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               Chapter 3 Health Behavior and Health Behavior Theory

Introduction

       Clear understandings of health behavior and health behavior theory are requisites

to the design of effective health promotion and disease prevention programs in the

worksite. All too often in worksites, and other program implementation venues,

simplistic programs are implemented because corporate decision makers do not

understand the complexity of human health behavior and all the factors that influence

health behavior. As a result, “Just Say No” campaigns are thought to be effective

substance abuse prevention efforts, a blood pressure screening is seen as a resolution to

hypertension concerns, and health risk assessments, featuring individualized computer

printouts, will reduce medical care costs. Approaches like this deny the complexity of

health behavior, the human condition and the environmental, social and policy factors

that influence health and health behavior.

       The purpose of Chapter II is to provide a basic background on determinants of

health and health behavior and contemporary health behavior theories applicable adult

and worksite populations. This discussion is not meant to be exhaustive. Rather, an

overview will be provided with an eye toward helping the program planners appreciate

the complexity of health behavior and the nature of the task when developing programs to

shape behavior, change behavior, and maintain behavior. Examples related to adults and

worksite health promotion application will support this discussion.

Definitions

       Health has been defined in many ways. Health has been thought to be the absence

of disease, ability to cope and adapt one’s environment or the quality of life one
                                                                                              2


experiences. For the purpose of this discussion, William Zimmerli’s definition of health

as a “personal, positive quality of life” will be used. Dr. Zimmerli believed that each

individual determined what a positive quality of life meant to them. This allows for both

intra-individual differences within the person across the lifespan and inter-individual

differences at any point in time. Intra-individual differences support the notion that

people can change their perception of what constitutes a positive quality of life for them.

We all reset our goals, expectations, and beliefs across our life course on a host of

factors, and health is no exception. Behaviors we embraced as college students are “no

longer” cherished once we enter the workforce, and what constitutes a positive quality of

life changes once we marry and have children.

       Inter-individual differences reflect diversity of human thoughts and preferences.

One person’s quality of life is enhanced by preparing to run a marathon while another’s is

enhanced by maintaining a fruitful garden. Although we may place values on the same

behaviors that may enhance one’s quality of life (ie. smoking, overeating, sky diving,

cycling without head protection), we all can observe the diversity of ways in which

people seek to develop and maintain a personal, positive quality of life. Keep in mind

that social norms often play a role in these intra and inter individual differences. In the

1950s, seldom would you observe adults out jogging or cycling. This type of behavior

was not the norm. Today outdoor physical activity is common, socially supported, and

encouraged in communities.

       In essence, health defined as a personal, positive quality of life is a consistent

construct. Those factors that may be considered quality of life indicators often change

across time.
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       Clear definitions of behavior and health behavior also help us to design health

promotion and disease prevention interventions. Green and Kreuter define behavior as

“an action that has a specific frequency, duration and purpose whether conscious or

unconscious.” This definition implies that a behavior is observable and measurable.

Although we may not be able to observe all behaviors of individuals all the time, a

behavior is purposeful and does occur. LaLonde defines a health behavior as “an

aggregation of decisions by individuals which affect their health and over which they

have more or less control.” This definition implies that health behavior is not one

decision but a series of decisions that yield a lifestyle or worldview for the individual.

This definition also implies that health behaviors tend to be interrelated. The marathon

runner is not likely to be a smoker, and diet and weight conscious people tend not to

abstain from exercise. This notion supports the notion that a health behavior change for

one’s behavior is often linked to other behaviors. So, as a person develops and maintains

an enhanced regimen of physical activity, they are often more likely to modify their diets

and sleep habits to support and augment their new physically active lifestyle.

Interestingly, a study conducted by Eddy and colleagues to examine the impact of a

corporate sponsored exercise programs for employees found, among other findings, that

employees who initiated and maintained participation in the program started to use their

car safety belts more than non-participants (keep in mind, this study was conducted

before safety belt laws had been enacted and enforced in most states). When a focus

group of employee participants in the exercise program were asked why safety belt use

had increased, the employees commented that the act of changing their level of physical
                                                                                              4


activity caused them to become more health conscious in general, and using their safety

belts was simply one more thing they could do to support a healthy lifestyle.

