/08
11:22 AM
Page xxxiv
Glanz.flast
7/2/08
11:22 AM
Page xxxv
HEALTH
BEHAVIOR
AND
HEALTH
EDUCATION
Glanz.flast
7/2/08
11:22 AM
Page xxxvi
Glanz.p01
7/2/08
11:23 AM
Page 1
PA RT
1
HEALTH EDUCATION
AND
HEALTH BEHAVIOR
The Foundations
Glanz.p01
7/2/08
11:23 AM
Page 2
Glanz.c01
7/2/08
11:12 AM
Page 3
CHAPTER
1
THE SCOPE OF
HEALTH BEHAVIOR AND
HEALTH EDUCATION
The Editors
KEY POINTS
This chapter will
䊏
䊏
䊏
䊏
䊏
䊏
Discuss the importance of developing successful strategies to improve health
behavior.
Summarize the leading causes of death and disease burden in the United States and
globally.
Describe the scope and evolution of health education.
Provide key definitions of health education, health behavior, and health promotion.
Discuss the diverse settings and audiences for health education.
Highlight progress and challenges in health behavior and health education research.
Perhaps never before have there been so many demands on those in health education and health behavior to facilitate behavior changes, or so many potential strategies from which to choose. Where professionals once might have seen their roles as
working at a particular level of intervention (such as changing organizational or individual health behaviors) or employing a specific type of behavior change strategy
(such as group interventions or individual counseling), we now realize that multiple
interventions at multiple levels are often needed to initiate and sustain behavior change
Glanz.c01
7/2/08
4
11:12 AM
Page 4
Health Behavior and Health Education
effectively. And where health education and behavior change professionals once might
have relied on intuition, experience, and their knowledge of the literature, increasingly we expect professionals to act on the basis of evidence. In the time since the
first edition of this book in 1990, the evidence base for health behavior change has
grown dramatically.
A number of systematic reviews have shown that using theory in crafting interventions can lead to more powerful effects than interventions developed without theory (for example, see Ammerman, Lindquist, Lohr, and Hersey, 2002; Legler and
others, 2002). It is an exciting time to contemplate behavior change. There are more
tools and strategies and a better understanding of the role theory can play in producing effective, sustained behavior change. And the stage has changed from one that is
primarily local and country-specific to one that is both global and local, in which
we increasingly see the world as interconnected.
These exciting opportunities could not be taking place at a more propitious time.
The positive changes of medical innovations, strong evidence base, and exciting
and novel tools for health promotion are buffeted by countercurrents of increasing
globalization, urbanization, industrialization, and inequalities that deter us from
fulfilling the promise of advances in medicine and health promotion. Major challenges include heavy promotion of unhealthy lifestyles, such as tobacco use and fastfood consumption across the globe, increasing pollution, and health problems associated
with poverty, such as overcrowding, lack of safe drinking water, unsafe neighborhoods, and limited access to health care services.
It is of little surprise that the number of topics on which health professionals and
health education specialists focus has grown and evolved as health problems have
changed around the world. Some professionals may counsel people at risk for AIDS
about safe sex; help children avoid tobacco, alcohol, and drugs; assist 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. Other
health professionals may focus on environmental concerns. We expect that, over the
next decade, more behavior change interventions will be directed at changing individual and community behaviors related to water consumption and to behaviors that
may affect global climate change.
Health education professionals work all over the world in a variety of settings, including schools, worksites, nongovernmental organizations (including voluntary health
organizations), medical settings, and communities. Since the first edition of this book,
there has been increased recognition that what happens in other parts of the world affects us all, wherever we may be. To the extent that public health is global health and
global health is local, we are committed in this volume to exploring the use of health
behavior theories around the world and to discussing the potential relevance of what
is learned in one setting to others. Although many of the examples are from research
conducted in the United States, our perspective is decidedly not U.S.-centric.
Since the last edition of this book six years ago, there have been other changes
as well. Part of what has made the world feel smaller and people more interconnected
is the growth of new communication and information technologies, which have opened
Glanz.c01
7/2/08
11:12 AM
Page 5
The Scope of Health Behavior and Health Education
5
up an unprecedented range of strategies for health behavior change programs. Through
the Internet, health behavior change interventions may reach people all over the world,
regardless of their location. This means that health behavior change interventions can
achieve scale never before imagined, potentially reaching millions of people rather
than hundreds or thousands.
