S E C O N D E D I T I O N Health Behavior Theory for Public Health Principles, Foundations, and Applications Ralph J. DiClemente, PhD Laura F. Salazar, PhD Richard A. Crosby, PhD Charles H. Candler Professor Rollins School of Public Health Emory University Atlanta, GA Professor Institute of Public Health Georgia State University Atlanta, GA Good Samaritan Endowed Professor Department of Health Behavior College of Public Health University of Kentucky Lexington, KY World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 info@jblearning.com www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. 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Cella Director of Product Management: Michael Brown Product Specialist: Carter McAlister Production Manager: Carolyn Rogers Pershouse Vendor Manager: Molly Hogue Senior Marketing Manager: Sophie Fleck Teague Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: codeMantra U.S. LLC Library of Congress Cataloging-in-Publication Data Names: DiClemente, Ralph J., author. | Salazar, Laura Francisca, 1960author. | Crosby, Richard A., 1959- author. Title: Health behavior theory for public health / Ralph DiClemente, Laura Salazar, Richard Crosby. Description: 2nd. | Burlington, Massachusetts: Jones & Bartlett Learning, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018008730 | ISBN 9781284129885 (paperback: alk. paper) Subjects: | MESH: Public Health | Health Behavior | Health Promotion | Models, Theoretical Classification: LCC RA776.9 | NLM WA 100 | DDC 614.4—dc23 LC record available at https://lccn.loc.gov/2018008730 6048 Printed in the United States of America 22 21 20 19 18 10 9 8 7 6 5 4 3 2 1 Project Management: codeMantra U.S. LLC Cover Design: Michael O’Donnell Rights & Media Specialist: Merideth Tumasz Media Development Editor: Shannon Sheehan Cover Image (Part Opener, Chapter Opener): © lzf/Shutterstock, Henrik Sorensen/Getty Images, MeskPhotography/Shutterstock, Hero Images/Getty Images Printing and Binding: Edwards Brothers Malloy Cover Printing: Edwards Brothers Malloy Dedications: To my three girls, Gina, Sahara, and Sianna. You are my Love, my Joy, my Passion, my Hope, and my Life. RJD To my wonderful and inspiring co-authors whose friendship, support, and mentorship mean the world to me and whose dedication and contribution to public health are an inspiration to all. LFS This book is dedicated to the next generation of public health professionals – the future of this profession, and the people it serves, are in your hands. RAC Special Dedication: James W. Curran, MD, MPH Dean, Rollins School of Public Health, Emory University To a friend, colleague, and public health leader. You have made an indelible footprint on the landscape of public health. Your leadership, passion, and scholarship are widely respected and an inspiration for all of us fortunate to serve with you in your effort to champion a public health of consequence. Contents Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Prologue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Acknowledgment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii SECTION I Overview 1 Chapter 1 Health Behavior in the Context of the “New” Public Health . . . . 3 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . . 23 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Chapter 2 How Theory Informs Health Promotion and Public Health Practice. . . . . . . . . . . . . . . . . . . . 25 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . . 39 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Chapter 3 The PRECEDE–PROCEED Planning Model. . . . . . . . . . . . . 41 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 An Applied Example. . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . . 55 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 SECTION II Conceptual and Theoretical Perspectives for Public Health Research and Practice 57 Chapter 4 Value–Expectancy Theories. . . . 59 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 An Applied Example. . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . . 72 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Chapter 5 Models Based on Perceived Threat and Fear Appeals. . . . . .73 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 An Applied Example. . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . . 91 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Chapter 6 Stage Models for Health Promotion . . . . . . . . . . . . . . . . . 94 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Global Application of the TMC. . . . . . . . . . . . . . . . 108 An Applied Example. . . . . . . . . . . . . . . . . . . . . . . . . . 113 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 113 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 v vi Contents Chapter 7 Social Cognitive Theory Applied to Health Behavior�����������������������������������116 Introduction�������������������������������������������������������������������117 Key Concepts�����������������������������������������������������������������118 An Applied Example���������������������������������������������������134 Take Home Messages�������������������������������������������������135 References ���������������������������������������������������������������������135 Chapter 8 Health Communication: Theory, Social Marketing, and Tailoring���������������������������137 Introduction�������������������������������������������������������������������138 Key Concepts�����������������������������������������������������������������141 Applied Examples�������������������������������������������������������155 Take Home Messages�������������������������������������������������158 References ���������������������������������������������������������������������158 Chapter 9 Ecological and Structural Approaches to Improving Public Health���������������������������160 Introduction�������������������������������������������������������������������161 Key Concepts�����������������������������������������������������������������164 Applied Examples�������������������������������������������������������175 Summary�������������������������������������������������������������������������177 Take Home Messages�������������������������������������������������177 References ���������������������������������������������������������������������178 Chapter 10 Social Network Theory. . . . . 180 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Intellectual Foundations and a Brief History. . . 181 Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Three Assets of Social Network Models. . . . . . . . 186 Health Effects of Social Networks . . . . . . . . . . . . . 188 Social Network Analysis. . . . . . . . . . . . . . . . . . . . . . . 190 Application Potential of Social Network Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 The Network-Individual-Resource Model. . . . . . 193 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 194 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Chapter 11 Diffusion of Innovations Theory�������������������������������������197 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 An Applied Example. . . . . . . . . . . . . . . . . . . . . . . . . . 212 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 213 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 SECTION III Application to Public Health Research and Practice 215 Chapter 12 Translating Research to Practice: Putting “What Works” to Work ���������217 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 238 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Chapter 13 Learning to Combine Theories: An Introduction to Intervention Mapping�����241 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 Understanding the Intervention Mapping Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 251 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252 Contents Chapter 14 Measurement and Design Related to Theoretically Based Health Promotion, Research, and Practice���������253 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 279 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Chapter 15 Evaluating Theory-Based Public Health Programs: Linking Principles to Practice�����������������������������������281 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284 vii A Step-by-Step Guide to Effective Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291 Making the Evaluation Even Better. . . . . . . . . . . . 296 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 300 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 Foreword John S. Santelli, MD, MPH Dr. Santelli is a Professor in the Department of Population and Family Health and Pediatrics in the Mailman School of Public Health at Columbia University. T heory is essential in understanding health behaviors and is critical in guiding health research. Theory helps us organize and understand information; it focuses attention on key issues; and it helps us select constructs for questionnaires. Theory is fundamental in designing, implementing, and evaluating interventions and in constructing policies to improve health and prevent disease. Thus, theory is essential to the work of public health. Health behaviors are influenced by factors related to the individual but are also shaped by the myriad of social and structural influences. For example, to understand adolescent contraceptive use, drug use, smoking, and drinking patterns, one needs to understand the origins of these behaviors and the social and environmental forces supporting them. Physicians who work in public health and address human behavior are well aware of this importance; while medicine is principally guided by a variety of biological theories, physicians rapidly come to understand that effective pharmacologic interventions often fail unless they address the behaviors of patients. Public health professionals intuitively grasp the importance of behavior change in influencing behaviors across the lifespan—from adolescent pregnancy prevention, to injury prevention and prevention of chronic disease, to promoting healthy aging. viii The “new public health” focuses on health promotion and the factors that enable individuals and communities to attain optimal health ­(Awofeso, 2004). In this new era, social education, and economic actions are provided to support attitudinal, behavioral, and social change. For example, health behavior theory has been highly influential in human immunodeficiency virus (HIV) prevention and treatment over the past 30 years, although the focus of interventions and the specifics of health behavior theory have shifted over time. In the early years of the HIV pandemic, behavioral risk reduction—­coupled with latex condoms and clean needles—was the only public health tool for prevention of new HIV infection (Lyles et al., 2007). With the advent of highly effective pharmacologic treatments, the new behavioral challenge became encouraging adherence to drug regiments. And when we discovered that effective pharmacologic treatment