       The definitions of behavior and health behavior also imply a level of volitional

control over the behavior. In other words, the person is in control of their behaviors and

can make conscious decisions. Although there are a variety of social, environmental,

economic, and political factors that influence health behavior, a behavior is not a

behavior unless we have control over the action. For example, most automobile

“accidents” are not accidents that are out of our control, but rather “unintentional

injuries” over which we have control. We can say we were in an accident when, in

actuality, driving at excessive speeds, driving under the influence, cell phone use, other

distractions, and failure to properly maintain the vehicle were antecedent behaviors which

led to the collision that yield the unintentional injures. Then, failure to wear a safety belt,

another volitional behavior, may exacerbate the unintentional injury.

Determinants of Health and Health Behavior

       We often look for the one best answer or the single factor that causes a problem.

Perhaps the lack for a singular explanation for what influences health and health behavior

is what frustrates many worksite decision makers as they try to solve the health and

medical care problems of employees and their dependents. As a backdrop to approach

many of the health problems of employees, it is important to understand the inter-

relationship of the many factors that determine health and help to shape healthy

behaviors.

       For the purpose of this discussion, these factors have been divided into

environmental and personal factors (Figure 2.1), although, as you can see, these factors
                                                                                              5


are clearly interrelated. This interrelatedness of factors that influence health and health

behavior often impacts our ability to arrive at a clear causation for many health

conditions and behaviors. Figure 2.2 provides an example of the possible factors that

influence smoking and physical activity behavior and increase risk of cancer and cardio

respiratory disease that are linked to smoking. These examples are noted as “quick facts”

about smoking, physical activity and health. Figure 2.2 highlights the interrelatedness of

the determinants of health and health behavior, and examples of this nature can be easily

created for numerous health and health promotion problems and concerns (e.g. cancer

and cancer control, stress and stress management, hypertension, CVD rise factors,

nutrition, weight management, unintentional injury control, etc).
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  Figure 2.1 Determinants of Health and Health Behavior

      Environmental Determinants                                 Personal
              Physical                                         Heredity
              Social                                           Physical Health
              Work                                             Mental Health
              Family                                           Knowledge
              Community                                        Attitudes
                                                                Practices/norms
                                                                Skills


  Figure 2.2 Quick Facts Related to Determinant of Health and Health Behavior For
  Smoking and Physical Activity

Environmental Factors        Quick Facts/Smoking                Quick Facts/Physical Activity
                          Smokers living in areas with          Safe, well lighted recreation areas
        Physical          high levels of air pollution          with good parking support
                          increase their risk of smoking        physical activities.
                          related illness.
                          Social groups and peers have          Some physical activities can only
         Social           been shown to support the             be done with teams, and co-
                          initiating of smoking behavior        workers support physical activity.
                          and continued smoking.
                          Worksites with properly               Providing access and supportive
                          designed and enforced                 policies at the worksite will
         Work             environmental tobacco smoke           increase physical activity.
                          policies have lover levels of
                          smoking among employees.
                          If parents smoke, there is an         Family support for physical
         Family           increased likelihood that their       activity increases prevalence.
                          children will smoke.
                          Appropriate and enforced state
                          and community ordinances
      Community           (e.g. sales to minors, smoking        See Physical factors above.
                          in restaurants, etc.) influence
                          smoking behavior.
Personal Factors          Quick Facts/Smoking                   Quick Facts/Physical Activity
                          The respiratory and immune            From a genetic perspective, some
                          systems for some individuals          people do not benefit from
        Heredity          are better able to handle smoke       physical activity and/or should not
                          and all its components (e.g.          engage in certain types of
                          Tar, Nicotine, CO, etc.)              activities.
                          People who engage in regular          Physical health and well-being
     Physical Health      physical activity tend not to         impacts the ability to perform
                                                                                  7




                  smoke.                             some activities.
                  Smoking may help boost             People who have a regular
Mental Health     energy for some smokers and        physical activity regimen can
                  relax others. Smokers often        better handle stressful situations.
                  enjoy smoking.
                  Almost all smokers know the        Skills needed to safely engage in
  Knowledge       health consequences of             physical activity can be learned.
                  smoking.
                  “It’s difficult to stop smoking”   Attitudes such as “exercise is
                  and “I’ll quit before I get ill”   work” and “physical activity
   Attitudes      are attitudes that support         relaxes me” influence behavior.
                  smoking behavior.

                  Environments and social            Worksites where physical activity
Practices/Norms   groups support smoking             is the norm have more employees
                  behavior.                          practicing physical activity.
                  Most people quit smoking cold
    Skills        turkey, but for other smoking      See Knowledge above.
                  cessation and behavior change
                  skills are helpful.
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       Corporate culture and other worksite related environmental concerns have been

discussed in Chapter I. For the purpose of this discussion, basic definitions of

environmental and personal factors that influence health and health behavior will be

briefly discussed below.

