Samenvatting Health Behavior theory, research, and practice:
Hoofdstuk 1:
It is an exciting time to contemplate behavior change. Perhaps never before have there been so
many demands on those who aim to facilitate positive changes in health behaviors and so many
potential strategies from which to choose. Where professionals once might have seen their roles as
working at a particular level of intervention (such as changing organizational or individual health
behaviors) or employing a specific type of behavior change strategy (such as group interventions or
individual counselling), we now realize that multiple kinds of interventions at different levels often
are needed to initiate and sustain behavior change effectively. Once, health behavior experts might
have relied on intuition, experience, and their knowledge of the literature. Increasingly, however,
professionals are expected to act on the basis of evidence. Along with the evidence base on behavior
change interventions is growing interest in using and assessing the impact of theories of behavior
change.
Unhealthy behaviors continue to account for a disproportionate share of deaths in countries around
the world. And the rise of noncommunicable diseases globally is a major threat to world health,
pushing many below the poverty line. National and global health policies must encourage and enable
people to practice healthy habits. Improved health is not dependent on medicine or health care
alone; it is the sum of multiple factors at multiple levels of societies.
Health, Disease, and Health Behavior: The Changing Context
Infectious diseases and as with chronic diseases, their trajectory may be influenced by the application
of effective health behavior interventions as well as by social determinants that influence health and
illness. Substantial suffering, premature mortality, and medical costs can be avoided by positive
changes in behavior at multiple levels.
During the past 20 years, there has been a dramatic increase in public, private, and professional
interest in preventing disability and death through changes in lifestyle and participation in screening
programs. Country and global population health goals are an essential part of the strategy. Much of
this interest in disease prevention and early detection has been stimulated by the epidemiologic
transition from infectious to chronic diseases as leading causes of death, the aging of the global
population, rapidly escalating health care costs, and data linking individual behaviors to increased
risk of morbidity and mortality. The evidence that early detection can save lives from highly prevalent
conditions has also been influential. The AIDS epidemic has also contributed. Moreover, around the
world, communicable diseases and malnutrition exist alongside increasing problems such as obesity
among the middle class.
Increased interest in behavioral and social determinants of health behavior change has spawned
numerous training programs and public and commercial service programs.
Data systems and surveillance initiatives now make it feasible to track trends in risk factors, health
behaviors, and healthy environments and policies in the United States and developed countries and,
in some cases, to tie these changes to disease incidence and mortality. The collective efforts of those
in health care, health education, and public health have made a difference.
Reducing the global disease burden is critical to the future of the planet.
Changes in health care systems are providing new supports and opportunities for health behavior
change. Respect for patients’ rights and more participatory, patient-centered communications can
lead to improved health outcomes. The U.S. Patient Protection and Affordable Care Act included
,expectations for health care systems to increase patients’ engagement and to measure their success
in achieving this outcome. Increasingly, patients are driving their own searches for health information
by using the Internet, though disparities remain in information seeking between those of higher and
lower socioeconomic status. Clinical prevention and behavioral interventions are often considered
cost effective but are neither universally available nor equally accessible across racial and
socioeconomic groups.
The rapid emergence of new communication technologies and new models of use for older
technologies, such as the telephone, also provide new opportunities and dilemmas. Just a few years
ago, ‘new’ electronic media for interactive health communications consisted mainly of the Internet,
CD-ROMs, and personal digital assistants. Today, social media, tablets, wireless communications, and
personal monitoring devices are widespread. They can serve as sources of individualized health
information, reminders, and social support for health behavior change. These new technologies also
may connect individuals with similar health concerns around the world. This may be especially
important for people with rare or stigmatized health conditions. However, the new products of the
communication revolution have not reached affluent and disadvantaged populations equally.
E-health and m-health strategies are becoming important behavior change strategies. Use of new
technologies should be based on theories of health behavior and evaluated. In the end, emphasis
should be on desired health outcomes. Technology can enable behavior change and measurement of
change but should not be an end in itself.
At the same time, new technologies have the potential to cause harm through misleading or
deceptive information, promotion of inappropriate self-care, and interference in the patient-provider
relationship, although the empirical evidence on harms remains to be documented. Interactive
health communications provide new options for behavioral medicine and preventive medicine, and
are altering the context of health behavior and health education as they unfold and as their effects
are studied.
Health Behavior and Health Behavior Change
Health Behaviors
Positive, informed changes in health behaviors are typically the ultimate aims of health behavior
change programs. If behaviors change but health is not subsequently improved, the result is a
paradox that must be resolved by examining other issues, such as the link between behavior and
health status, or the ways in which behavior and/or health are measured. Informed decision making
is a desirable endpoint for problems involving medical uncertainty, and studies suggest that shared
decision making may lead to improved patient satisfaction and health outcomes. Likewise,
environmental or structural interventions to change presumed social environmental determinants of
health behaviors are intended to improve health by changing behavior. Thus efforts to improve
environments, policies, and other outcomes should ultimately be evaluated for their effects on
health behaviors and health. If a policy changes but does not lead to measurable changes in
behavior, the change may be either too weak, too short-lived, ineffectively implemented, or only a
limited determinant of behavior.
