theory and behavior change

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CHAPTER 2

THEORY, RESEARCH, AND PRACTICE IN HEALTH BEHAVIOR

The Editors

Theory, Research, and Practice: Interrelationships

Aristotle distinguished between theoria and praxis. Theo-

ria signifies those sciences and activities concerned with

knowing for its own sake, whereas praxis corresponds to

action or doing. This contrast between theory and practice

(Bernstein, 1971) permeates Western philosophical and

scientific thought from Aristotle to Marx and on to Dewey

and other contemporary twentieth-century philosophers.

Theory and practice have long been regarded as opposites

with irreconcilable differences. Within academic depart-

ments, there is often a hierarchical split between those

who conduct theoretical work and those who pursue

practice. Dewey attempted to resolve the dichotomy by

focusing on similarities and continuities between theoret-

ical and practical judgments and inquiries. He described

experimental knowing as essentially an art that involves a

conscious, directed manipulation of objects and situations.

“The craftsman perfects his art, not by comparing his prod-

uct to some ‘ideal’ model, but by the cumulative results

of experience—experience which benefits from tried and

tested procedures but always involves risk and novelty”

(Bernstein, 1971). Dewey thus described empirical investi-

gation, that is, research, as the ground between theory and

practice and the testing of theory in action.

Although the perception of theory and practice as a

dichotomy has a long tradition in intellectual thought,Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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24 CHAPTER 2: THEORY, RESEARCH, AND PRACTICE IN HEALTH BEHAVIOR

we follow in Dewey’s tradition and focus on the similarities and continuities rather than

on the differences. Theory, research, and practice are a continuum along which the skilled

professional should move with ease. Not only are they related but they are each essential

to understanding health behavior and health behavior change. There is a tension between

theory and practice that one must navigate continually, but they are not in opposition. Theory

and practice enrich one another by their dynamic interaction. The best theory is informed

by practice; the best practice should be grounded in theory. There is too little of both in

health behavior. And as Green (2006) has written compellingly, there is also a need for more

practice-based evidence. Researchers and practitioners may differ in their priorities, but the

relationship between research and its application can and should move in both directions.

There is a critical need for more “reflective practitioners,” professionals who can ensure that

theories and practice build on each other (Schön, 1983).

Among the most important challenges facing us is to understand health behavior and to

transform knowledge about behavior into effective strategies for health enhancement. Research

in health behavior ultimately will be judged by its contributions to improving the health of

populations. Although basic behavioral research is important in developing theories, we must

ultimately test our theories iteratively in real-world contexts (Green, 2006). When we do so,

theory, research, and practice begin to converge. The authors of this book examine theories in

light of their applicability. By including an explanation of theories and their application in each

chapter, we aim to break down the dichotomy between theory and practice.

Relationships among theory, research, and practice are not simple or linear. The larger

picture of health improvement and disease reduction is better described as a cycle of interacting

types of endeavors, including fundamental research (research into determinants as well

as development of methodologies), intervention research (research aimed toward change),

surveillance research (research that tracks population-wide trends, including maintenance of

change), and application and program delivery (Hiatt & Rimer, 1999). At the heart of this

cycle is knowledge synthesis. Regularly updated critical appraisals of the available literature are

central to identifying interventions that should be disseminated in order to reduce the burden

of disease (Rimer, Glanz, & Rasband, 2001). There is increasing recognition that, as Green

has stated, “if we want more evidence-based practice, we need more practice-based evidence”

(Green & Glasgow, 2006).

This fifth edition of Health Behavior: Theory, Research, and Practice aims to help health

care providers, public health professionals, behavior change experts, and educators—whatever

their backgrounds or disciplines—to understand some of the most important theoretical

underpinnings of health behavior and to use theory to inform research and practice. The

authors of this volume believe that “there is nothing so useful as a good theory” (Lewin, 1935).

Each chapter demonstrates the practical value of theory; each summarizes what was learned

through conceptually sound research and practice; and each draws the linkages between theory,

research, and practice.

Professionals charged with responsibility for improving health behavior are, by and large,

interventionists. They are action oriented. They use their knowledge to design and imple-

ment programs to improve health. This is true whether they are working to encourageGlanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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THEORY, RESEARCH, AND PRACTICE: INTERRELATIONSHIPS 25

health-enhancing changes in individual or community behavior or conditions. It is equally

true of most health behavior research. Often, in the process of attempting to change behavior,

environments, or policies, researchers must do precisely what practitioners do—develop and

deliver interventions. At some level, both practitioners and researchers are accountable for

results, whether these are measured in terms of participants’ satisfaction with programs or

changes in awareness, knowledge, attitudes, beliefs, or health behaviors; improved decision

making; institutional norms; community integration; or more distal results, including morbid-

ity, mortality, and quality of life. They may assess these results anecdotally, complete in-depth

qualitative assessments, or conduct rigorous empirical evaluations.