                  Physical Environment- Air, water, climate, land, noise, lighting, and

                   heating/cooling factors that impact health and health behaviors.

                  Social Environment- Coworkers, friends, social structures and

                   organizations that influence health and health behavior.

                  Work Environment- The culture, norms, policies, values and

                   supported factors of worksites either encourage or discourage heath

                   behaviors and influence health status in numerous ways.

                  Family Support- Health and other behaviors are learned and

                   supported in families.

                  Community Environment- Community policies, enforcement of

                   regulation, parks and regulation facilities, cultural events, etc can

                   influence health behaviors and, in some cases, health.

       A variety of personal factors can influence health and health behaviors. As can be

noted from a quick review of Figure 2.2, these factors are often interrelated.

                  Heredity- Genetic predisposition determines potential life span, body

                   type, resistance to certain disease, and other physical body functions.

                  Physical Health- Our physical health, at any point in time, will

                   influence our overall quality of life.
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                  Mental Health- Levels of mental health and well-being impacts our

                   attitudes and physical health in many ways.

                  Knowledge- Awareness of health problems and concerns is often the

                   first stop to changing lifestyles to improve health and well being.

                  Attitudes- Our beliefs and feelings, whether right or wrong, influence

                   our health behaviors and ultimately our health. Attitudes are often

                   more difficult to change than knowledge or behavior.

                  Practice/Norms- The prevailing behaviors and norms in companies

                   and communities influence the behaviors of employees and

                   community members.

                  Skills- Many successful approaches to help people adopt or maintain

                   healthful behaviors require skill development. These skills are often

                   easily learned.

       Obviously, a thorough discussion of the environmental and personal factors that

influence health and health behavior is not possible in this text. Suffice to say that a basic

understanding of all the factors that influence health and health behavior will help the

program planner develop a more realistic perspective of all the factors that need to be

considered when developing health promotion and disease prevention programs for adult

and community populations. You’ll see many of these determinants of health and health

behavior in the discussion of health behavior theory that follows.

Health Behavior Theory

       Glanz defines a theory as “a systematic way of understanding events or situations.

It is a set of concepts, definitions and propositions that explains or predicts these events
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or situations by illustrating the relationships between variables” (p 4). In the design of

worksite health promotion programs, the use of theory will help the program planning to

better focus on those factors that have been shown to influence the desired behaviors.

       Glanz also states that health behavior theories have both explanatory and change

functions. Explanatory theory helps to determine why the problems exists or what factors

facilitate or inhibit the behavior. For example, poor dietary behavior could be related to a

lack of knowledge of nutrition, lack of healthy food choices, insufficient resources to

purchase health foods, influences from family members and peers, or a combination of all

of these factors. Change theories help program planners to be more specific about the

assumptions and theoretical underpinnings upon which their program is based.

       Figure 2.3 is taken from the National Cancer Institute publication titled “Theories

at a Glance: A Guide for Health Promotion Practice” written by Karen Glanz. This

schematic highlights the reciprocal and circular nature of the relationship between

explanatory theory and exchange theory. This dynamic relationship supports the fact that

many health behaviors are both explanatory and change in nature. This notion will be

highlighted in greater detail as selected theories are discussed.
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  Figure 3.3 Using Explanatory Theory and Change Theory to Plan and Evaluate

  Programs




Explanator                              Change
    y             Problem               Theory
 Theory           Behavior
                      or                 Which
  Why?            Situation            strategies?
 What can                                Which
    be                                 messages?
 changed?                            Assumptions
                                      about how a
                                        program
                                     should work?
                                                                                            12




         As the selected theories are discussed, terms such as concepts, constructs,

variables and models will be used. Glanz provides the operational definitions of these

terms.

                   Concepts are the building blocks—the primary elements—of a theory.

                    Constructs are concepts developed or adopted for use in a particular

                    theory. The key concepts of a given theory are its constructs.

                   Variables are the operational forms of constructs. They define the way

                    a construct is to be measured in a specific situation. Match variables

                    to constructs when identifying what needs to be assessed during

                    evaluation of a theory-driven program.

                   Models may draw on a number of theories to help understand a

                    particular problem in a certain setting or context. They are not always

                    as specified as theory (p. 4).