There is increased recognition that the fruits of research take too long to reach
people who could benefit from them (Glasgow and Emmons, 2007; Viswanath, 2006).
This has led to an increased emphasis on the dissemination of evidence-based interventions. Part of the rationale for this book is to speed the dissemination of knowledge about how to use theory, so that theory can inform those who develop and use
health behavior interventions around the world.
Health experts 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 among theory, research, and
practice is most likely to produce effective health education. The editors believe fundamentally that theory and practice should coexist in a healthy dialectic; they are not
dichotomies. The best theory is likely to be grounded in real lessons from practice.
The best practice should be grounded in theory.
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 the
human 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 and health promotion are recognized increasingly as ways to meet public
health objectives and improve the success of public health and medical interventions
around the world. Although this increasing amount of 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 and
rapidly evolving; they reflect an amalgamation of approaches, methods, and strategies from social and health sciences, drawing on the theoretical perspectives, research,
and practice tools of such diverse disciplines as psychology, sociology, anthropology,
communications, nursing, economics, 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. Evidence-based
groups like the Cochrane Collaboration (http://www.cochrane.org) and the CDC’s
(Centers for Disease Control and Prevention) Guide to Community Preventive Services (http://www.thecommunityguide.org) offer regular syntheses of behavioral interventions, some of which include theoretical constructs as variables in analyses of
effectiveness.
Many kinds of professionals contribute to and conduct health education and health
behavior (HEHB) programs and research. Health education practice is strengthened
Glanz.c01
7/2/08
6
11:12 AM
Page 6
Health Behavior and Health Education
by the close collaboration among professionals of different disciplines, each concerned with the behavioral and social intervention process and each contributing a
unique perspective. Although health behavior professionals have usually worked this
way, there is increasing emphasis on an interdisciplinary or even a transdisciplinary
focus (Turkkan, Kaufman, and Rimer, 2000). Psychology brings to health education
a rich legacy of over one hundred years of research and practice on individual differences, motivation, learning, persuasion, and attitude and behavior change (Matarazzo
and others, 1984), as well as the perspectives of organizational and community psychology. Physicians are important collaborators and are in key roles to effect change
in health behavior (Grol and others, 2007). 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 are partnerships with genetic
counselors and other specialists in this rapidly developing field.
THE CHANGING CONTEXT OF HEALTH AND BEHAVIOR
The most frequent causes of death in the United States and globally are chronic diseases, including heart disease, cancer, lung diseases, and diabetes (Yach, Hawkes,
Gould, and Hofman, 2004). Behavioral factors, particularly tobacco use, diet and activity patterns, alcohol consumption, sexual behavior, and avoidable injuries are among
the most prominent contributors to mortality (Schroeder, 2007; Mokdad, Marks,
Stroup, and Gerberding, 2004, 2005). Projections of the global burden of disease
for the next two decades include increases in noncommunicable diseases, high rates
of tobacco-related deaths, and a dramatic rise in deaths from HIV/AIDS (Mathers and
Loncar, 2006; Abegunde and others, 2007). Worldwide, the major causes of death by
2030 are expected to be HIV/AIDS, depressive disorders, and heart disease (Mathers and Loncar, 2006).
At the same time, in many parts of the world, infectious diseases continue to pose
grim threats, especially for the very young, the old, and those with compromised immune systems. Malaria, diarrheal diseases, and other infectious diseases, in addition to AIDS, are major health threats to the poorest people around the world (The
PLoS Medicine Editors, 2007). And, like chronic diseases, their trajectory may be influenced by the application of effective health behavior interventions. Substantial suffering, premature mortality, and medical costs can be avoided by positive changes
in behavior at multiple levels. Most recently, there has been a renewed focus on public health infrastructure to plan for emergencies, including both human-made and natural disasters.
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 epidemiological transition
from infectious to chronic diseases as leading causes of death, the aging of the pop-
Glanz.c01
7/2/08
11:12 AM
Page 7
The Scope of Health Behavior and Health Education
7
ulation, rapidly escalating health care costs, and data linking individual behaviors
to increased risk of morbidity and mortality. The evidence that early detection can
save lives from highly prevalent conditions such as breast and colorectal cancer has
also been influential. The AIDS epidemic has also contributed. Moreover, around the
world communicable diseases and malnutrition exist alongside increasing problems, like obesity among the middle class (Abegunde and others, 2007).