The design of interventions that yield desirable changes can be improved when it is done

with an understanding of theories of behavior change and an ability to use them skillfully in

research and practice (Grol, Bosch, Hulscher, Eccles, & Wensing, 2007). Most public health

educators and managers, and behavior change clinicians, work in situations in which resources

are limited. This makes it essential that they reach evidence-informed judgments about the

choice of interventions, both in the interest of efficiency and to improve the odds of success.

There may be no second chance to reach a critical target audience.

A synthesis of theory, research, and practice will advance what is known about health

behavior. A health behavior change agent without a theory is like a mechanic or a technician,

whereas the professional who understands theory and research comprehends the “why” and can

design and craft well-tailored interventions. In health behavior, the circumstances include the

nature of the target audience and the setting, resources, goals, and constraints (Bartholomew,

Parcel, Kok, & Gottlieb, 2006). There are a number of good planning models available to

help professionals and communities decide which problems and variables to focus on and

also help them understand key elements of the background situation (see Chapter Nineteen

for examples).

An understanding of theory may guide users to measure more carefully and astutely in

order to assess the impact of interventions (Glasgow & Linnan, 2008; Grol et al., 2007). Learning

from successive interventions and from published evidence strengthens the knowledge base

of individual health professionals. Over time, such cumulative learning also contributes to the

knowledge base of all.

The health professional in a health maintenance organization who understands how to

use the Transtheoretical Model or Social Cognitive Theory (SCT) may be able to design better

interventions to help patients lose weight or stop smoking. The community health educator

who understands principles of social marketing and media communication can make better

use of the mass media than one who does not. The nurse who recognizes that observational

learning is important to how people learn, as postulated in SCT, may do a better job of teaching

diabetics how to administer their injections. A working knowledge of community organization

can help the educator identify and mobilize key individuals and groups to develop or maintain

a health promotion program. The physician who understands interpersonal influence can

communicate more effectively with patients. The health psychologist who understands the

Transtheoretical Model of change will know how to design better smoking cessation and

exercise interventions and how to tailor them to the needs of his or her patients.Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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26 CHAPTER 2: THEORY, RESEARCH, AND PRACTICE IN HEALTH BEHAVIOR

What Is Theory?

A theory is a set of interrelated concepts, definitions, and propositions that present a systematic

view of events or situations by specifying relations among variables, in order to explain and

predict events or situations. The notion of generality, or broad application, is important, as

is testability (van Ryn & Heaney, 1992). Theories are by their nature abstract: that is, they

do not have a specified content or topic area. Like an empty coffee cup, they have a shape

and boundaries but nothing concrete inside. They only come alive in public health and health

behavior when they are filled with practical topics, goals, and problems.

A formal theory—more an ideal than a reality—is a completely closed deductive system

of propositions that identifies the interrelationships among the concepts and is a systematic

view of the phenomena (Blalock, 1969; Kerlinger, 1986). In reality, there is no such system in

the social sciences or health promotion and education; it can only be approximated (Blalock,

1969). Theory has been defined in a variety of ways, each consistent with Kerlinger’s definition.

Table 2.1 summarizes several definitions of theory. These definitions, put forth in the 1970s

and 1980s, have stood the test of time. They have been articulated in more recent works

without substantive changes (Isaac & Michael, 1995; Sussman, 2001).

Theories are useful during the various stages of planning, implementing, and evaluating

interventions. Program planners can use theories to shape the pursuit of answers to why?

what? and how? That is, theories can be used to guide the search for why people are not

following public health and medical advice or not caring for themselves in healthy ways. They

can help pinpoint what one needs to know before developing and organizing an intervention

program. They can provide insight into how to shape program strategies to reach people and

organizations and make an impact on them. They can also help to identify what should be

monitored, measured, and/or compared in a program evaluation (Glanz, Lewis, & Rimer, 1996;

Glanz, Rimer, & Lewis, 2002; Glasgow & Linnan, 2008).

Thus theories and models explain behaviors and suggest ways to achieve behavior change.