         Before providing more specific information on the selected health behavior

theories that have relevance for worksite health promotion programs, it is important to

discuss why the program planner should use theories to design and organize their health

promotion and disease prevention program activities. First, health behavior theory helps

to focus on the target behavior and the environmental context within which that behavior

occurs. You’ll note that many of the health behavior theories discussed in this chapter

require an assessment of the environmental context of the behavior and a determination

of what environmental changes may foster the targeted behavior. Second, health

behavior theory helps the program planner to answer the why? what? and how?
                                                                                           13


questions. Explanatory aspects of theory will help us to determine why a behavior exists

(such as, lack of readiness to change, ignorance, or a social environment that supports

that behavior). While the change theory component will provide direction on what

variables should be targeted and the potentially most effective methods to foster the

appropriate behavior change. In essence, the use of a health behavior theory helps us to

both understand the nature and scope of the behavior of interest and to identify the most

suitable participants to include in the program and methods to foster the desired behavior.

The use of theory help us focus on “the big picture.” Health behavior theory help the

program planner to stay grounded and focused on the objectives and goals of the

programming effort. And finally, the use of theory will help others replicate successful

programs. An important caveat here is that the process used to design a program, in this

case, the health behavior theory, is more important to the program planner than the actual

program that was implemented by another company. The nature of work, work life, and

employees varies between organizations, so program replication of another company’s

program may not work even if that program was successful. It would be more important

to replicate the process used by the successful program to design their program. In other

words, the process that health behavior theories force us to use will better equip us to

design, implement, and evaluate programs that meet the needs and interests of employees

in the context and environment where the employee works.
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Theories of Health Behavior and Health Behavior Change

       Health behavior change is complex. Clearly, there is no unified theory of health

behavior, nor one that is universally accepted by all or most health promotion

professionals. This chapter presents a brief discussion of models and theories of health

behavior. In addition, a discussion of how incentives for health behavior can be

integrated into health promotion programs is included.

       It should be noted that the discussion of health behavior change theory that

follows is designed to provide the health promotion manager with a basic understanding

of these concepts. This discussion is designed to introduce the health promotion manger

to related terms and concepts.

Social Ecology of Health Promotion

       The Social Ecology of Health Promotion Model presents a global perspective on

factors that influence health behavior and factors to include in worksite health promotion

interventions to more effectively help employees change health behaviors and help the

company implement policies, procedures, and environmental support activities to

influence and support healthy behaviors. The Social Ecology of Health Promotion

approach goes beyond “victim blaming” to establish interventions that focus on the

social, environmental, and economic factors, as well as individual health behaviors that

may influence health status. For example, it is easy to say that employees need to

manage their stress to be more productive and healthier employees. The Social Ecology

of Health Promotion approach encourages health promotion program planners to also

address the interpersonal, institutional, community, and policy factors that influence

behavior.
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       From the perspective of worksite health promotion, the ecological approach

should encourage the health promotion manager to examine all possible factors that

influence behavior:

          Intrapersonal Factors – knowledge, attitudes, skills, and self-concept of the

           individual.

          Interpersonal Processes – Impact of family, friends, co-workers, and other

           social support groups on health behavior.

          Institutional Factors – Formal and informal rules and regulations that affect

           health behavior.

          Community Factors – Relationships between the organization and other

           institutions and networks in the community.

          Public Policy – Local, state, and national laws and policies that affect health

           behaviors.

       Table 2.4 provides an operational example of how to apply the Social Ecology of

Health Promotion Model to worksite health promotion. These examples are just the “tip

of the iceberg” of possible ways to infuse this model into the worksite health promotion

program. Suffice to say, the more factors that you address in your health promotion

program, the greater are your chances of success. The program will also be a Healthy

Company approach rather than an individual, victim blaming approach.
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Table 2.4: Social Ecology of Health Promotion – Background and Worksite Examples

          Concept                              Definition                                         Worksite Examples
Intrapersonal Level          Individual characteristics that influence             Health risk appraisals
                             behavior, such as knowledge, attitudes,               Health communication campaigns
                             beliefs, and personality traits.                      Smoking cessation programs
                                                                                   Health education classes (i.e. stress, physical
                                                                                    activity, eating well, safety belts, etc.)
Interpersonal Level          Interpersonal processes and primary groups            Walking clubs
                             that provide social identity, support, and role       Including family in programs
                             definition.                                           Support groups
                                                                                   Team competitions
Community Level              Rules, regulations, policies, and informal            Corporate policies
Institutional factors        structures, which may constrain or promote            Medical care provision
                             recommended behaviors.                                Preventive screening offers
                                                                                   Corporate culture norms and values
Community Factors            Social networks and norms, or standards,              Community recreation facilities
                             which exist as formal or informal among               Public health initiatives
                             individuals, groups, and organizations.               Support of community organizations, including
                                                                                    faith based groups
                                                                                   Community/school/business partnerships
Public Policy                Local, state, and federal policies and laws that      Safety belts, DUI laws, etc.
                             regulate or support healthy actions and               Community health policies
                             practices for disease prevention, early               Environmental tobacco smoke regulation
                             detection, control, and management.                   OSHA Guidelines