could be an effective HIV prevention strategy (so-called “treatment as prevention” approach, Cohen, McCauley, & Gamble, 2012), we realized again that behavioral change was essential to the success of this new biomedical strategy. In my field, adolescent health, understanding the origins of and influences on health risk behaviors is critical to effective health promotion. A recent Lancet Commission report outlined the triple dividend of investing in adolescent health: improving the health adolescents today, across the lifespan, and for the next generation (Patton et al., 2016). These investments need to address the social and structural factors (Viner et al., 2012) that influence adolescent risk behaviors. Behavioral theory is essential to understanding these social forces and promoting adolescent health and well-being. Foreword Health Behavior Theory for Public Health, ­Second Edition addresses the need to provide students with a highly accessible (easy to understand) collection of basic “tools” needed to design, implement, and evaluate health promotion programs. The most essential of these tools is an accurate understanding of the tenets and constructs comprising commonly used behavioral and social science theories. The selection of theories is carefully balanced to provide students with the diverse skill sets that are needed to design effective health promotion programs. In this new edition, all chapters have been updated and refined to improve the student learning experience—and new chapters added. All chapters also now contain pull quotes to ­highlight key points relevant to the chapter objectives. Chapter 9 on ecological strategies has been greatly augmented by adding two key theories commonly used to help resolve social inequalities: minority stress theory and intersectionality theory. The authors have updated applied examples, with one featuring the highly successful ­structural-level of intervention of Citibike in New York City and a second illustrating an ecological intervention in a campus-based violence prevention program. A new chapter (Chapter 13) teaches students the value of combining multiple theories to better understand—and thus better resolve—social inequalities in preventing disease. Using Intervention Mapping as the framework, this chapter provides an efficient set of practices that can be vital to public health professionals who are faced with challenges not easily addressed by the use of one theory in isolation. ix Finally, the three authors of this revised text (Ralph, Rick, and Laura) are among the “best of the best”, superb social and behavioral scientists who have devoted years to improving health via theory-driven, innovative public health interventions. Their life’s work has been dedicated to health promotion. Their thinking in this new edition is very much aligned with modern thinking about ecological influences. Moreover, because it is an authored text, there is strong integration of the chapters. Visuals, margin quotes, learning objectives, practice questions, make the text a unified learning experience. With this second edition, they have created a “one-stop shop” to prepare the next generation of public health professionals to carry on the important work of behavior change. ▸▸ References Awofeso, N. (2004). What’s new about the “new public health”? American Journal of Public Health, 94(5), 705–709. Cohen, M. S., McCauley, M., & Gamble, T. R. (2012). HIV treatment as prevention and HPTN 052. Current Opinion in HIV and AIDS, 7(2), 99. Lyles, C. M., Kay, L. S., Crepaz, N., Herbst, J. H., Passin, W. F., Kim, A. S., … Mullins, M. M. (2007). Best-evidence interventions: Findings from a systematic review of HIV behavioral interventions for US populations at high risk, 2000–2004. American Journal of Public Health, 97(1), 133–143. Patton, G.C., Sawyer, S. M., Santelli, J. S., Ross, D. A., Afifi, R., Allen, N. B., … Viner, R. M. (2016). Our future: A Lancet commission on adolescent health and wellbeing. The Lancet, 387(10036), 2423–2478. Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., & Currie, C. (2012). Adolescence and the social determinants of health. The Lancet, 379(9826), 1641–1652. Prologue H ealth promotion is a cornerstone of public health practice. In turn, the primary task of health promotion involves leveraging and sustaining long-term health-­protective behaviors across diverse populations. Meeting the very difficult challenges inherent in fostering health-protective behaviors requires the wise and parsimonious use of behavioral and social science theories. These theories can best be viewed as the tools of the trade, and this text is designed to help you master those all-so-­important tools. Before you begin this learning process, it is crucial that you understand a basic principle: learning about the full array of currently used theories in health promotion practice is essential to the ultimate success of any public health program you may design and implement. In many ways, your work in health promotion is similar to that of a highly skilled craftsperson. You will be crafting interventions and it is unlikely that any two programs will be “built” in the same way. This is true because even if you plan to change the same behavior in a subsequent program, the population served by that program is bound to be markedly different than the population originally served by the same program. So, think of yourself as a craftsperson who can effectively assess the needs of any population relative to their longterm adoption of health-protective behaviors. Your theory “toolbox” will facilitate this assessment and it will also allow you to develop an effective intervention approach. Another important preliminary lesson is that each of the theories in your toolbox may, at first blush, appear to be distinctively different. As you read this text, rest assured that the theories you learn about each have a unique role in changing x health behavior. Learning about and using only a few of the many theories is unlikely to lead to successful health promotion programs. Similarly, learning about theory in the absence of learning about core practices such as measurement, evaluation, and planning will not be adequate if your goal is to truly have an impact on population health. As such, the second edition of Health Behavior Theory for Public Health will provide you with a balanced professional education—one that teaches you about the essential spectrum of theoretical tools as well as the core practices. This text will open by providing you with a firm foundation (Section I) for developing expertise in public health theory and related core practices. Please pay special attention to the concepts and terminology, as this added effort will certainly pay great dividends in your career. ­Section I is focused on health, public health, health behavior, and health promotion planning, rather than theory per se. Indeed, you will learn in this section that there is much more to understanding and changing health behavior than ­simply being wellversed in theory. Section II provides you with the ability to gain a command of the theories and approaches most commonly applied in public health research and programs. We have taken great strides to present this material in a very straightforward manner and within the context of current relevant challenges in the field. As you finish this section you will see how theory “fits” into the larger scope of public health research and practice as described in Section I. The text will close by providing you with a diverse set of application “tools” (Section III). These fairly advanced chapters were designed to Prologue bring all that you have learned in Section I and Section II into a more practical light. Here, you will learn about the essential tasks of translation, learning to combine theories, measurement, and program evaluation. Again, we emphasize the point that understanding and changing health behavior is challenging and requires multiple skills beyond the ability to apply theory. Finally, we invite you to use an evaluative eye as you read this text. By using this phrase, we are suggesting that you should avoid the academic trap of looking at ideas as being correct or incorrect. Instead, think of each new idea as an opportunity to indulge in critical thinking. When learning about various theories or core practices, you may want to ask yourself questions such as “Is this approach logical and can it be reasonably translated into practice?” Learn to think in terms that transcend the universal terms of correct or xi incorrect and challenge yourself to think about questions such as, “When would this approach work best and when would it work poorly, or not at all?” Our goal for the next generation of public health professionals is for them to develop effective programs designed to avoid premature morbidity and mortality. We recognize that this work is as important as the work of traditional medical professionals and that effective public health programs can make a difference that transcends the limitation of a medical paradigm. This text will provide you a broad acumen of knowledge and skills that will ultimately serve your needs in the work you do to advance health promotion practice. We trust that your dedication to preventing disease will become greater than ever as you gain the ability to truly have an impact on the lives of others. Acknowledgment We wish to thank Mike Brown of Jones & ­Bartlett Learning for believing in this text and encouraging us to write this second edition. His collegiality, great humor, and dedication to quality are all greatly appreciated traits. We look forward to working with him in the future. xii Contributors John Acker, BA Department of Psychology University of Georgia Rita K. Noonan, PhD Behavioral Scientist Centers for Disease Control & Prevention Michael T. Amlung, MS Department of Psychology University of Georgia Lara Ray, PhD Department of Psychology University of California, Los Angeles James G. Emshoff, PhD EMSTAR Research, Inc. Colleen A. Redding, PhD Research Professor Cancer Prevention Research Center University of Rhode Island James MacKillop, PhD Department of Psychology University of Georgia Center for Alcohol and Addiction Studies Brown University James H. Walker, BA, BS Rollins School of Public Health Emory University Cara M. Murphy, BS Department of Psychology University of Georgia Seth M. Noar, PhD Associate Professor School of Journalism and Mass Communication Lineberger Comprehensive Cancer Center University of North Carolina at Chapel Hill xiii SECTION I Overview ▸▸ Introduction Above all else in life, the maintenance of health may be the one universal value. Being healthy means being free of disease and having the resources to take active measures to fortify the body against the onset of both chronic and infectious diseases—this level of prevention also provides people with a vitality that leads to productive and satisfying lives. Unfortunately, many societies (including the United States) broadly