Explanatory theories, often called a theory of the problem, help to describe and identify why

Table 2.1 Definitions of Theory

Definition Source

A set of interrelated constructs (concepts), definitions, and propositions that presents a

systematic view of phenomena by specifying relations among variables, with the purpose

of explaining and predicting phenomena

Kerlinger, 1986, p. 9

A systematic explanation for the observed facts and laws that relate to a particular

aspect of life

Babbie, 1989, p. 46

Knowledge writ large in the form of generalized abstractions applicable to a wide range

of experiences

McGuire, 1983, p. 2

A set of relatively abstract and general statements which collectively purport to explain

some aspect of the empirical world

Chafetz, 1978, p. 2

An abstract, symbolic representation of what is conceived to be reality—a set of abstract

statements designed to “fit” some portion of the real world

Zimbardo, Ebbesen, & Maslach, 1977, p. 53

Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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WHAT IS THEORY? 27

a problem exists. These theories also predict behaviors under defined conditions. They guide

the search for modifiable factors like knowledge, attitudes, self-efficacy, social support, lack

of resources, and so on. Change theories, or theories of action, guide the development of

interventions. They also form the basis for evaluation, pushing the evaluator to make explicit

her or his assumptions about how a program should work. Implementation theories are change

theories that link theory specifically to a given problem, audience, and context (Institute of

Medicine, 2002; also see Chapter Sixteen). These two types of theories often have different foci

but are complementary.

Even though various theoretical models of health behavior may reflect the same general

ideas, each theory employs a unique vocabulary to articulate the specific factors considered

important. The why tells us about the processes through which changes occur in particular

target variables. Theories vary in the extent to which they have been conceptually developed

and empirically tested. Bandura (1986) stressed that “theories are interpreted in different ways

depending on the stage of development of the field of study; in some younger fields, theories

specify the determinants governing the phenomena of interest.” The term theory is used in

the latter sense in Health Behavior: Theory, Research, and Practice, because this field is still

relatively young.

As we discuss later in this chapter, many new theories and models have been and continue

to be proposed in health behavior (Michie, West, Campbell, Brown, & Gainforth, 2014). The

proliferation of theories in health behavior poses a challenge: When do we accept a theory as

truly advancing our understanding of a phenomenon? Lakatos and Musgrave (1970), though

referring to theories in physics, offer some rules of thumb. A new theory can be considered

acceptable if it explains everything that the prior theories explain, provides explanations for

phenomena that could not be explained by prior theories, and identifies conditions under

which the theory could be falsified. Another expectation of an established theory is that there

should be a body of research testing it, and supporting it, by multiple scientists beyond the

original developer(s).

Concepts, Constructs, and Variables

Concepts are the major components of a theory; they are its building blocks or primary

elements. Concepts can vary in the extent to which they have meaning, or can be understood

outside the context of a specific theory. When concepts are developed or adopted for use in a

particular theory, they are called constructs (Kerlinger, 1986). The term subjective normative

belief is an example of a construct within Ajzen and Fishbein’s (1980) Theory of Reasoned

Action (see Chapter Six); this specific construct has a precise definition in the context of that

theory. Another example of a construct is perceived susceptibility in the Health Belief Model

(see Chapter Five).

Variables are the empirical counterparts, or operational forms, of constructs. They

specify how a construct is to be measured in a specific situation. Variables should be

matched to constructs when identifying what should be assessed in the evaluation of a theory-

driven program.Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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28 CHAPTER 2: THEORY, RESEARCH, AND PRACTICE IN HEALTH BEHAVIOR

Principles

Theories go beyond principles. Principles are general guidelines for action. They are broad and

nonspecific and may actually distort realities or results based on research. Principles may be

based on precedent or history or on research. At their best, principles are based on accumulated

research. In this best form, principles are the basis for hypotheses, “leading ideas” in the words

of Dewey, and serve as our most informed hunches about how or what we should do to obtain

a desired outcome in a target population. Principles should not be so broad that they invite

multiple interpretations and are therefore unreliable. Nor should they be ambiguous so that

they can be all things to all people.

Models

Health behavior and the guiding concepts for influencing it are far too complex to be explained

by a single, unified theory. Models draw on a number of theories to help understand a specific

problem in a particular setting or context. They are often informed by more than one theory,

as well as by empirical findings (Earp & Ennett, 1991). Several models that support program

planning processes are widely used in health promotion and education: Green and Kreuter’s

PRECEDE-PROCEED Model (2005; also see Chapter Nineteen) and social marketing (see

Chapter Nineteen) and ecological models (McLeroy, Bibeau, Steckler, & Glanz, 1988; also see

Chapter Three).

