The Scope of Health Behavior
In the past few years, wearable tracking devices have become commonplace in the United States. These devices enable users to count steps, track calories burned and miles covered, be reminded when they have been sitting too long, share data with others, and examine trends over time. More and more, consumers have accessible tools to assess their own health behaviors and health risks in ways that once were available only through health providers. For example, researchers at the Massachusetts Institute of Technology have produced sensor-infused bands that send alerts when a person may be about to suffer an epileptic seizure (Poh et al., 2012). This is an example of how the frontiers of communication and behavior have expanded far beyond what we imagined twenty-five years ago, when we wrote the first edition of this book.
It is an exciting time to contemplate behavior change. Perhaps never before have there been so many demands on those who aim to facilitate positive changes in health behaviors and so many potential strategies from which to choose. Whether it is the need to reduce the rate of hospital readmissions in order to avoid costly penalties from Medicare or communities faced with increased rates of childhood obesity, there is growing recognition that health behavior changes are needed across the world if population health is to improve. 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 kinds of interventions at different levels often are needed to initiate and sustain behavior change effectively. Once, health behavior experts might have relied on intuition, experience, and their knowledge of the literature. Increasingly, however, professionals are expected 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. Along with the evidence base on behavior change interventions is growing interest in using and assessing the impact of theories of behavior change.
Many systematic reviews have examined whether using theory in crafting interventions can lead to more powerful effects than interventions developed without theory (Glanz & Bishop, 2010; Michie, West, Campbell, Brown, & Gainforth, 2014). Reviews have varied in how they code theory use and specific theories, and how they interpret findings related to the theory use–impact question. Some reviews found that using theoretical foundations for interventions was associated with better outcomes (Albada, Ausems, Bensing, & van Dulmen, 2009; Ammerman, Lindquist, Lohr, & Hersey, 2002; Legler et al., 2002; Noar, Benac, & Harris, 2007; Noar, Black, & Pierce, 2009; Taylor, Conner, & Lawton, 2011). Some reviews found no association or mixed results (Gardner, Wardle, Poston, & Croker, 2011; Prestwich et al., 2013).
As the body of literature of systematic reviews and meta-analyses of interventions that examine theory use grows, the picture becomes more complex. Our interpretation from a “review of reviews” to date suggests that outcomes are better when theory is applied or more thoroughly applied. But this is not a simple, strong, or unequivocal conclusion. Nonetheless, there are many reasons for both researchers and practitioners to be well versed in the theoretical foundations of health behavior and facile with applying them in their work. It is even more important to become skilled at using and testing theories, because some equivocal results may be due to failures in theory specification and testing.
Today we have many tools and strategies for improving our understanding of the role that health behavior theories can play in producing effective, sustained behavior changes. These tools and strategies are more and more accessible from web-based repositories. Furthermore, the stage for health behavior change research and practice has changed from one that was primarily local and country-specific to one that is both global and local, in a world that is increasingly interconnected.
These exciting opportunities are occurring at a propitious time. The positive and rapid changes in medical innovations, a strong evidence base, and increasingly accessible tools for health promotion are buffeted by countercurrents of increasing globalization, urbanization, industrialization, and inequalities that may deter us from fulfilling the promise of advances in medicine and health promotion. Major challenges include the billions of dollars spent yearly across the world on the promotion of unhealthy lifestyles, such as tobacco use and sugary beverage consumption, and also the challenges of physical inactivity, increasing pollution, and health problems associated with poverty, including overcrowding, lack of safe drinking water, unsafe neighborhoods, and limited access to health care.
Unhealthy behaviors continue to account for a disproportionate share of deaths in countries around the world. And the rise of noncommunicable diseases globally is a major threat to world health, pushing many below the poverty line (Choi, 2012; Lueddeke, 2015). National and global health policies must encourage and enable people to practice healthy habits (Lueddeke, 2015). Improved health is not dependent on medicine or health care alone; it is the sum of multiple factors at multiple levels of societies.
The topics on which health professionals and health behavior specialists focus have grown and evolved as health problems have changed around the world (Fisher et al., 2011). Professionals may counsel people at risk for AIDS about safe sex; help children avoid tobacco, alcohol, and drugs; assist adults to stop smoking; teach patients to manage and cope with their chronic illnesses; and organize communities and advocate policy changes aimed at fostering health improvement. Health professionals also may address environmental concerns, such as safe, accessible water and healthy air. Over the next decade, more behavior change interventions around the world will be directed at changing individual and community behaviors related to basic hygiene and clean water consumption (Briscoe & Aboud, 2012) while also trying to reduce noncommunicable diseases around the world. The former problems are often a result of poverty and poor living conditions while the latter stem, in part, from growing influence of the developed world on developing nations.
Public health professionals work all over the world and in a variety of settings, including schools, worksites, nongovernmental organizations (including voluntary health organizations), medical settings, and communities. And professional fields other than health may also influence health behavior.
Since the time of the first edition of this book, there has been increased recognition that what happens in one part of the world affects us all, wherever we may be. Rapid changes in communication technologies have made the world a much smaller place and have accelerated the pace of sharing information and ideas. To the extent that public health is global health, and global health is local, we are committed in this volume to explore the use of health behavior theories around the world and to discuss the potential relevance of what is learned in one setting to other areas. While many of our examples are from research conducted in the United States, our perspective is decidedly global.
Since the fourth edition of this book was published seven years ago, the growth of new information and communication technologies has opened up an unprecedented range of strategies for health behavior change programs. Through the Internet, mobile devices, and wearables, health behavior change interventions are accessible to people all over the world, regardless of location. The result could be positive changes in health behaviors and health on a scale never before imagined, potentially reaching millions of people rather than hundreds or thousands.
There also is increased recognition that the fruits of research take too long to reach people who could benefit from them (Glasgow & Emmons, 2007; Viswanath, 2006). This has led to an increased emphasis on the dissemination of evidence-based interventions and attention to how interventions are implemented and scaled and to the growing field of implementation science. 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: Theory, Research, and Practice is that a dynamic exchange among theory, research, and practice is most likely to produce positive health behaviors. The editors believe, fundamentally, that theory and practice should coexist in a healthy d...