Adapted from: National Cancer Institute, Theories at a Glance, NIH publication NO. 05-3869, September 2005.
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Health Belief Model

       The Health Belief Model is based on the notion that the perceived threat of

disease serves as a motivator to action. In other words, informing employees of the

likelihood that high stress levels, lack of exercise, and poor diet will lead to

cardiovascular disease in an effort to motivate employees to modify such behaviors, so

that their health risks can be reduced, provides an example of how the HBM works.

Numerous other factors have an impact on this simple paradigm, thus influencing health

behavior.

       Three factors from a worksite perspective would be the employees’ belief related

to the following:

           Perceived susceptibility – Does the employee believe he or she is “at risk” for

            the targeted health problem?

           Perceived seriousness – Is the health problem thought to be serious enough to

            take the required action?

           Perceived efficacy – Does the employee believe that the required action will

            improve health or prevent disease?

       Let’s examine the use of this model to help explain one health behavior, safety

belt use, and how the HBM could be used to structure a program intervention.

           History – employee’s family and social support group influences safety belt

            use.

           Characteristics of the individuals – age, sex, race, and personality will

            influence safety belt use.
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          Health communications – all types of media messages can change employees’

           perceived threat of injury or death from not wearing safety belts.

          Advice/action of others – In some cases, advice from others (friends, family,

           and health professionals) can influence perceptions and behaviors for safety

           belt use.

          Critical life events – A critical life event (marriage, the birth of a child, the

           death of a family member) can influence safety belt use.

          Public policy/social support – For some employees, initiation of a company

           policy or state law mandating safety belt use will influence behavior.

       The National Cancer Institute publication titled “Theories at a Glance,” (2005)

provides an excellent description of the concepts included in a contemporary depiction of

the Health Belief Model (Table 2.5). In addition, this publication also provides the

following example of how the Health Belief Model (HBM) applies to hypertension.

       High blood pressure screening campaigns often identify people who are at high

risk for heart disease and stroke, but who say they have not experienced any symptoms.

Because they don’t feel sick , they may not follow instructions to take prescription

medicine or lose weight. The HBM can be useful for developing strategies to deal with

noncompliance in such situations.
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Table 2.5 Health Belief Model – Background and Worksite Physical Activity Examples

Concept                  Definition                 Potential Strategies                            Worksite Physical Activity Examples
Perceived                Beliefs about the           Define what populations are at risk and        Link lack of physical activity to CVD,
susceptibility           chances of getting a          their levels of risk                            obesity, high blood pressure, etc.
                         condition                   Tailor risk information based on an            Link physical activity to reduced stress and
                                                       individual’s characteristics or behaviors       quality life
                                                     Help the individual develop an accurate        Link lack of physical activity to back pain,
                                                       perception of his or her own risk               mobility, etc.
Perceived severity       Beliefs about the           Specify the consequences of a condition        Through health risk assessment, show lost
                         seriousness of a              and recommended action                          years of life
                         condition and its                                                           Reveal the impact of regular physical activity
                         consequences                                                                  on delaying the onset of chronic disease
                                                                                                       (diabetes, CVD, cancer)
Perceived benefits       Beliefs about the           Explain how, where, and when to take           Physical benefits
                         effectiveness of taking      action and what the potential positive         Mental and emotional benefits
                         action to reduce risk or     results will be                                Health benefits
                         seriousness
Perceived barriers       Beliefs about the           Offer reassurance, incentives, and               Lack of facilities / environment to engage in
                         material and                 assistance; correct misinformation                physical activity
                         psychological costs of                                                        Child care, family, work constraints
                         taking action                                                                 Cost of equipment, membership, etc.
Cues to action           Factors that activate       Provide “how to” information, promote            Health communications
                         “readiness to change”        awareness, and employ reminder systems           Incentives
                                                                                                       Encouragement from managers and co-
                                                                                                        workers
                                                                                                       Encouragement from physicians
Self efficacy            Confidence in one’s         Provide training and guidance in                 Start with simple, do-able activities and build
                         ability to take action       performing action                                 from there
                                                     Use progressive goal setting                     Encourage goal setting activities
                                                     Give verbal reinforcement                        Reward the attainment of physical activity
                                                     Demonstrate desired behaviors                     goals