Paradigms for Theory and Research in Health Behavior

A paradigm is a basic schema that organizes our broadly based view of something (Babbie,

1989). Paradigms are widely recognized scientific achievements that, for a time, provide model

problem-solving approaches to a community of practitioners and scientists. They include

theory, application, and instrumentation and constitute models that represent coherent

traditions of scientific research (Kuhn, 1962). Paradigms gain status because they are more

successful than their competitors at solving pressing problems (Kuhn, 1962), but they can also

impede scientific progress by protecting inconsistent findings until a crisis point is reached;

these crisis points lead to scientific revolutions.

Paradigms create boundaries within which the search for answers occurs. They do not

answer particular questions, but they do direct the search for answers (Babbie, 1989). Paradigms

circumscribe or delimit what is important to examine in a given field of inquiry. The collective

judgments of scientists define the dominant paradigm that constitutes the body of science

(Wilson, 1952).

In the science of health behavior (and in this text), the dominant paradigm that supports

the largest body of theory and research is logical positivism, or logical empiricism. This basic

view, developed in the Vienna Circle from 1924 to 1936, has two central features: (1) an

emphasis on the use of induction, or sensory experience, feelings, and personal judgments as

the source of knowledge; and (2) the view that deduction is the standard for verification or

confirmation of theory so that theory must be tested through empirical methods and systematicGlanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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PARADIGMS FOR THEORY AND RESEARCH IN HEALTH BEHAVIOR 29

observation of phenomena (Runes, 1984). Logical empiricism reconciles the deductive and

inductive extremes; it prescribes that the researcher begin with a hypothesis deduced from

a theory and then test it, subjecting it to the jeopardy of disconfirmation through empirical

testing (McGuire, 1983).

An alternative worldview that is also important in health behavior relies more heavily on

induction and is often identified as a predominantly constructivist paradigm. This perspective

argues that the organization and explanation of events should be revealed through a process

of discovery rather than organized into prescribed conceptual categories before a study

begins. In this paradigm, data collection methods such as standardized questionnaires and

predetermined response categories have a limited place. Ethnography, phenomenology, and

grounded theory are examples of approaches using a constructivist paradigm (Kendler, 2005;

Strauss, 1987). It has become increasingly common in the health behavior field for work to

originate in a constructivist paradigm and shift toward a focus on answering specific research

questions using methodologies from the logical positivist paradigm. The use of mixed methods

that include both qualitative and quantitative measures has gained traction in health behavior,

psychological research, and other social sciences (Cacioppo, Semin, & Berntson, 2004; Creswell,

2013). However, without quantitative data, a theory is unlikely to be accepted.

Lewin’s meta-theory stipulates the rules to be followed for building good theory. The

rules are consistent with logical positivism but focus on his view that the function of social

psychology is to further understanding of the interrelationships between the individual and the

social environment (Gold, 1992). This meta-theory is an orientation, or approach, distinct from

Lewin’s specific field theory (Gold, 1992), and it has been influential in health behavior theory

since the earliest attempts to use social science to solve public health problems (Rosenstock,

1990). Key rules of Lewin’s “meta-theory” include analysis that starts with the situation

as a whole, contemporaneity, a dynamic approach, a constructive method, a mathematical

representation of constructs and variables, and a psychological approach that explains both

inner experiences and overt actions from the actor’s perspective (Lewin, 1951). The last of these

rules implies a single level of analysis requiring “closed theory” and poses a serious limitation

to solving the problems of contemporary health behavior. It raises the issue—one that those

concerned with health behavior often grapple with—that we must often trade off theoretical

elegance in favor of relevance (Gold, 1992).

Ultimately, those who study and practice in fields that involve health behavior are generally

concerned with approaches to solving social problems, and in many cases, solving some of the

most significant threats and problems facing the world today. In other words, they are grappling

with fundamental challenges of behavior change in the health domain. Considerable scholarly

and practitioner effort has been devoted to developing techniques that change behavior.