support recovery from chronic and infectious diseases at the expense of the more complicated task of preventing these problems in the first place. The ethic of placing prevention on the “pedestal of medicine” is a largely unrealized vision. A more practical vision is known as “upstream thinking,” which implies that preventing the onset of disease or injury is the greatest priority in public health. The concept of upstream thinking implies that nations should prioritize prevention over treatment. Given the overarching influence of social determinants on health, this concept also implies that social equity must become a frontline effort of health-promotion programs. Health equity is the obtainment of the highest level of health for all members of a population. Health inequities then are differences in health that are avoidable and therefore unjust. To achieve health equity, we need to foster efforts pertaining to eliminating those avoidable health inequities and their corresponding outcomes (i.e., health disparities). Health equities pertain to health, whereas social equities pertain to equal opportunities for all people, regardless of race, ethnicity, gender, sexual orientation, or religious beliefs. Social equity guarantees health equity because it promotes unfettered access (and comparable access) to the advantages of a society that protect health and prevent disease. Achieving social equity, however, implies that some members of a population will need more support/access than others to bring them to the same level of opportunity. Stated differently, social disadvantages create an initial unequal starting point for some people—these people cannot be said to have social equity until those deficits are made up. This means that some people will have more support/access needs than others, and thus, a need exists for disproportionate distribution of resources before true social equity. Upstream thinking is not always an easy paradigm. It demands an understanding of why people place themselves at risk of disease and why they adopt health-protective behaviors. It also demands an understanding of how people 1 2 Section I Overview manage to successfully adopt health-protective behaviors, especially those behaviors requiring daily repetition. Most importantly, it demands a thorough understanding of the social determinants of health and a corresponding commitment to achieving equity on the distribution of these determinants. Fortunately, a vast range of theories can be used to traverse these multiple challenges of upstream thinking. Modern theory spans a range from those that locate the behavior and change efforts strictly at the individual level to ecological theories, suggesting that behavior is a product of multiple and often interlocking environmental influences. All theories are ultimately useful in the larger process of changing health-risk behaviors. This process, however, is far more involved than one might first imagine. A central starting point is to empirically identify the determinants of health-risk and health-protective behaviors. Determinants that are potentially modifiable can then be conceived as hypothesized mediators of behavior change. Theory can be used to define specific objectives meant to alter these hypothesized mediators in a way that leads to effective behavior change for large numbers of people, even entire populations The wise selection of theory is, of course, vital, because the process just described is one that can easily go wrong if program objectives are ill-conceived because of a theory that poorly matches the identified health-promotion challenge at hand. In the first two chapters, you will learn much more about the concept of upstream thinking, particularly with respect to the concepts of primary prevention and universal care. Some of what you learn may challenge current beliefs you hold regarding health and medical care, and may even challenge the concept that apparently simple health behaviors may be influenced by a complex web of ecological factors. We suggest that any challenges to your current belief systems be embraced, as this is the first and most critical stage of your growth as a health-promotion professional. Further, we suggest that you diligently learn the basic vocabulary of health promotion as shown by the bolded terms in these two chapters. You will soon become proficient at using terms such as construct, proximal influence, distal ­influence, and multilevel intervention. We also implore you to study Chapter 3 quite carefully. This chapter provides you with a widely used framework that is useful for conceptualizing the entire process of planning a health-promotion program. As you study Chapter 3, please bear in mind that theory application and program planning are not synonymous. Think of theory application as a subset of program planning. Program planning is a larger concept simply because it includes elements related to problem assessment, goal setting, and evaluation. Chapter 3 introduces a long-standing and highly practical approach known as the PRECEDE–PROCEED model. For several decades, this planning model has served public health effectively through its ability to achieve targeted and judicious use of resources and health-promotion efforts. An important caveat is warranted before you begin reading these three chapters: public health practice is an activity rather than a specific discipline. This statement reflects the growing tendency of public health practice to implicate a spectrum of likely intervention points for any given health behavior. Thus, public health efforts span a continuum ranging from media-based health communication programs to making products easily accessible (e.g., condoms, low-fat foods, bicycle helmets, exercise facilities). The continuum spans further to include changes to public policy and laws. It will become apparent that people from numerous professional backgrounds are needed to promote conditions favoring widespread and longterm adoption of health-protective behaviors. The question you may then ask is, “What holds all of these various professionals together in a unified effort to promote health in an upstream thinking paradigm?” To this question, we respectfully suggest that the concepts you will learn about in the entire text represent a type of shared wisdom that indeed defines the work of health promotion. Your dedication to these chapters will have an important influence on your ability to protect the health of the public through prevention of disease and conditions that would otherwise limit the quality and longevity of people’s lives. CHAPTER 1 Health Behavior in the Context of the “New” Public Health Laura F. Salazar, Richard A. Crosby, and Ralph J. DiClemente The health of the people is really the foundation upon which all their happiness and all their powers as a state depend. —Benjamin Disraeli, British Politician (1804–1881) PREVIEW Unhealthy behaviors contribute to the leading causes of early mortality. As such, if health-promotion efforts can prevent people from engaging in many of these behaviors, then health-promotion can make a significant impact on the rates of early mortality and morbidity. Using a wide range of theories in its endeavors, health promotion seeks to change environments, settings, policies, regulations, and individuals so that optimal health can be achieved. OBJECTIVES 1. Compare and contrast the three levels of prevention. 2. Understand the different types of health behaviors. 3. Define health promotion and understand the multidisciplinary nature of health promotion. 4. Understand the importance of multiple theories in health-promotion efforts. 5. Understand that health behavior is highly influenced by the physical, economic, legal, and social environments that define people’s daily existence; thus, a broad range of theoretical approaches provides increased assurance of leveraging change. 3 4 Chapter 1 Health Behavior in the Context of the “New” Public Health ▸▸ Introduction Without question, health should be the most valuable thing in a person’s life. An old Arabic proverb states, “He who has health, has hope; and he who has hope, has everything.” But what, exactly, is health? Some would argue that health is simply the absence of disease. According to the World Health Organization (WHO), health is not merely the absence of disease or infirmity; rather, health should encompass a state of complete physical, mental, and social well-being. Expanding on this definition at a seminal conference in Ottawa, Ontario, Canada, the WHO reconceptualized health, in that it should be defined from an ecological perspective to encompass the “extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs; and, on the other hand, to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living; it is a positive concept emphasizing social and personal resources, as well as physical capacities” (World Health Organization, 1986). Using these definitions, health would seem to transcend an individual’s state of physical being at any given moment to also include his or her ability to optimize his or her health and the availability of environmental resources that enable him or her to maintain his or her health over time. Thus, to embrace these definitions of health requires perhaps a paradigm shift in terms of conceptualizing what health is, what the determinants of health are, and most importantly how to promote health. A basic premise of Health Behavior Theory for Public Health: Principles, Foundations, and Appli­ca­tions is that, as Benjamin Disraeli so succinctly stated, an important goal for any nation is the health of its peoHealth is not merely ple, but we advocate that the means to this the absence of end lie in adopting disease or infirmity; strategies that modify rather, health should environments, setencompass a state tings, and policies/ of complete physical, regulations while also mental, and social targeting the many individual factors that well-being. influence health. A key principle in health promotion involves understanding the nature of the diseases that are most likely to occur in a population. At the turn of the 20th century (see FIGURE 1-1), the top three causes of death were attributed to infectious disease agents that caused pneumonia, tuberculosis, diarrhea, and enteritis (Centers for Disease Control and Prevention [CDC], 1999). Early public health efforts were very successful in implementing important new biomedical advances (e.g., vaccinations and antibiotics) and developing public health programs that remedied many types of infectious diseases (e.g., water sanitation to reduce cholera), eradicated some diseases (e.g., smallpox), and mitigated many afflictions. However, as the incidence of these diseases decreased, chronic diseases (e.g., cardiovascular disease, diabetes, and cancer) flourished. Toward the end of the 21st century, individual lifestyle behaviors, such as smoking, poor diet and exercise, alcohol consumption, and the use of illicit drugs, were primary contributors