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
for the Nation (U.S. Department of Health and Human Services, 1980) and its successors, Healthy People 2000: National Health Promotion and Disease Prevention
Objectives and Healthy People 2010 (U.S. Department of Health and Human Services, 1991, 2000). Similarly, international agencies are drawing attention to the global
burden of diseases and health inequalities (World Health Organization, 2007). Increased interest in behavioral and social determinants of health behavior change
spawned numerous training programs and public and commercial service programs.
Data systems and surveillance initiatives now make it feasible to track trends in
risk factors, health behaviors, and healthy environments and policies in the United
States and developed countries and, in some cases, to tie these changes to disease incidence and mortality (http://www.who.int/research/en). Indeed, positive change has
occurred in several areas. A major accomplishment in the United States 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. Following major litigation against the tobacco industry and a multistate settlement, there are increased restrictions on tobacco advertising and enforcement of
laws against selling tobacco to minors (Glanz and others, 2007). In the United States,
fewer adults are using tobacco products—the reduction in adult smoking from 42.4
percent to 20.8 percent between 1965 and 2006 (Centers for Disease Control and Prevention, 2007b) is hailed as one of the top public health achievements of the past century. More adults are meeting dietary guidelines for higher consumption of fruits,
vegetables, and grain products, as well as decreased dietary fat as a percentage of
calories (National Center for Health Statistics, 2001). Rates of HIV/AIDS in the
United States 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 exceeded the goal of 60 percent in forty-seven states in
the past decade. Yet the recent leveling off of mammography use in the United States
indicates just how fragile behavior change can be and points to the need for attention
to maintenance of behavior changes (Centers for Disease Control and Prevention,
2007a; Breen and others, 2007). The collective efforts of those in health education
and public health have indeed made a difference.
Glanz.c01
7/2/08
8
11:12 AM
Page 8
Health Behavior and Health Education
Although this progress is encouraging, much work remains to be done in these
areas. 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 and remain at 67 percent—well
below the target rate of 85 percent (National Center for Health Statistics, 2001). Onefifth 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. Ethnic minorities and those
in poverty still experience a disproportionate burden of preventable disease and disability, and the gap persists between disadvantaged and affluent groups in use of preventive services (National Commission on Prevention Priorities, 2007).
The disease burden is not limited to the United States. Data from Popkin (2007)
and others suggest that, like the tobacco epidemic, the obesity epidemic has taken on
global proportions. One study of the burden of chronic diseases in twenty-three lowand middle-income countries posits that chronic disease is responsible for 50 percent
of the disease burden in 2005 and estimates an economic loss of almost $84 billion
(U.S. dollars) between 2006 and 2015 if nothing is done to address the burden (Mathers and Loncar, 2006).
Changes in the health care system provide new supports and opportunities for
health education. Respect for patients’ rights and more participatory patient-centered
communication can lead to improved health outcomes (Arora, 2003; Epstein and Street,
2007), and shared decision making 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). Increasingly, patients are driving their
own searches for health information by using the Internet (see, for example, Rimer
and others, 2005; Hesse and others, 2005), though disparities remain in information
seeking between those of higher and lower socioeconomic status (Ramanadhan and
Viswanath, 2006). Clinical prevention and behavioral interventions are often considered cost-effective but are neither universally available nor equally accessible across
race and socioeconomic groups (Schroeder, 2007; Gostin and Powers, 2006).
The rapid emergence of new communication technologies and new uses of older
technologies, such as the telephone, also provide new opportunities and dilemmas. A
variety of electronic media for interactive health communication (for example, the
Internet, CD-ROMs, and personal digital assistants [PDAs]) can serve as sources of
individualized health information, reminders, and social support for health behavior
change (Viswanath, 2005; Ahern, Phalen, Le, and Goldman, 2007). These new technologies also may connect individuals with similar health concerns around the world
(Bukachi and Pakenham-Walsh, 2007). This may be especially important for people
with rare or stigmatized health conditions. However, the new products of the communications revolution have not equally reached affluent and more disadvantaged
populations (Viswanath, 2005, 2006).
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, along with wireless technologies, can support many of the Health Behavior
Glanz.c01
7/2/08
11:12 AM
Page 9
The Scope of Health Behavior and Health Education
9
and Health Education strategies based on the theories presented in this book. Use
of new technologies should be based on theories of health behavior and be evaluated (Ahern, Phalen, Le, and Goldman, 2007). Otherwise, we risk being technologydriven instead of outcome-driven.