Although these efforts grew out of a desire to produce a better world, techniques that “push”

people to change were experienced by many as manipulative, reducing freedom of choice, and

sustaining a balance of power in favor of the “change agent” (Kipnis, 1994). A paradigm shift

occurred, and many techniques for promoting individual behavior change (e.g., social support,

empowerment, and personal growth) shifted focus to become based on reducing obstacles to

change and promoting informed decision making, rather than on pushing people to change.Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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30 CHAPTER 2: THEORY, RESEARCH, AND PRACTICE IN HEALTH BEHAVIOR

New paradigms for understanding, studying, and applying knowledge about human

behavior continue to arise and may be influential in the future of applied social sciences in

health behavior and education. The Institute of Medicine’s Committee on Capitalizing on

Social Science and Behavioral Research to Improve the Public’s Health recommended strongly

that “interventions on social and behavioral factors should link multiple levels of influence”

rather than focusing on a single or limited number of health determinants (Smedley & Syme,

2000, p. 7). Today, this recommendation is echoed as health educators and social scientists

struggle with some of the most challenging health behavior issues, such as tobacco control

and obesity prevention, at a time when ecological models are beginning to be more clearly

articulated and studied (see Chapter Three).

Trends in Use of Health Behavior Theories and Models

Theories that gain recognition in a discipline shape the field, help to define the scope of practice,

and influence the training and socialization of its professionals. Today, no single theory or

conceptual framework dominates research or practice for understanding and changing health

behavior. Instead, one can choose from a multitude of theories.

Previous Reviews of the Most Often Used Theories

For the first four editions of this book, we reviewed a sample of publications to identify the

most often used theories. In a review of 116 theory-based articles published between 1986 and

1988 in two major health education journals, conducted during planning for the first edition

of this book, we found fifty-one distinct theoretical formulations. At that time, the three most

frequently mentioned theories were Social Learning Theory, the Theory of Reasoned Action,

and the Health Belief Model (Glanz, Lewis, & Rimer, 1990).

To plan for the second edition of this book, we reviewed 526 articles from twenty-four

journals in health education, medicine, and behavioral sciences, published from mid-1992

to mid-1994. Sixty-six theories and models were identified, and twenty-one of these were

mentioned eight times or more. Two-thirds of the total instances of theory use in the 497

articlesinvolvingoneormoreofthetwenty-onemostcommontheories/modelswereaccounted

for by the first eight: the Health Belief Model, Social Cognitive Theory, self-efficacy (Bandura,

1997), the Theory of Reasoned Action/Theory of Planned Behavior, community organization,

the Transtheoretical Model/Stages of Change, social marketing, and social support/social

networks (Glanz et al., 1996).

In our review of all issues of twelve journals in health education, health behavior, and

preventive medicine published in 1999 and 2000, conducted for the third edition of this book

(Glanz et al., 2002), ten theories or models clearly emerged as the most often used. The first

two, and by far the most dominant, were Social Cognitive Theory and the Transtheoretical

Model/Stages of Change. The remainder of the top ten theories and models were the

Health Belief Model, social support and social networks, patient-provider communication, the

Theory of Reasoned Action and Theory of Planned Behavior, stress and coping, community

organization, ecological models/social ecology, and Diffusion of Innovations.Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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TRENDS IN USE OF HEALTH BEHAVIOR THEORIES AND MODELS 31

In a review of theory use in published research between 2000 and 2005, we found

that the most often used theories were the Transtheoretical Model, Social Cognitive Theory,

and the Health Belief Model (Painter, Borba, Hynes, Mays, & Glanz, 2008). Overall, the same

theories found to be dominant in 1999 and 2000 were still dominant. Like previous reviews,

this review revealed that dozens of theories and models were used, though only a few of them

were used in multiple publications and by several authors. Some were minor variations of

another theory. Several key constructs cut across the most often cited models for understanding

behavior and behavior change: the importance of the individual’s view of the world, multiple

levels of influence, behavior change as a process, motivation versus intention, intention versus

action, and changing behavior versus maintaining behavior change (Glanz & Oldenburg, 2001).

Updated Review of the Most Often Used Theories

There has been a continuing proliferation of theories and models up to the present. Rather than

conducting a new literature review for the fifth edition of this book, we looked to published

reviews. We identified several reviews that examined the use of theory for behavior change in

specific behavioral categories, such as dietary change, cancer screening, and reducing sexual

risk (Albada, Ausems, Bensing, & van Dulmen, 2009; Ammerman, Lindquist, Lohr, & Hersey,

2002; Gardner, Wardle, Poston, & Croker, 2011; Glanz & Bishop, 2010; Legler et al., 2002; Noar,

Benac, & Harris, 2007; Noar, Black, & Pierce, 2009; Prestwich et al., 2013; Taylor, Conner,

& Lawton, 2011; Webb, Joseph, Yardley, & Michie, 2010). A recently published compendium

of behavior change theories, using clearly defined inclusion criteria, provides summaries of

eighty-three theories and models (Michie et al., 2014). As these reviews assessed primarily

individual outcomes of behavior change interventions, we also examined reviews of strategies

for implementation and dissemination in health and mental health services (Powell et al., 2012;

Tabak, Khoong, Chambers, & Brownson, 2012) and a review of social ecological contextual

levels of health promotion interventions across a twenty-year period (Golden & Earp, 2012).