to the six leading causes of death (Mokdad, Marks, Stroup, & Gerberding, 2004). These behaviors are deemed “lifestyle behaviors” because they take place within the context of individuals’ everyday lives. These specific lifestyle behaviors have been cited as actual causes of death because they have been linked directly to the top five chronic diseases: heart disease, cancer, cerebrovascular disease, respiratory disease, and diabetes (McGinnis & Foege, 1993; Mokdad et al., 2004). Clearly, a person who contracts an infectious disease such as cholera, pneumonia, or tuberculosis would most likely hold the perception that they were not healthy; however, it may not be as clear to people who smoke, eat high-fat foods, do not exercise, consume too much alcohol, or use illicit drugs that they are unhealthy. They may hold an inaccurate perception of their health, which is most likely due to the hidden contribution of engaging in unhealthy lifestyle behaviors to the development of chronic diseases, rather than the more noticeable infectious or communicable diseases. Chronic diseases manifest over time, are not always apparent, and may be long-lasting or recurring. In TABLE 1-1, we list various chronic diseases that may result from engaging in several unhealthy lifestyle behaviors and are linked to the leading Introduction Public health issues, 1900 Pneumonia and influenza 12.0% 11.0% Tuberculosis 8.3% Diarrhea and enteritis Heart disease 6.2% Stroke 6.0% Liver disease 5.2% Injuries 4.2% Cancer 3.7% Senility 2.9% Diphtheria 2.3% 0% 10.0% 20.0% 30.0% 40.0% Percentage of all deaths, 1900 Public health issues, 1997–present 31.4% Heart disease 23.3% Cancer Stroke 6.9% Chronic lung disease 4.7% Unintentional injury 4.1% Pneumonia and influenza 3.7% Diabetes 2.7% Suicide 1.3% Kidney disease 1.1% Chronic liver disease 1.1% 0% 10.0% 20.0% 30.0% 40.0% Percentage of all deaths, 1997 FIGURE 1-1 The 10 leading causes of death, as a percentage of all deaths—the United States, 1900, 1997 Centers for Disease Control and Prevention, National Center for Health Statistics. (1999). Achievements in Public Health, 1900–1999: Control of infectious diseases, 1900–1999. Morbidity & Mortality Weekly Report, 48, 621–629. 5 6 Chapter 1 Health Behavior in the Context of the “New” Public Health TABLE 1-1 Chronic Diseases Associated with Unhealthy Lifestyle Behaviors SMOKING: Acute myeloid leukemia; cancers of the cervix, kidney, bladder, esophagus, larynx, lung, mouth, pancreas, and stomach; abdominal aortic aneurysms; cataracts; periodontitis; pneumonia; chronic lung disease; chronic heart and cardiovascular diseases; osteoporosis; peptic ulcers; reproductive problems HIGH-FAT DIET: Coronary heart disease, type 2 diabetes, cancers (endometrial, breast, and colon), hypertension (high blood pressure), dyslipidemia (e.g., high total cholesterol or high levels of triglycerides), stroke, liver and gallbladder disease, sleep apnea and respiratory problems, osteoarthritis (a degeneration of cartilage and its underlying bone within a joint), gynecological problems (abnormal menses, infertility) ALCOHOL: Cardiovascular disease; liver disease; chronic pancreatitis; pancreatic, breast, liver, oral, colon, and throat cancers ILLICIT DRUGS: Suicide, homicide, motor vehicle injury, HIV infection, pneumonia, violence, mental illness, hepatitis Photos from top to bottom, © Photos.com, © Digital Vision/Photodisc/Thinkstock, © SunnyS/Shutterstock © Vladimir V. Georgievskly/Shutterstock causes of death in the United States. In viewing the associated disease outcomes, you may surmise that many people are unaware that these diseases are significantly linked to these unhealthy behaviors. Although there is no definitive answer as to exactly how many years of unhealthy lifestyle behavior it takes to develop some of these chronic diseases, it is generally agreed that the time is best thought of in terms of years. Thus, it is understandable why so many people engaging in these lifestyle behaviors may not perceive themselves at risk for disease in the same way as a person who was recently exposed to someone coughing on an airplane or who may have worked in an environment that was harmful (e.g., manufacturing of asbestos textiles). If the consummate goal is to ensure the health of the people, then individual perceptions of health or what constitutes “unhealthy” may exert some influence on whether appropriate action is taken by society or by the individual. This text emphasizes that public health initiatives to combat both chronic and infectious diseases and improve the health of the public should be multidimensional—that is, health-promotion efforts should target systems and political structures to affect the underlying social determinants of health and their corresponding health behaviors. This emphasis on the significant role of environmental influences in shaping individual behavior and affecting health is the driving force behind the “new public health.” An expedient summary of the new public health is provided by the director of the Centers for Disease Control and Prevention, under the Obama administration. ­FIGURE 1-2 illustrates the relative strength Introduction Increasing population impact Counseling and education 7 Increasing individual effort needed Clinical inerventions Long-lasting protective interventions Changing the context to make individual’s default decisions healthy Socioeconomic factors FIGURE 1-2 Frieden pyramid Reproduced from Frieden, Thomas. A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health. 2010 April; 100(4): 590–595. of five factors influencing public health, with the largest (i.e., strongest) contribution coming from socioeconomic status. This is precisely why the new public health has an emphasis on social equity. Beyond socioeconomic status, in order of strength, the remaining four factors involve Public health making ecological changes that enable initiatives to combat the “easy” adoption both chronic and of health-­protective infectious diseases and behaviors, the use improve the health of of planned interthe public should be vention programs multidimensional— shown to have long-­ lasting effects on that is, healthhealth behavior, clinpromotion efforts ical interventions, should target and counseling/ systems and political education-­based prostructures to affect grams. Noteworthy the underlying in this pyramid is that clinical interventions social determinants occupy a relatively of health and their small fraction of the corresponding health overall influence behaviors. on the health of a population. This chapter provides an overview of the importance of health behavior (i.e., reducing unhealthy behaviors while also promoting healthy ones) in achieving optimal health. We describe how the best approach emphasizes prevention and targets settings where behavior takes place. You have most likely heard the famous adage attributed to Benjamin Franklin: “An ounce of prevention is worth a pound of cure.” He believed that it is wiser and more cost-­effective to try and prevent a disease from manifesting rather than to treat it. Public health, in general, embraces this adage; its mission is prophylaxis, or prevention, of early mortality, ­morbidity, and associated negative health ­outcomes. Changing or modifying health behaviors that are associated with morbidity and early mortality is considered one aspect of a prevention approach. Because health behaviors can contribute significantly to early mortality and morbidity, understanding and changing health behaviors and the surrounding conditions that influence behavior are critical to achieving public health’s mission. We also provide an overview of public health and describe the rationale for public health approaches that target whole populations rather than only those individuals at heightened risk. We Chapter 1 Health Behavior in the Context of the “New” Public Health articulate the role of health promotion in the context of public health and the basic principles and strategies used. We express that the field of public health is multidisciplinary and involves a process, rather than being a unified field, like physics or chemistry. Finally, we highlight the role of theory in public health research and practice and the importance of choosing the proper framework. ▸▸ Key Concepts Why the Emphasis on Prevention? Once one is afflicted with a disease, medical approaches must be used for treatment. Treatment can be very costly, not everyone has access to treatment, and furthermore, treatment is not always a panacea; treatment cannot “fix” many health issues (e.g., dead heart muscle tissue). In 2015, the United States spent $3.2 trillion (representing 17.8% of the gross domestic product) on health care or $9,990 per person (Centers for Medicaid and Medicare Services [CMS], 2015). As shown in FIGURE 1-3, the United States spends more on health care, both as a proportion of gross domestic product and on a per capita basis, than any other country in the world (WHO, 2009). Given the enormous price tag associated with U.S. healthcare costs, you would imagine that the United States should be getting what they pay for in terms of much lower early mortality and morbidity rates. Unfortunately, statistics do not support this assertion. In fact, the United States ranks 47th in terms of life expectancy, 9th in terms of cancer death rates, 13th in heart disease death rates, and 1st in obesity rates (http://www .NationMaster.com). Despite its drastically smaller population size (approximately 300 million), the United States ranks with India (approximately 1.1 billion people) and China (approximately The cost of a long life 82 5000 United States Average life expectancy 81 4500 4000 80 3500 79 3000 78 2500 77 2000 1500 76 1000 75 500 74 Japan San Marino Monaco Switzerland Australia Sweden Iceland Andorra Canada France Italy Austria Spain Norway Singapore Israel Luxembourg New Zealand Netherlands Germany Greece Malta Belgium Finland United Kingdom Denmark United States Cuba Cyprus Ireland Portugal 0 Life expectancy Per capita spending (International dollars) FIGURE 1-3 Per capita healthcare costs and life expectancy around the world Reproduced from UC Atlas of Global Inequality, http://ucatlas.ucsc.edu/spend.php, Health care spending. Per capita spending 8 Key Concepts 1.3 billion people) in terms of the number of estimated cases of diabetes. Diabetes is an excellent example of a prime opportunity for improved population-based prevention. Type 2 diabetes is the most common form of diabetes and has been linked to obesity, inactivity, and genetic factors. Ignoring the genetic component (as this is largely not amenable to change), obesity is considered a modifiable risk factor as it can be changed. If the rates of obesity and inactivity among the population were somehow reduced significantly, a reduction in the prevalence of type 2 diabetes should be experienced as well, thereby reducing the associated mortality rate. Now consider that one out of every five U.S. federal healthcare dollars is