At the same time, 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), although the empirical evidence on harms remains to be documented. 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 (Hesse and others, 2005).
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 longstanding concern with the impact of social, economic, and political forces on health. Focusing merely on downstream (individual)
causes of poor health rather than the upstream causes risks missing important opportunities to improve health (McKinlay and Marceau, 2000).
Over the past forty years, leaders in health education have 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. 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). Green and Kreuter’s PRECEDE/PROCEED Model
(2005; see Chapter Eighteen), which was first widely introduced over twenty-five
years ago, addresses the multiple forces that affect health. Individual health does not
exist in a social vacuum.
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
Glanz.c01
7/2/08
11:12 AM
Page 10
10
Health Behavior and Health Education
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 influence, 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 addition to the individual-level theories. In this context, definitions of
health education and health promotion can be recognized and discussed as overlapping and intertwined.
Definitions of Health Education
According to Griffiths (1972), “health education attempts to close the gap between what
is known about optimum health practice and that which is actually practiced.” Simonds
(1976) defined health education as aimed at “bringing about behavioral changes in individuals, groups, and larger populations from behaviors that are presumed to be detrimental to health, to behaviors that are conducive to present and future health.”
Subsequent definitions emphasized voluntary, informed behavior changes. In
1980, Green defined health education as “any combination of learning experiences
designed to facilitate voluntary adaptations of behavior conducive to health” (Green,
Kreuter, Deeds, and Partridge, 1980). The Role Delineation Project defined it as “the
process of assisting individuals, acting separately or collectively, to make informed
decisions about matters affecting their personal health and that of others” (National
Task Force on the Preparation and Practice of Health Educators, 1985).
Health education evolved from three settings: communities, schools, and patient care settings. Kurt Lewin’s pioneering work in group process and his developmental field theory during the 1930s and 1940s provide the intellectual roots for much
of health education practice today. One of the earliest models developed to explain
health behavior, the Health Belief Model (HBM), was developed during the 1950s to
explain behavior related to tuberculosis screening (Hochbaum, 1958).
As we already have noted, health education includes not only instructional activities and other strategies to change individual health behavior but also organizational
efforts, policy directives, economic supports, environmental activities, mass media,
and community-level programs. Two key ideas from an ecological perspective help direct the identification of personal and environmental leverage points for health promotion and education interventions (Glanz and Rimer, 1995). First, behavior is viewed
as being affected by, and affecting, multiple levels of influence. Five levels of influence for health-related behaviors and conditions have been identified: (1) intrapersonal, or individual factors; (2) interpersonal factors; (3) institutional, or organizational
factors; (4) community factors; and (5) public-policy factors (McLeroy, Bibeau, Steckler, and Glanz, 1988). The second key idea relates to the possibility of reciprocal causation between individuals and their environments; that is, behavior both influences
and is influenced by the social environment (Glanz and Rimer, 1995; Stokols, Grzywacz,
McMahan, and Phillips, 2003).
Glanz.c01
7/2/08
11:12 AM
Page 11
The Scope of Health Behavior and Health Education
11
Health education covers the continuum from disease prevention and promotion
of optimal health to the detection of illness to treatment, rehabilitation, and long-term
care. It includes infectious and chronic diseases, as well as attention to environmental issues. Health education is delivered in almost every conceivable setting—universities, schools, hospitals, pharmacies, grocery stores and shopping centers, recreation
settings, community organizations, voluntary health agencies, worksites, churches,
prisons, health maintenance organizations, migrant labor camps; it is delivered through
mass media, over the Internet, in people’s homes, and in health departments at all levels of government. These settings are discussed later in this chapter.
Health promotion is a term of more recent origin than health education. As defined
by Green, it is “any combination of health education and related organizational, economic, and environmental supports for behavior of individuals, groups, or communities
conducive to health” (Green and Kreuter, 1991). A slightly different definition is suggested by O’Donnell (1989): “Health promotion is the science and art of helping people change their lifestyle toward a state of optimum health. . . . Lifestyle changes can be
facilitated by a combination of efforts to enhance awareness, change behavior, and create environments that support good health practices.” Definitions arising in Europe and
Canada have yet another emphasis (Kolbe, 1988; Hawe, Degeling, and Hall, 1990). The
Ottawa Charter for Health Promotion defines health promotion as “the process of enabling people to increase control over, and to improve, their health . . . a commitment to
dealing with the challenges of reducing inequities, extending the scope of prevention,
and helping people to cope with their circumstances . . . create environments conducive to health, in which people are better able to take care of themselves” (Epp, 1986).