Adapted from: National Cancer Institute, Theories at a Glance, NIH publication NO. 05-3869, September 2005.
                                                                                          21


       According to the HBM, asymptomatic people may not follow a prescribed

treatment regimen unless they accept that, though they have no symptoms, they do in fact

have hypertension (perceived susceptibility). They must understand that hypertension

can lead to heart attacks and strokes (perceived severity). Taking prescribed medication

or following a recommended weight loss program will reduce the risks (perceived

benefits) without negative side effects or excessive difficulty (perceived barriers). Print

materials, reminders letters, or pill calendars might encourage people to consistently

follow their doctors’ recommendations (cues to action). For those who have, in the past,

had a hard time losing weight or maintaining weight loss, a behavioral contract might

help establish achievable, short-term goals to build confidence (self-efficacy).

Stages of Change Theory

       The Stage Theory as outlined by Prochaska and DiClemente (1986), provides a

simple yet comprehensive paradigm to examine how the health promotion manager may

design an implementation. The Stage Theory says that employees fall into four levels or

stages related to a health behavior or health promotion activity, and the purpose is to

move employees along the continuum from stage to stage. A wide range of information

sharing and skill activities is required for employees at each stage.

       1. Pre-contemplation. Employees in this stage are not thinking about modifying

       the target health behavior.

       2. Contemplation. Employees in this stage are thinking about changing a health

       behavior.

       3. Preparation. Employees tend to act on a behavior within the next 30 days and

       have to take some actions to prepare for the change.
                                                                                        22


       4 Action. Employees in the maintenance stage try to maintain behavior change

       across time.

       5. Maintenance. Employees in the maintenance stage try to maintain behavior

       change across time.

       The stage approach to health promotion forces the health promotion manager to

view employees and employee interests in health promotion activities realistically.

Health promotion managers need to implement many different activities to meet the

health promotion needs of employees at various levels.

       Table 2.6 provides a description of the Stages of Change Model process provided

by the National Cancer Institute Publication “Theories at a Glance.” As you can note,

many of the activities to move employees from the pre-contemplation to contemplation

stages relates to health communication and personal health assessment activities.

Guidelines to design, implement, and evaluate such activities are discussed in other

chapters of the Healthy Company Handbook. In addition, Theories at a Glance (2005)

also provides an excellent example of how to apply the stages of change model to plan a

smoking cessation program for employees.
                                                                                              23



Table 2.6: Stages of Change Model – Key concepts and Worksite Examples

Stage                        Definition                         Potential Change Strategies           Worksite Examples
Pre-contemplation            Has no intention of taking         Increase awareness of need for         Health communication activities
                             action within the next six         change; personalize information        Health risk appraisals (HRAs)
                             months                             about risks and benefits               Health screening / secondary
                                                                                                        prevention activities
                                                                                                       Increase perceived susceptibly and
                                                                                                        perceived severity
Contemplation                Intends to take action in the      Motivate; encourage making             Incentives
                             next six months                    specific plans                         Encouragement from management
                                                                                                        and co-workers
                                                                                                       Supportive policies
Preparation                  Intends to take action with        Assists with developing and            Guidelines to change behavior
                             the next thirty days and has       implementing concrete action           Environment support approach to
                             taken some behavioral steps        plans; help set gradual goals           behavior change
                             in this direction                                                         Encouragement and support from
                                                                                                        management and co-workers
Action                       Has changed behavior for           Assist with feedback, problem          Continued management and co-
                             less than six months               solving, social support, and            worker support
                                                                reinforcement                          Incentives for reaching behavioral
                                                                                                        goals
                                                                                                       Self efficacy awareness
                                                                                                       Environmental support for behavior
                                                                                                        change
Maintenance                  Has changed behavior for           Assist with coping, reminders,         Relapse prevention techniques
                             more than six months               finding alternatives, avoiding         Continue social and environmental
                                                                slips / relapses (as applicable)        support
                                                                                                       Supportive company policies
Adapted from: National Cancer Institute, Theories at a Glance, NIH publication NO. 05-3869, September 2005
                                                                                         24




       Suppose a large company hires a health educator to plan a smoking
       cessation program for its employees who smoke (200 people). The
       health educator decides to offer group smoking cessation clinics to
       employees at various times and locations. Several months pass,
       however, and only 50 of the smokers sign up for the clinics. At this
       point, the health educator faces a dilemma: how can the 150 smokers
       who are not participating in the clinics be reached?