spent treating people with diabetes (American Diabetes Association, 2008). If treating people with diabetes represents 20% of healthcare dollars spent, then a better approach may be to prevent diabetes rather than treat diabetes. Unfortunately, according to former U.S. Surgeon General Dr. David Satcher, of the total dollars spent on national health care in the year 1999, only 1% went to population-based prevention. Some estimates suggest that the U.S. government spends $1390 per person to treat disease, while spending only $1.21 per person on prevention. Although this represents an enormous imbalance in the amount of money spent on treatment versus prevention, the United States does make a concerted effort. To combat many of the lifestyle diseases afflicting its populace in the later part of the 20th century and to enhance the health of its people, the United States created a national prevention agenda. The 1979 Surgeon General’s Report on health promotion and disease prevention, Healthy People, outlined the tremendous gains made in combating infectious diseases in the earlier part of the 20th century, stating that “the health of the American people has never been better.” However, he also stated that further improvements could be achieved through a “renewed national commitment to efforts designed to prevent disease and to promote health” (U.S. Department of Health, Education & Welfare, 1979, p. 3). Healthy People laid the foundation for a national prevention agenda that spanned a wide range of health goals focused 9 on reducing early mortality and morbidity, such as a reduction in smoking, an increase in physical activity, and a reduction in injuries. Most important is that Healthy People as a policy signified that the United States must take responsibility for the health of its people. The agenda has since been updated and goals reexamined every 10 years. The 1980 Promoting Health/Preventing Disease: Objectives for the Nation and Healthy People 2000: National Health Promotion and Disease Prevention Objectives both established national health objectives and served as the basis for the development of state and community plans. Presently, Healthy People 2020 has built on the work of the past three decades and has implemented a 10-year health-promotion program with four overarching goals: 1. 2. 3. 4. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages. The focus is on different health areas (e.g., sexually transmitted diseases, substance abuse, tobacco use, diabetes, cancer, HIV), accompanied by 600 public health objectives and leading health indicators to measure the progress toward meeting its goals. The question remains, however, as to whether the U.S. government will balance the scales and devote enough funds toward prevention so that it can meet these goals. Passage of the Affordable Care Act in 2010 created historic strides toward shifting funds to the prevention of disease. Whether these strides continue in the future will be crucial to the health of U.S. citizens. Health Behavior Is Complex The central question, irrespective of funding, is: how do we work toward achieving these prevention goals? Focusing on type 2 diabetes, specifically, how 10 Chapter 1 Health Behavior in the Context of the “New” Public Health do we prevent people from becoming obese? How can we motivate and enable people to adopt better dietary habits, lose weight, and exercise more? What systems-level changes or policy/regulations changes can be made to promote consistent exercise behaviors and improved dietary habits among persons most at risk of diabetes? What social inequities must be addressed and rectified to optimally prevent diabetes? We may think that all we need to do is tell people that they are at risk and that making people aware of their risks will result in them changing their dietary and exercise behaviors. Unfortunately, changing behavior is not as simple as it seems. Persuading a person to change his or her habits is a major challenge indeed, especially when the behavior is viewed as enjoyable (e.g., eating a juicy hamburger) or when they may not have complete control (e.g., a child whose parent makes the decisions about food or a person who can only afford high-calorie foods of low nutritional value such as fast-food “bargains”). The reality is that human behavior is complex and influenced by many factors; therefore, changing it requires a thorough understanding of the range of influences. For example, changing dietary habits such that whole foods (i.e., foods that are unrefined and unprocessed) compose the majority of the daily caloric intake implies understanding (1) why people prefer processed foods; (2) what people do not like about whole foods; (3) the benefits that people perceive from consuming less processed foods; (4) the physical, economic, political, cultural, and social barriers that people perceive relative to the consumption of whole foods; (5) the barriers to stocking produce and other whole foods among grocery stores; and (6) the national and local policies that translate to the cost-prohibitiveness of providing whole foods. In essence, Before we can change reducing the obesity health behavior, we epidemic will involve must understand the h e a lt h - prom ot i on determinants of the efforts that address all behavior, the nature six of these questions, of the behavior, and with an emphasis on the latter three. the motivation for the Before we can behavior. change health behavior, we must understand the determinants of the behavior, the nature of the behavior, and the motivation for the behavior. Influencers (also referred to as “drivers”) of behavior can theoretically be infinitesimal and can include a range of factors, such as biological characteristics, personality characteristics, family, peers, the community, society, and the built environment. Moreover, the nature of health behaviors can vary along many dimensions. For example, some health behaviors may occur once in a lifetime (e.g., polio ­vaccine), some on a daily basis (e.g., diet, exercise), and some are conditional to the context (e.g., using a condom). Furthermore, motivation for engaging in a health behavior or to stop engaging in an unhealthy behavior will also be affected by numerous individual, environmental, and policy/ regulatory factors. So, how do we begin to make a dent in achieving the prevention goals of Healthy People 2020 and eventually Healthy People 2030? First, understanding what factors contribute, cause, precede, influence, and motivate health behaviors, and then how to effectively modify those factors so that behavior change is achieved is the basic premise of health promotion. Health promotion is an integral part of the “new public health” approach and involves two aspects: research and practice. Indeed, public health professionals are increasingly recognizing that the mainstays of epidemiology and healthcare service administration lack the ability to change population-level indicators of health. The realization is that changing behaviors in a population and creating environments conducive to healthy behaviors are possibly the ultimate solutions to the long-standing question of how best to improve the health of the public. Health-promotion research is at the forefront of understanding the underlying individual, environmental, and policy/regulatory factors that influence health behavior. Conversely, health-­promotion practice is at the forefront of designing and implementing interventions to modify those factors and to ultimately change behavior. Thus, health promotion can be viewed as a process for which many public health, medical, and education professionals, whether on the research side or the practice side, have a responsibility and play an integral role in promoting health. The tool used for health-promotion research and practice is theory. Key Concepts A theory is a set of testable propositions that is used to explain a group of facts or phenomena. In health promotion, theory enables researchers to better understand health behavior and make predictions about how to change behavior. Just as there are a multitude of health behaviors, there are many theories that attempt to explain these health behaviors. Unfortunately, in this text, we cannot cover all of them; however, we do describe many of the theories widely used today in health promotion research and practice. Before we proceed to the description of these theories, it may be helpful to provide a foundation of health behavior in the context of public health. Prevention and the Public Health Approach In broad terms, public health seeks to promote health, prevent early mortality and morbidity, and enhance or ensure quality of life. Prevention is the basic principle underlying the public health approach. In fact, the leading public health agency in the United States—the Centers for Disease Control and Prevention (CDC)—has the following mission statement: “To promote health and quality of life by preventing and controlling disease, injury, and disability.” The CDC motto of “Saving Lives, Protecting People” is very much a reflection of a prevention-based orientation. From a public health perspective, the essence of prevention is creating healthy populations, meaning that the incidence of chronic disease, infectious disease, and injury decline dramatically. In our experience, the implications of a prevention-­ oriented approach to public health are often difficult for students to fully comprehend without first “divorcing” themselves from a medical orientation to public health. FIGURE 1-4 provides a visual depiction, suggesting that the prevention of disease entails far more than averting clinically observable illness. As shown in Figure 1-4, clinically observable illness can be viewed as the midpoint of a continuum ranging from optimal wellness to extreme illness. Coronary vascular disease serves as a good example to illustrate this division. Clinically observable early warning signs of a heart attack, for example, can be diagnosed through a treadmill stress test. Proxy measures of pending blockages in coronary arteries include high serum cholesterol levels, high blood pressure, and high body mass index (BMI). From a medical orientation, the prevention of a heart attack is about defining a threshold for high blood serum cholesterol, high blood pressure, and a risky level of BMI. Once these thresholds are established, any person who exceeds any one threshold can be “treated” under the prevailing medical paradigm. Failure to do so will presumably result in increased coronary occlusion followed by the eventual blockage of the blood supply to the heart, possibly inducing death. Wellness Illness Prevention orientation Medical orientation Clinically observable problems FIGURE 1-4 Wellness–illness continuum 11 12 Chapter 1 Health Behavior in the Context of the “New” Public Health a second figure may be The inherent problem quite useful. The public health of intervening only at orientation, in contrast, the tail is that even is perhaps best