In its broadest sense, health behavior refers to the actions of individuals, groups, and organizations
as well as those actions’ determinants, correlates, and consequences, including social change, policy
development and implementation, improved coping skills, and enhanced quality of life. This is similar
to the working definition of health behavior that Gochman proposed: it includes not only observable,
overt actions but also the mental events and feeling states that can be reported and measured.
,Gochman defined health behavior as ‘those personal attributes such as beliefs, expectations,
motives, values, perceptions, and other cognitive elements; personality characteristics, including
affective and emotional states and traits; and overt behavior patterns, actions, and habits that relate
to health maintenance, to health restoration, and to health improvement’.
Kasl and Cobb defined 3 categories of health behavior:
- Preventive health behavior: any activity undertaken by an individual who believes himself (or
herself) to be healthy, for the purpose of preventing or detecting illness in an asymptomatic
state.
- Illness behavior: any activity undertaken by an individual who perceives himself to be ill, to
define the state of health, and to discover a suitable remedy.
- Sick-role behavior: any activity undertaken by an individual who considers himself to be ill,
for the purpose of getting well. It includes receiving treatment from medical providers,
generally involves a whole range of dependent behaviors, and leads to some degree of
exemption from one’s usual responsibilities.
Disciplinary Influences on Health Behavior Change over Time
Health behavior change has been the focus of multiple fields and professions, including health
education, public health, psychology, social work, and various health and medical specialties.
Advocates of system-level changes to improve health called for renewal of a broad vision of health
education and promotion. These calls for moving health education toward social action heralded a
tighter connection to the broad field of public health. They are consistent with the longstanding
concern of public health with the impact of social, economic, and political forces on health. Thus the
idea that focusing on downstream (individual) causes of poor health to the exclusion of the upstream
causes risks missing important opportunities to improve health is not new in public health and health
education and promoting, but continues to receive increasing attention.
The view of health behavior change strategies as instruments of social change has been renewed and
invigorated during the past decade. Policy, advocacy, and organizational change have been adopted
as central activities of public health and health education. Most recently, experts have explicitly
recommended that interventions on social and behavioral factors related to health should link
multiple levels of influence, including the individual, interpersonal, institutional, community, and
policy levels.
Settings and Audiences for Health Behavior Change
Settings: Where Are Health Behavior Change Strategies Provided?
7 major settings are particularly relevant to contemporary health behavior: schools, communities,
worksites, health care settings, homes, the consumer marketplace, and the communication
environment.
Schools
Health behavior change programs in schools include classroom teaching, teacher training, and
changes in school environments that support healthy behaviors. To support long-term health
enhancement initiatives, theories of dissemination and implementation can be used to encourage
adoption of comprehensive smoking control programs in schools.
Communities
, Community-based health promotion draws on social relationships and organizations to reach large
populations with media and interpersonal strategies. Models of community engagement and
community mobilization enable program planners both to gain support for and to design suitable
health messages and delivery mechanisms.
Worksites
Because people spend so much time at work, the workplace is a source of both stress and social
support. Effective worksite programs can harness social support as a buffer to stress, with the goal of
improving worker health and health practices. Today many businesses, particularly large
corporations, provide health promotion programs for their employees. The U.S. Affordable Care Act
provides incentives for employees to alter health behaviors, further advancing worksite health
behavior change initiatives. Both high-risk and population-wide strategies have been used in worksite
health behavior change programs to reduce chronic disease risk factors.
Health Care Settings
Health behavior change programs for high-risk individuals, patients, their families, and the
surrounding community and in-service training for health care providers are all part of health care
today. The changing nature of health service delivery has stimulated greater emphasis on
implementing health behavior change and provider-focused quality improvement strategies in
physicians’ offices and medical homes, health maintenance organizations, public health clinics, and
hospitals. Primary care settings, in particular, provide an opportunity to reach a substantial number
of people and to achieve goals of improved population health. The use of community health workers
for patients discharged from hospitals is increasingly considered a strategy for reducing readmission
rates.
Homes
Health behavior change interventions can be delivered to people in their homes, both through
traditional public health means – home visits – and through a variety of communication channels and
media, such as the Internet, telephone calls, and mail. Strategies, such as mailed tailored messages
and motivational interviewing by telephone, make it possible to reach larger groups and high-risk
groups in a convenient way that reduces barriers to their receiving motivational messages. In-home
coaching that helps people improve their home health environments to support health behavior
change has also shown promise.
The Consumer Marketplace
Social marketing, with its roots in consumer behavior theory, is used increasingly by health educators
to enhance the salience of health messages and to improve their persuasive impact. Health
information policies intended to support informed consumer decision making, such as policies that
encourage adding calorie information to menus and require graphic warning labels on cigarette
packs, have emerged prominently in the past few years.
The Communication Environment
There have been striking and rapid changes in the availability and use of new information and
communication technologies (ICTs), ranging from mass media changes to personalized, mobile, and
interactive media and a host of wireless tools in homes, businesses, and communities. These
channels can be used in any of the settings described above. Yet they are unique, increasingly