       The Stages of Change Model offers perspective on ways to approach
       this problem. First, the model can be employed to help understand
       and explain why they are not attending the clinics. Second, it can be
       used to develop a comprehensive smoking program to help more
       current and former smokers change their smoking behavior, and
       maintain that change. By asking a few simple questions, the health
       educator can assess what stages of contemplation potential program
       participants are in. For example:

       * Are you interested in trying to quit smoking? (Pre-contemplation)
       * Are you thinking about quitting smoking soon? (Contemplation)
       * Are you ready to plan how you will quit smoking? (Preparation)
       * Are you in the process of trying to quit smoking? (Action)
       * Are you trying to stay smoke-free? (Maintenance)

       The employees’ responses will help to pinpoint where the
       participants are on the continuum of change, and to tailor messages,
       strategies, and programs appropriate to their needs. For example,
       individuals who enjoy smoking are not interested in trying to quit,
       and therefore will not attend a smoking cessation clinic; for them, a
       more appropriate intervention might include educational
       interventions designed to move them out of the “pre-contemplation”
       stage and into “contemplation” (e.g., using carbon monoxide testing
       to demonstrate the effect of smoking on health). On the other hand,
       individuals who are ready to plan how to quit smoking (the
       “preparation” stage) can be encouraged to do so, and moved to the
       next stage, “action.”

Social Cognitive Theory

       The basic premise of the Social Learning Theory (SLT), also known as Social

Cognitive Theory (SCT) is that the potential for a behavior to occur in any given situation

is a function of the employee’s belief that the behavior will be rewarded or reinforced in
                                                                                         25


some manner. Glanz (2005) states about the Social Cognitive Theory that it describes a

dynamic, ongoing process in which personal factors, environmental factors, and human

behavior exerts influence upon each other.

        According to SCT, three main factors affect the likelihood that a
       person will change a health behavior: (1) self-efficacy, (2) goals, and
       (3) outcome expectancies. If individuals have a sense of personal
       agency or self-efficacy, they can change behaviors even when faced
       with obstacles. If they do not feel that they can exercise control over
       their health behavior, they are not motivated to act, or to persist
       through challenges. As a person adopts new behaviors, this causes
       changes in both the environment and in the person. Behavior is not
       simply a product of the environment and the person, and
       environment is not simply a product of the person and behavior.
       SCT evolved from research on Social Learning Theory (SLT), which
       asserts that people learn not only from their own experiences, but by
       observing the actions of others and the benefits of those actions.

       Table 2.7 provides a description of the key concepts of the Social Cognitive

Theory. Please note that this theory provides a menu of possible ways to intervene to

address a health problem, and it is not likely that a health promotion manager would

develop interventions using all these strategies (concepts) for a particular heath problem.

The strategies chosen should be based on the nature of the problem and the available

resources.
                                                                                    26




Table 2.7: Social Cognitive Theory – Key concepts and Worksite Examples

Concept                   Definition                         Potential Change Strategies         Worksite Examples
Reciprocal determinism    The dynamic interaction of the     Consider multiple ways to            Assess environment
                          person, behavior, and the          promote behavior change,             Identify existing behaviors
                          environment in which the           including making adjustments to      Assess knowledge and skills
                          behavior is performed              the environment or influencing       Identify barriers
                                                             personal attitudes
Behavioral capacity       Knowledge and skill to perform a   Promote mastery learning through     Conduct knowledge and skill
                          given behavior                     skills training                       analysis
                                                                                                  Provide skill training
                                                                                                  Evaluate/recycle skill training
Expectations             Anticipated outcomes of a             Model positive outcomes of         Identify all possible outcomes
                         behavior                              healthful behavior. Model skills   Provide successful models of
                                                               to perform behavior.                outcomes and health behavior
                                                                                                   from the workforce
Self-efficacy            Confidence in one’s ability to        Approach behavior change in        Recognize success
                         take action and overcome barriers small steps to ensure success; be      Allow all to succeed in some
                                                               specific about the desired change   way
                                                                                                  Build on success
                                                                                                  View failure as one relapse
Observational learning   Behavioral acquisition that occurs Offer credible role models who        Recognize success
(modeling)               by watching the actions and           perform the targeted behavior      Show process used to be
                         outcomes of others’ behavior                                              successful
                                                                                                  Use coworkers when possible
Reinforcements           Response to a person’s behavior       Promote self-initiates, rewards,   Provde a variety of incentives
                         that increase or decrease the         and incentives                     Reward behavior change
                         likelihood of reoccurrence                                               Reward goal attainment
Adapted from: National Cancer Institute, Theories at a Glance, NIH publication NO. 05-3869, September 2005
                                                                                       27