embodwhen success occurs ied by the motto of the and these people join Bloomberg School of the masses near the Public Health at Johns mean, more people Hopkins University: Protecting Health, Savwill continue to move ing Lives—Millions into the tail. at a Time. This extension of the CDC motto clearly defines health at the population level. In his book titled The Strategy of Preventive Medicine, Geoffrey Rose, a British physician, developed the skewed distribution curve shown in FIGURE 1-5, also known as the Rose curve (Rose, 1992) that guides thinking about population-level intervention. This drawing is quite useful because it gives a visual image of those considered “at risk” because of their diet and the associated negative health outcomes as composing the right-end tail of the distribution; those not at risk would fall under the rest of the area under the curve. Think of the tail in this curve as being the portion of a population located on the right side of the wellness–illness continuum. It follows, then, that the remaining area under the curve represents that portion of a population somewhere to the left of the center point in the wellness–­ illness continuum. The medical orientation can be Percentage of population Percentage of population The problem with the “prevention ← medical” orientation is that it begins with a diagnosis and is reactive, thereby restricting the arena of the doctor–patient relationship and defining prevention in medical terms. This limits the public health approach to changing people literally one at a time. Conversely, the “prevention → medical” orientation (left part of Figure 1-4) lends itself to a ­population-level approach because it is not predicated on an individual medical diagnosis. Instead, this orientation acknowledges that defining what levels constitute high cholesterol, high blood pressure, and high body mass is problematic and that everyone in a population can benefit from lower cholesterol, lower blood pressure, and less body fat. In this orientation, prevention activities are most often implemented before clinically defined levels of risk are reached by people. The intent is to figuratively “pull” people further to the left of the continuum (as far away from illness as possible). Unlike the medical approach, this orientation does lend itself to intervening with entire populations, rather than taking a one-at-a-time approach to public health. Unfortunately, the one-at-a-time approach to prevention has been frequently applied without success to the task of changing health behaviors, as well as changing risk factors (such as high cholesterol) through medication. This individual-level approach to behavior change is not necessarily relegated to the right side of the wellness–illness continuum shown in Figure 1-4. Thus, at this juncture, Low consumption High consumption Low consumption Fat in diet A FIGURE 1-5 Example of a Rose curve High consumption Fat in diet B Key Concepts viewed as a type of intervention that only happens with people located in the tail of the curve. The inherent problem of intervening only at the tail is that even when success occurs and these people join the masses near the mean, more people will continue to move into the tail. This occurs because the social inequities, system influences, and policy/ regulatory influences do not change. Thus, the task of intervening with people who are already ill becomes never ending. Think of Sisyphus rolling his boulder up the hill for all of eternity! The following reference to the Multiple Risk Factor Intervention Trial (MRFIT) depicts this concept: [E]very time we helped a man in [MRFIT] to stop smoking, on that day, probably one to two children in a schoolyard somewhere were taking their first tentative puffs on a cigarette . . . So, even when we do help high-risk people to lower their risk, we do nothing to change the distribution of disease in the population because, in one-to-one programs . . . we do nothing to influence forces in society that caused the problem in the first place (Syme, 1996, p. 463) As a result of the limitations that accompany the at-risk paradigm, public health strategies have increasingly been directed at the goal of moving the population mean to the left of the curve shown in Figure 1-5. By shifting the mean to the left, everyone in the distribution benefits and ultimately the population as a whole experiences an increase in health behavior, and perhaps a decrease in eventual morbidity and mortality (Syme, 1996). The concept of moving the population mean to the left of the Rose curve corresponds quite nicely with a prevention-orientation goal—the goal is to lower everyone’s level of risk rather than targeting only those at greatest risk or those who have manifested the disease. This goal allows intervention to transcend a one-at-a-time approach, thereby allowing for change strategies that can be applied to entire populations. This involvement at the level of entire populations is the essence of public health. A popular analogy to illustrate the concept of population-based prevention versus individual 13 treatment is the “upstream allegory.” In this story, fishermen fishing downstream observe streams of people coming down the river struggling not to drown. The fishermen must spend all their time pulling these individuals out of the river to save them. After exhausting their efforts, they finally decide to move upstream to see why so many people have fallen into the river. They quickly ascertain that there is no protective barrier at the edge of the riverbank; thus, when people are drawn to the riverbank, it is quite easy for them to fall into the raging waters. Consequently, community leaders decide to put up a railing at the edge of the riverbank, which results in significantly fewer people falling into the water. Not only does this benefit the people who would have fallen in, but it also benefits the fishermen, as they do not have to spend their time and resources rescuing people. This “intervention,” in turn, benefits the entire community: the community has reduced rates of early mortality; they have more fish to eat; and they sell what is left over to the neighboring community, generating economic revenue. Thus, everyone’s quality of life has improved in many ways. From this story, it is easy to see why the medical approach is considered a downstream approach (treating individuals on a case-by-case basis after falling in), whereas public health is considered an upstream approach (instituting changes to prevent large numbers of people from ever falling in). The upstream approach equates with primary prevention, which is one of three levels of prevention identified by epidemiologists Hugh Leavell and Guerney Clark (1960), with secondary prevention and tertiary prevention being the other two levels. Using our analogy, secondary prevention equates with saving people who perhaps have just fallen in, but well before they have been caught up in the current and are drowning. Tertiary prevention in public health targets people who can treat the disease and/or people who have the disease with the goal of mitigating the disease’s effects; thus, tertiary prevention would equate with targeting the fishermen and teaching them how to more effectively save drowning people or targeting the drowning people and teaching them to tread water to buy them more time so that they can be saved. These different levels of prevention equate with the three stages of the 14 Chapter 1 Health Behavior in the Context of the “New” Public Health Individual-level intervention Population-level intervention Tertiary prevention Secondary prevention Indicated Universal or selected* Primary prevention Universally applied * Depending on the disease/condition in question. FIGURE 1-6 Three levels of prevention disease, injury, or behavioral process, where each stage may require a different prevention strategy. A graphic depiction is provided in FIGURE 1-6. The public health approach is predicated on primary prevention. In primary prevention, efforts are made to intercept the onset or occurrence of disease, injury, or behavior. Primary prevention examples include vaccination programs, water fluoridation, abstinence programs, motorcycle helmet laws, bicycle helmet laws for children, mandatory seatbelt and child safety seat laws, mandatory minimum smoking/drinking age requirements, and antismoking media campaigns. These are just a few examples, and many of these initiatives have been very effective in reducing associated morbidity and early mortality. For example, increasing price may be the most effective way to prevent teens from becoming daily smokers. A joint study from the University of Illinois at Chicago and the UniIn primary prevention, versity of Michigan efforts are made to Institute for Social intercept the onset or Research conducted an analysis where they occurrence of disease, matched price hikes injury, or behavior. of cigarettes with teen smoking rates over a period of 6 years. They found that a 10% price increase would decrease the number of children who started to smoke between 3% and 10%, depending on their stage of smoking (Chaloupka & ­Warner, 2000). Moreover, analyses indicate that in addition to preventing disease, pain, suffering, disability, death, or loss of function, many prevention programs are also cost-effective. Primary prevention involves intervening before disease onset. In the context of public health, it must be broad in scope and aimed at large portions of the population. This is defined as adopting a universal approach, and it corresponds with the notion of intervening at the “bell” rather than the tail in the Rose curve shown in Figure 1-5. A universal approach is when an entire population (e.g., a nationwide crime-prevention media campaign) or subgroups of the population (e.g., children 16 years of age and under to enforce bicycle helmet use) are targeted regardless of whether individuals in the group have specific risk factors. Because whole populations are targeted, a large number of individuals are reached and the economic benefits of prevention become substantial. Moreover, if the focus of the preventive effort (e.g., diabetes, Key Concepts obesity, motor vehicle injury, alcohol abuse) corresponds to a high rate within the population, then the universal approach is extremely cost-­ effective. However, it is important to note that if the rate is infrequent, then an ounce of prevention may not equate with a pound of cure (see Cohen, Neumann, and ­Weinstein (2008) for detailed analyses on this subject). In some situations, instead of taking a universal approach, primary prevention efforts target those in the population who are at heightened risk. This type of approach is called a selective approach. Typically, those individuals are targeted on the basis of biological, psychological, social, or environmental risk factors known to be associated with the disease or condition. For example, as mentioned previously, obesity is a risk factor for type 2 diabetes. A selective