Although greater precision of terminology might be achieved by drawing a clear
distinction between health education and health promotion, to do so would be to ignore longstanding tenets of health education and its broad social mission. Clearly,
health educators have long used more than “educational” strategies. In fact, the terms
health promotion and health education are often used interchangeably in the United
States. In some countries, such as Australia, health education is considered a much
narrower endeavor than health promotion. Nevertheless, although the term health promotion emphasizes efforts to influence the broader social context of health behavior,
the two terms remain closely linked and overlapping, share historical and philosophical foundations, and are often used in combination. In most cases, we consider the
two terms too closely related to distinguish between them. In this book, the term health
education is used most often. It is to be understood in the historical sense—as a broad
and varied set of strategies to influence both individuals and their social environments,
in order to improve health behavior and enhance health and quality of life.
Definitions of Health Behavior
The central concern of health education is health behavior, writ large. It is included
or suggested in every definition of health education and is the crucial dependent variable in most research on the impact of health education intervention strategies. Positive, informed changes in health behavior are typically the ultimate aims of health
Glanz.c01
7/2/08
11:12 AM
Page 12
12
Health Behavior and Health Education
education programs. If behaviors change but health is not subsequently improved, the
result is a paradox that must be resolved by examining other issues, such as the link
between behavior and health status or the ways in which behavior and health (or both)
are measured. Informed decision making is a desirable endpoint for problems involving medical uncertainty, and studies suggest that shared decision making may lead to
improved patient satisfaction and health outcomes (Rimer and others, 2004). Likewise, environmental or structural interventions to change presumed social environmental determinants of health behavior are intended to improve health by changing
behavior (Smedley and Syme, 2000; Story, Kaphingst, Robinson-O’Brien, and Glanz,
2008). Thus, efforts to improve environments and policies should ultimately be evaluated for their effects on health behavior. If policy changes but does not lead to measurable changes in behavior, it may be either too weak or too short-lived, or it could
be only a limited determinant of behavior.
In the broadest sense, health behavior refers to the actions of individuals, groups,
and organizations, as well as their determinants, correlates, and consequences, including social change, policy development and implementation, improved coping
skills, and enhanced quality of life (Parkerson and others, 1993). This is similar to
the working definition of health behavior that Gochman proposed (though his definition emphasized individuals): it includes not only observable, overt actions but also
the mental events and feeling states that can be reported and measured. He defined
health behavior as “those personal attributes such as beliefs, expectations, motives,
values, perceptions, and other cognitive elements; personality characteristics, including affective and emotional states and traits; and overt behavior patterns, actions, and
habits that relate to health maintenance, to health restoration, and to health improvement” (Gochman, 1982, 1997).
Gochman’s definition is consistent with and embraces the definitions of specific
categories of overt health behavior proposed by Kasl and Cobb in their seminal articles (1966a, 1966b). Kasl and Cobb define three categories of health behavior:
1. Preventive health behavior: any activity undertaken by an individual who believes himself (or herself) to be healthy, for the purpose of preventing or detecting illness in an asymptomatic state.
2. Illness behavior: any activity undertaken by an individual who perceives himself to be ill, to define the state of health, and to discover a suitable remedy
(Kasl and Cobb, 1966a).
3. Sick-role behavior: any activity undertaken by an individual who considers
himself to be ill, for the purpose of getting well. It includes receiving treatment
from medical providers, generally involves a whole range of dependent behaviors, and leads to some degree of exemption from one’s usual responsibilities
(Kasl and Cobb, 1966b).
SETTINGS AND AUDIENCES FOR HEALTH EDUCATION
During the past century and more specifically during the past few decades, the scope
and methods of health education have broadened and diversified dramatically. This
Glanz.c01
7/2/08
11:12 AM
Page 13
The Scope of Health Behavior and Health Education
13
section briefly reviews the range of settings and audiences of health education today.
We note that the ideas of “settings” and “audiences” have expanded and become more
diversified over the past decade.
Where Health Education Is Provided
Today, health education can be found nearly everywhere. The settings for health education are important because they provide channels for delivering programs, provide access to specific populations and gatekeepers, usually have existing
communication systems for diffusion of programs, and facilitate development of policies and organizational change to support positive health practices (Mullen and others, 1995). Seven major settings are particularly relevant to contemporary health
education: schools, communities, worksites, health care settings, homes, the consumer marketplace, and the communications environment.