       To operatunalize the Social Cognitive Theory, Parcel and Baronowsky have

outlined four phases of a process to foster behavior change using Social Cognitive

Theory. These phases are:

       1. Pre-training phase. The pre-training phase involves gathering information
          on employees to structure a behavior change process. The employee needs
          assessment section in Chapter 1 provides information useful in this phase.
       2. Training phase. This phase involves providing employee programs and
          opportunities to change behavior.
       3. Initial testing phase. This phase starts when a member of the target audience
          attempts to change the behavior learned in the training phase.
       4. Continual performance phase. This phase provides reinforcement and
          support of employee behavior change.

       Table 2.8 provides an example of activities that could be implemented in each

stage of this training process.

Relapse Prevention

       The models of health behavior discussed previously in this chapter include a

significant relapse prevention or maintenance component. In general, health promotion

professionals have focused on leading employees to a behavior change, but have placed

little emphasis on maintenance of positive health behaviors.

       In relapse prevention, the health promotion manager focuses some attention on

helping employees to maintain a behavior change. Relapse prevention in worksite health

promotion can be defined as educational programs, environmental/organizational

modifications, and policy changes designed to provide employees with the knowledge,

skills, and support to cope with problems of relapse.
                                                                                          28




Table 2.8: Social Cognitive Theory – Four Phases of Behavior Change with Cancer
Examples

Pre-training Phase
         Assessment of current lifestyles related to cancer risk
         Assessment of beliefs and anxieties related to cancer
         Examination of factors influencing behavior change related to cancer risk
           reduction
         Identification of how the target audience might seek help to reduce cancer risk
         Initiation of awareness activities to shape attitudes and beliefs, related to
           cancer risk reduction (such as posters, pay envelope stuffers, awareness,
           articles in company newsletters, etc.)

Training Phase
        Educational seminars and awareness activities on selected protective and risk
           factors (adding vitamins C and A, the relationship of the sun and skin cancer,
           the effects of cured meats, etc.)
        Skill training sessions for selected protective and risk factors (how to add fiber
           to your diet, how to trim fat from the diet, techniques to protect yourself from
           the sun, etc.)
        Selected behavior change programs (smoking cessation programs, weight
           control sessions, and responsible drinking techniques)

Initial Testing Phase
          Assess the environmental support capabilities of the corporation
          Suggest activities to enhance the testing of cancer risk reduction behaviors
             (develop an effective smoking policy, add healthy snacks to vending
             machines, include appropriate foods in cafeterias, etc.)

Continuing Performance Phase
        Implement relapse prevention techniques
        Provide reinforcers and incentives for members of the target audience who
          participate and complete activities (novelties, recognition, other rewards, etc.)
        Create social support groups as appropriate
        Develop long term self-control manuals for selected cancer risk behaviors
          (smoking, weight control, fiber, etc.)
                                                                                        29




       Educational programs provide behavior skills and cognitive techniques to train

employees to cope with problems of relapse. These include:

       1. Behavioral self-management skills. Strategies to help employees manage

          their behavior over an extended time frame. For a program dealing with

          dietary habits, this would include detailed guidelines on how to monitor

          dietary intake and make wise food choices.

       2. Analysis of situational factors that influence relapse. In this aspect of

          relapse prevention, employees discuss how they would cope with a situation

          that may cause a relapse. For dietary habits, the employees may discuss how

          they would handle controlling eating during a special event, such as an office

          party or Thanksgiving dinner.

       3. Dealing with psychological factors that impact relapse. Employees need to

          address specific emotions and attitudes which affect the relapse process.

          These include (1) self-efficacy – an employee’s belief about how capable he

          or she is of maintaining a behavior change; and (2) abstinence violation

          effect (AVE) – an employee convinces himself or herself that he or she is not

          capable of maintaining the behavior change.

				
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