primary intervention to combat type 2 diabetes would target those individuals whose BMI is above 25, but who have not yet developed type 2 diabetes. Thus, although the focus is on those who are at increased risk, this approach is still considered primary prevention. Indeed, this approach was used by Knowler et al. (2002) in their randomized controlled trial of a primary prevention educational intervention (curriculum to affect diet and exercise behaviors) in preventing type 2 diabetes. They targeted clinic patients who had a BMI above 24 and whose glucose levels were elevated but not diagnostic of diabetes. At the 2-year follow-up, they found the educational ­intervention was nearly twice as effective as pharmaceutical treatment (metformin) in preventing the onset of diabetes. Secondary and tertiary are the other two levels of prevention identified by Leavell and Clark. Secondary prevention occurs when a disease process is diagnosed in an early stage of progression, thereby enhancing the odds of treatment success. The focus of secondary prevention is to minimize consequences through early detection and intervention. Screening programs for sexually transmitted diseases, cancer, or diabetes and smoking cessation programs are examples of secondary prevention. A good example is the use of mammography to diagnose localized tumors of the breast before these tumors progress. A tumor may indeed form, but with mammography the early diagnosis may lead to a simple lumpectomy as opposed to what may 15 have become a radical mastectomy. Pap The focus of testing and colonossecondary prevention copy are also common is to minimize forms of secondary consequences through prevention because early detection and they screen for cerviintervention. cal dysplasia and polyps, respectively. Tertiary prevention occurs when a disTertiary prevention ease state is diagnosed involves mitigating in time to apply treatthe consequences of ment that may prevent further organic damdisease or an injury age or death. Thus, after the fact. the difference between secondary and tertiary prevention can essentially be thought of as the difference between early and late diagnosis. Tertiary prevention involves mitigating the consequences of disease or an injury after the fact. The goal of tertiary prevention is to provide treatment and rehabilitation so that negative impact is reduced and function can be restored. An indicated approach is used in tertiary prevention. Examples of tertiary prevention would include providing patients who have type 2 diabetes with educational pamphlets to help them better manage their disease, providing mental health counseling for rape victims, and instituting outreach programs to monitor people with mental disorders who live in the community to ensure they are adhering to their medication regimens. In many ways, tertiary prevention in the public health model is similar to treatment in the medical model. Primary, secondary, and tertiary prevention can be integrated with the concepts of universal, selective, and indicated approaches. Figure 1-6 provides a visual depiction of this integration. As shown by the wide angle of this cone, the vast majority of health-promotion practice is primary prevention applied on a universal basis. This application can and should occur at the population level. Conversely, the least prevalent form of health promotion occurs with the indicated application of tertiary prevention—this application occurs at the individual level. This bipolar 16 Chapter 1 Health Behavior in the Context of the “New” Public Health continuum therefore leaves secondary prevention in the middle of the cone, suggesting that it is practiced less often than primary prevention but more often than tertiary prevention. Consistent with our description of a selective approach, secondary prevention may be universally applied to an entire population or selectively applied to a defined subset of a population. Prioritizing and Conceptualizing Health Behaviors To fulfill the public health mission of prevention, public health professionals must first have a clear understanding of which diseases and types of injuries are having the greatest impact, so that efforts are correctly positioned. Epidemiologists conduct surveillance studies and analyze records to determine the rates of diseases and the leading causes of death. Consequently, the causes and contributing risk factors have been well established. Although in the 21st century chronic diseases are at the top of the list, there are many other public health concerns. Injury from firearms and motor vehicle crashes are on the list, while infectious diseases such as influenza, HIV/AIDS, tuberculosis, chlamydia, human papillomavirus (HPV), Ebola, and methicillin-resistant Staphylococcus aureus (MRSA), to name a few, are also responsible for substantial morbidity and early mortality. From a global perspective, infectious diseases still remain a significant source of morbidity and early mortality. Six infectious ­diseases—pneumonia, HIV/AIDS, diarrhea, tuberculosis, malaria, and ­measles—account for half of the premature deaths globally. The top causes of death worldwide are listed in TABLE 1-2. Although the etiology is quite different for chronic and infectious diseases, as well as for sustaining injury, all can be prevented to some degree. At a minimum, onset can be delayed and the risk TABLE 1-2 Top Causes of Death Worldwide, 2004 Cause of Death Number of Deaths in Millions Deaths (%) Coronary heart disease 7.20 12.2 Stroke and other cerebrovascular diseases 5.71 9.7 Lower respiratory infections 4.18 7.1 Chronic obstructive pulmonary disease 3.02 5.1 Diarrheal diseases 2.16 3.7 HIV/AIDS 2.04 3.5 Tuberculosis 1.46 2.5 Road traffic accidents 1.27 2.2 Prematurity and low birth weight 1.18 2.0 Reproduced from World Health Organization. (2008). The 10 leading causes of death by broad income group (2004). Retrieved from http://www.who.int /mediacentre/factsheets/fs310/en/index.html Key Concepts of death mitigated. Many of these 21st-century “scourges” have underlying health behaviors, and public health efforts that target these health behaviors are integral to a comprehensive preventive effort. For example, one in four child deaths from malaria could be prevented if children at risk slept under bed nets at night to avoid mosquito bites (WHO, 1999). In the United States, motor vehicle injuries are the leading cause of death for children aged 4–11 years (CDC, 2008). For children aged 4–7 years, the use of belt-positioning booster seats reduces this risk by 59%, compared with the use of seat belts alone (Durbin et al., 2003). “Using a bed net” and “using a booster seat” are merely two types of health behaviors that can be affected or modified to prevent the acquisition of malaria or the risk of auto accident injury, respectively; however, there are other health behaviors that could be changed to prevent malaria and injuries. When conceptualizing health behavior, many people may not perceive that “using a bed net” or “buying a booster seat” should be classified as health behaviors. Generally speaking, when people think of health behavior, they think of things like exercising or taking vitamins. They might not consider that their decision to get a mammogram or to get a flu shot is a health behavior. Furthermore, they might not categorize testing their home for the presence of radon as a health behavior. Regardless of the general public’s perceptions of what constitutes a health behavior, it should be defined so that health-promotion research can be used to gain a better understanding of health behavior, and subsequently, health-promotion practice can be used to alter it. Behavior in the broadest sense is the manner in which something acts, functions, responds, or reacts. This definition can apply not only to individual people but also more broadly to collectives and systems. Along these lines, health behavior can be defined as the actions, responses, or reactions of an individual, group, or system that prevent illness, promote health, and maintain quality of life. Examples of individual health behaviors would be using a condom, buckling up the seat belt, or getting vaccinated. Collective health behaviors could be a neighborhood association making changes to the built environment to encourage physical 17 activity (e.g., putting in sidewalks, installing better lighting), initiating a safety patrol, or starting a local co-op farmer’s market. Sociopolitical system behaviors could involve instituting a citywide smoking ban, implementing community-wide condom accessibility/availability programs, or banning trans fats in restaurants. Again, we emphasize the importance of using a multilevel approach to promote health in a population; a focus on only one of these levels is unlikely to be productive. We also emphasize that any approach taken must be made with the goal of social equity in mind. This implies that intervention resources and efforts will be intensified for marginalized populations, most at risk of morbidity and early mortality. Often, with extreme social inequities, intervention efforts as simple as food provision are tremendously helpful (see FIGURE 1-7). FIGURE 1-7 Food provision is a basic part of public health practice Courtesy of WFP/Rein Skullerud 18 Chapter 1 Health Behavior in the Context of the “New” Public Health Just as there are different levels to prevention, health behaviors can be similarly qualified according to the nature of the health behavior. Most health behaviors can be classified into three categories: ­preventive, illness, or sick role (Gochman, 1988; Kasl & Cobb, 1966). These categories are presented in TABLE 1-3. Generally, the health-related behaviors of healthy people and those who try to maintain their health are considered preventive behaviors and are strongly tied to primary prevention. The previous examples of different health behaviors can be viewed as preventive health behaviors. Illness behavior is defined as any behavior undertaken by individuals who perceive themselves to be ill and who seek relief or definition of the illness. Illness behaviors are linked closely to secondary prevention as the goal is the early intervention and control of a disease. Some examples of illness behaviors would be seeking care from a healthcare provider to obtain a diagnosis, turning to self-help strategies to lose weight if overweight or to reduce anxiety, or seeking help for a drinking problem by going to a 12-step program. Illness behavior stems from the perception that something may Health behavior can be defined as the actions, responses, or reactions of an individual, group, or system that prevent illness, promote health, and maintain quality of life. be wrong physically and/or psychologically and is therefore subject to an individual’s interpretation of the situation or symptoms. Furthermore, even if people perceive that they may be sick, they may not seek care due to lack of health insurance or other resources. A logical extension of illness