Schools. Health education in schools includes classroom teaching, teacher training,
and changes in school environments that support healthy behaviors (Luepker and others, 1996; Franks and others, 2007). To support long-term health enhancement initiatives, theories of organizational change can be used to encourage adoption of
comprehensive smoking control programs in schools. Diffusion of Innovations theory and the Theory of Reasoned Action have been used to analyze factors associated
with adoption of AIDS prevention curricula in Dutch schools (Paulussen, Kok,
Schaalma, and Parcel, 1995).
Communities. Community-based health education draws on social relationships and
organizations to reach large populations with media and interpersonal strategies. Models of community organization enable program planners both to gain support for and
to design suitable health messages and delivery mechanisms (see Chapter Thirteen).
Community interventions in churches, clubs, recreation centers, and neighborhoods
have been used to encourage healthful nutrition, reduce risk of cardiovascular disease,
and use peer influences to promote breast cancer detection among minority women.
Worksites. Since its emergence in the mid-1970s, worksite health promotion has grown
and spawned new tools for health educators. Because people spend so much time at
work, the workplace is both a source of stress and a source of social support (Israel and
Schurman, 1990). Effective worksite programs can harness social support as a buffer
to stress, with the goal of improving worker health and health practices. Today, many
businesses, particularly large corporations, provide health promotion programs for their
employees (National Center for Health Statistics, 2001). Both high-risk and populationwide strategies have been used in programs to reduce the risk of cancer (Tilley and
others, 1999a, 1999b; Sorenson and others, 1996) and cardiovascular disease (Glasgow
and others, 1995). Integrating health promotion with worker safety and occupational
health may increase effectiveness (Sorensen and Barbeau, 2006).
Health Care Settings. Health education for high-risk individuals, patients, their fam-
ilies, and the surrounding community, as well as in-service training for health care
providers, are all part of health care today. The changing nature of health service
Glanz.c01
7/2/08
11:12 AM
Page 14
14
Health Behavior and Health Education
delivery has stimulated greater emphasis on health education and provider-focused
quality improvement strategies in physicians’ offices, health maintenance organizations, public health clinics, and hospitals (Grol and others, 2007). Primary care settings, in particular, provide an opportunity to reach a substantial number of people
(Campbell and others, 1993; Glanz and others, 1990). Health education in these settings focuses on preventing and detecting disease, helping people make decisions
about genetic testing, and managing acute and chronic illnesses.
Homes. Health behavior change interventions are delivered to people in their homes,
both through traditional public health means, like home visits, and through a variety
of communication channels and media such as Internet, telephone, and mail (Science
Panel on Interactive Communication and Health, 1999; McBride and Rimer, 1999).
Use of strategies such as mailed tailored messages (Skinner and others, 1999) and
motivational interviewing by telephone (Emmons and Rollnick, 2001) makes it possible to reach larger groups and high-risk groups in a convenient way that reduces
barriers to their receiving motivational messages.
The Consumer Marketplace. The advent of home health and self-care products, as
well as use of “health” appeals to sell consumer goods, has created new opportunities for health education but also can mislead consumers about the potential health
effects of items they can purchase (Glanz and others, 1995). Social marketing, with
its roots in consumer behavior theory, is used increasingly by health educators to enhance the salience of health messages and to improve their persuasive impact (see
Chapter Nineteen). Theories of Consumer Information Processing (CIP) provide a
framework for understanding why people do or do not pay attention to, understand,
and make use of consumer health information such as nutrient labels on packaged
food products (Rudd and Glanz, 1990).
The Communications Environment. As noted earlier, there have been striking and
rapid changes in the availability and use of new communications technologies, ranging from mass media changes (for example, online versions of newspapers, blogs of
radio programs) to personalized and interactive media (for example, PDAs, interactive telephone and Internet exchanges) and a host of wireless tools in homes, businesses, and communities (Viswanath, 2005). These channels are not “settings” per se
and can be used in any of the settings described earlier. Yet they are unique and increasingly specialized, providing opportunities for intervention; they also require
evaluation of their reach and impact on health behaviors (Ahern and others, 2007).