behavior is sickrole behavior. Once an individual is diagnosed with a disease, the treatment plan constitutes the sick-role behavior. Sick-role behavior is denoted as any behavior undertaken to get well. Thus, sick-role behavior is typical of patients in clinical settings and is related to tertiary prevention. One example of sick-role behavior would be adherence to a medically prescribed regimen such as antiretroviral therapy (ART) for patients diagnosed with HIV or switching to a low-­carbohydrate/ high-fiber diet and exercise regimen for patients diagnosed with type 2 diabetes or cardiovascular disease. Given that patient adherence with medication regimens may be exceedingly poor, sick-role behavior is increasingly being viewed as necessitating individual and environmental intervention and is fast becoming a public health issue. Numerous behavioral, social, economic, medical, and policy-related factors contribute to poor adherence and must be addressed if rates are to improve. For instance, as few as of one of every six people living with HIV receive, and become adherent to, the life-saving advantages of ARTs (Gardner, McLees, Steiner, Del Rio, & Burman, 2011). Adherence issues include lack of TABLE 1-3 Categories of Health Behaviors and Link to Prevention Level Type of Health Behavior State of Person Behavior Prevention Level Preventive Healthy Exercise, high-fiber diet, colonoscopy at 50 wear bicycle helmet Primary Illness Perceives health problem Doctor visit, alternative medicine therapies, join Weight Watchers®, mammogram at 40 Secondary Sick role Receives diagnosis Adherence to treatment regimen (medication, exercise, diet, etc.) Tertiary Key Concepts awareness among clinicians about basic adherence management principles, poor communication between patients and clinicians, operational aspects of pharmacy and medical practice, and professional barriers, all of which compromise the effectiveness of therapy. Given all these issues, it is no wonder that adherence to drugs that decrease hypertension and lower cholesterol, for example, is problematic even among people recovering from a heart attack (Ho, Bryson, & Rumsfeld, 2009). As C. Everett Koop, former surgeon general of the United States, stated succinctly, “Drugs don’t work in patients who don’t take them.” Health Promotion: Definition and Background Public health seeks to create healthful living conditions. In the 19th century, the focus was on creating safe and healthy environmental infrastructures to reduce the spread of infectious diseases. Early in the 20th century, the focus shifted to the individual with large-scale immunization programs. Beginning in the late 20th century and continuing into the 21st century, a new public health movement emerged where both ends of the spectrum were and are continuing to be addressed. Public health initiatives became multidimensional by targeting individuals, systems, and political structures to affect health behaviors. More importantly, a shift occurred that emphasized the significant role of environmental influences in shaping individual behavior and affecting health; the said influences included but were not limited to culture, public policy, areas of technology, work, energy production, and urbanization. Also, along the same lines as the old public health, the new public health considered the influence of not only built environments but also the natural environment, and thus, conservation of natural resources became a primary goal. This shift in theoretical perspective and scope has been deemed the “new public health” (Macdonald & Bunton, 1992). Although in some ways the new public health has come full circle from the early beginnings of 19 the old public health The new public (i.e., focusing on environmental struchealth embraces the tures to affect health role of individuals outcomes), the new in changing their public health also health behavior while includes an emphasis also emphasizing on how those relethe relevant vant environmental structures and influenvironmental and ences affect individstructural elements ual health behavior, within their context to which in turn is facilitate the adoption linked to health outof health-promoting comes. The new pubbehaviors. lic health embraces the role of individuals in changing their health behavior while also emphasizing the relevant environmental and structural elements within their context to facilitate the adoption of health-promoting behaviors. Health promotion emerged as a field against this backdrop of the new public health; it arose out of necessity in part from the insufficiency and costliness of biomedical approaches in improving the public’s health, but also from the inability of medical professionals to understand fully how to affect health behavior. In simple terms, health promotion can be viewed as a process of enabling people to increase control over, and to improve, their health and the conditions that affect their health (WHO, 1986). Thus, health promotion is concerned not only with empowering people to remain free from illness but also with enhancing their ability to avoid, resist, or overcome illness—moving them to the left side of the wellness–illness continuum shown in Figure 1-4. By enabling people to recognize health threats and creating conditions that facilitate protective action, health promotion can be viewed as a “behavioral” inoculation in the same way that a traditional vaccine inoculates against infectious agents (Ewart, 1991). Although there are many other definitions of health promotion, we provide one that is more comprehensive and also “official” in the sense that it was used as part of legislation introduced 20 Chapter 1 Health Behavior in the Context of the “New” Public Health in the U.S. Senate in 2004. Health promotion is defined as the art and science of motivating people to enhance their lifestyle to achieve complete health, not just the absence of disease. Complete health involves a balance of physical, mental, and social health. As a first impression, this definition of health promotion indicates that health-promotion’s objectives are diverse, broad, and complex, and that it embraces a multifaceted and integrated approach in achieving those objectives (e.g., “facilitate behavior change” and “develop supportive environments”). But the unanswered question is: how does health promotion accomplish such lofty and wide-ranging goals? Health promotion is defined as the art and science of motivating people to enhance their lifestyle to achieve complete health, not just the absence of disease. Complete health involves a balance of physical, mental, and social health. Health-Promotion Strategies In FIGURE 1-8, we depict the different strategies that health promotion uses to achieve goals. As you can see, the strategies are general and are not limited to any one specific health problem or to a specific set of behaviors. Each strategy can be applied to a range of settings, risk factors, population groups, diseases, or negative health outcomes. Moreover, these strategies are not typically applied in isolation, but overlap and are integral to achieving health-promotion objectives. For example, research is at the forefront of any health-promotion endeavor, and it also informs all of the other strategies shown in the figure. Research can reveal the ­epidemiology (i.e., the scope, causes, and risk factors of disease) of the health issue, the underlying environmental and individual determinants, and the negative outcomes, as well as provide insight into targeted, at-risk populations and their environments. Furthermore, research provides a valid and reliable way to understand the health issue from multiple theoretical perspectives and to Program development and evaluation Social marketing Research Health promotion strategies Community capacity building Advocacy Policy development FIGURE 1-8 Health-promotion strategies Health education Key Concepts inform health-promotion activities, whether they are part of a health education program, a social marketing program, or activities involved in policy development. Research is also critical in determining whether the health-promotion initiative was effective in reaching its goals, and, if so, research can also show how the goals were achieved. This type of research is critical in supporting ­evidence-based health-promotion practice so as to improve the quality and cost-effectiveness of health-promotion interventions. Against this research backdrop, advocacy represents an important and related strategy. Advocacy is necessary to gain the political commitment, policy support, social acceptance, and systems support for a particular health program. Advocacy may be carried out through lobbying, social marketing, a health education program, or community organizing. Finally, building community capacity is a key strategy for sustaining health-­promotion efforts. Community capacity represents the community’s ability to do things that promote and sustain its well-being. A number of factors have been proposed as contributing to capacity building, such as leadership, resources, knowledge, skills, and collaboration (Provan, Nakama, ­Veazie, Teufel-Shone, & Huddleston, 2003). Achieving community capacity by affecting all of these factors may not be feasible, yet many of these factors are modifiable through the use of other health-promotion strategies. For example, health education can be used to convey information and knowledge and impart skills to community members and service organizations; social marketing can also be used in tandem with health education efforts to raise awareness of health information or to inform community members about resources; and research can be used to create an inventory of social organizations, agencies, and other stakeholders within the community so that a network of resources can be constructed. Thus, in reviewing these strategies used in health promotion, you can appreciate why health promotion is considered a process that employs multiple strategies in partnership to achieve its goals of optimal health. 21 Theory in Health-Promotion Research and Practice What is missing from Figure 1-8, however, is the inclusion of another circle that would convey that the cornerstone of all health-promotion strategies is theory. Health-promotion researchers, policymakers, and practitioners use theory to guide many of their health-promotion strategies. Theory informs what variables to measure, how to measure them, and how they are interrelated. Within the context of health promotion, theory is viewed as a tool for enhancing our understanding of complex situations versus something that offers universal explanations or predictions (Green, 2000). This more practical perspective is grounded in praxis and acknowledges that theory should be relative to the context in which it is used. Health Behavior Theory for Public Health describes many of the more relevant theories used in health promotion. We acknowledge that, like any t...
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