Audiences for Health Education
For health education to be effective, it should be designed with an understanding of
recipients’—target audiences’—health and social characteristics, beliefs, attitudes,
values, skills, and past behaviors. These audiences consist of people who may be
reached as individuals, in groups, through organizations, as communities or sociopolitical entities, or through some combination of these. They may be health professionals,
Glanz.c01
7/2/08
11:12 AM
Page 15
The Scope of Health Behavior and Health Education
15
clients, people at risk for disease, or patients. This section discusses four dimensions
along which the potential audiences can be characterized: (1) sociodemographic characteristics, (2) ethnic or racial background, (3) life cycle stage, and (4) disease or atrisk status.
Sociodemographic Characteristics and Ethnic/Racial Background. Socioeconomic
status has been linked with both health status and health behavior, with less affluent
persons consistently experiencing higher morbidity and mortality (Berkman and
Kawachi, 2000). Recognition of differences in disease and mortality rates across
socioeconomic and ethnic or racial groups has led to increased efforts to reduce or
eliminate health disparities (Smedley, Stith and Nelson, 2003; World Health Organization, 2007). For example, it has long been known that African Americans die at
earlier ages than whites. Life expectancy for African American males is almost seven
years less than for white males. The difference of five years for African American
versus white women is smaller, but still alarmingly discrepant. The gaps have grown
over the past three decades and are even greater for those with lower levels of education and income (Crimmins and Saito, 2001; Franks, Muennig, Lubetkin, and Jia, 2006).
A variety of sociodemographic characteristics, such as gender, age, race, marital
status, place of residence, and employment characterize health education audiences.
The United States has experienced a rapid influx of new immigrant populations, especially from Africa and Europe, and the proportion of non-white minority residents continues to climb. These factors, although generally not modifiable within the
bounds of health education programs, are important in guiding the targeting of strategies and educational material, and identifying channels through which to reach consumers. Health education materials should be appropriate for, and ideally matched
to, the educational and reading levels of particular target audiences and be compatible with their ethnic and cultural backgrounds (Resnicow, Braithwaite, DiIorio, and
Glanz, 2002).
Life Cycle Stage. Health education is provided for people at every stage of the life
cycle, from childbirth education, whose beneficiaries are not yet born, to self-care education and rehabilitation for the very old. Developmental perspectives help guide the
choice of intervention and research methods. Children may have misperceptions about
health and illness. For example, they may think that illnesses are punishment for bad
behavior (Armsden and Lewis, 1993). Knowledge of children’s cognitive development
helps provide a framework for understanding these beliefs and ways to respond to
them. Adolescents may feel invulnerable to accidents and chronic diseases. The Health
Belief Model (HBM; see Chapter Three) is a useful framework for understanding the
factors that may predispose youth to engage in unsafe sexual practices. Older adults
and their health providers may attribute symptoms of cancer to the inexorable process
of aging rather than the disease itself. Such beliefs should be considered in designing,
implementing, and evaluating health education programs (Rimer and others, 1983;
Keintz, Rimer, Fleisher, and Engstrom, 1988). Federal health protection goals stress
reaching people in every stage of life, with a special focus on vulnerability that may
affect people at various life cycle stages (http://www.cdc.gov/osi/goals/people.html).
Glanz.c01
7/2/08
11:12 AM
Page 16
16
Health Behavior and Health Education
Disease or At-Risk Status. People who are diagnosed with specific diseases often
experience not only symptoms but also the distress associated with their prognosis
and having to make decisions about medical care (see Chapter Ten). Thus, they may
benefit from health education, but illness may compromise their ability to attend to
new information at critical points. Because of this, timing, channels, and audiences
for patient education should be carefully considered. Successful patient education
depends on a sound understanding of the patient’s view of the world (Glanz and Oldenburg, 2001). For individuals at high risk due to family history or identified risk factors, health behavior change interventions may have heightened salience when linked
to strategies for reducing individual risk (see Chapter Six on the Precaution Adoption Process Model). Even so, strategies used to enable initial changes in behavior,
such as quitting smoking, may be insufficient to maintain behavior change over the
long term, even in these people. Models and theories of health behavior can suggest
strategies to prevent relapse and enhance maintenance of recommended practices for
high-risk individuals (Glanz and Oldenburg, 2001).
PROGRESS IN HEALTH PROMOTION
AND HEALTH BEHAVIOR RESEARCH
Over the past two decades, research programs have b…

Order an Essay Now & Get These Features For Free:

Turnitin Report

Formatting

Title Page

Citation

Outline

Place an Order