These reviews point to several key conclusions about the use of theories and models

for health behavior change research. The first is the inescapable observation that there are

many available theories and models. For example, the (acknowledged) selective review of

eighty-three theories in Michie and others’ book (2014); the sixty-eight distinct strategies

identified by Powell and others (2012); and the sixty-one models included in Tabak and others’

dissemination and implementation research review (2012). These theories and models are not

mutually exclusive. As Tabak and colleagues have stated, “there is substantial overlap between

models, as the included constructs are often similar” (2012). Review authors have used different

coding schemes to classify the theories in their reviews. A novel approach taken by Michie and

others (2014) to examine the interconnectedness of the eighty-three theories summarized in

their book was to use network analysis methods to examine contributions, links, and patterns

among the theories they describe.

Our synthesis of the various reviews, and the Michie et al. network analysis (2014), leads

to the conclusion that, indeed, only a small number of theories and models have been widely

used and/or have informed numerous other theories. In fact, those theories are the same onesGlanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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32 CHAPTER 2: THEORY, RESEARCH, AND PRACTICE IN HEALTH BEHAVIOR

identified in the last three editions of this book: the Health Belief Model, Social Cognitive

Theory (and Social Learning Theory, its predecessor), Theory of Planned Behavior (and Theory

of Reasoned Action, its predecessor), social support, Diffusion of Innovations, and the Social

Ecological Model.

A third issue in examining the use of theories and models for health behavior change is

the level at which they seek to understand and/or influence behavior and its determinants

(see Chapter Three). Golden and Earp reviewed 157 intervention articles published in the

journal Health Education & Behavior (and its predecessor through 1997, Health Education

Quarterly) between 1989 and 2008. They coded intervention levels of focus according to the

Social Ecological Model and found that, across all settings, theories, topics, and time periods,

the intervention strategies and targets for change were most likely to be at the individual

and interpersonal levels, and were less often at the institutional, community, and policy levels

(Golden & Earp, 2012). In contrast, Tabak and colleagues (2012) found that most of the

models for dissemination and implementation research that they identified were distributed

across all levels of the Social Ecological Model. The focus and scope of the two reviews was

very different—with Golden and Earp looking at a single journal over time, and the Tabak

review examining inherently multilevel issues (dissemination and implementation) across a

wide range of sources. Viewing these contrasting findings through the interdisciplinary lens of

health behavior research and practice, an important conclusion is that broader exposure across

topics and published sources appears to be associated with greater application across multiple

levels of study and intervention.

How Are Theories Being Used in Health Behavior Research and Practice?

Along with the published observations about which theories are being used, concerns have

been raised about how theories are used (or not used) in research and practice. A common

refrain is that researchers may not understand how to measure and analyze constructs of health

behavior theories (Marsh, Johnson, & Carey, 2001; Rejeski, Brawley, McAuley, & Rapp, 2000) or

that they may pick and choose variables from different theories in a way that makes it difficult

to ascertain the role of theory in intervention development and evaluation (Michie et al.,

2014). Considerable conceptual confusion—among both researchers and practitioners—about

interrelationships among related theories and variables has also been observed (Rosenstock,

Strecher, & Becker, 1988; Weinstein, 1993). Others have cautioned about the limitations of

theory testing because of overreliance on correlational designs (Weinstein, 2007), and the

paucity of studies that empirically compare more than one theory (Noar & Zimmerman, 2005;

Weinstein & Rothman, 2005). The difficulty of reliably translating theory into interventions

to improve clinical effectiveness has led to calls for more pragmatic trials, and increasing

attention to the generalizability and translation of interventions into real-world clinical

practice (Rothwell, 2005) and community settings (Rohrbach, Grana, Sussman, & Valente,

2006). These are reasonable questions that should encourage us all to question how we use

theory, how we test theory, how we turn theories into interventions, and what conclusions we

draw from research.Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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SELECTION OF THEORIES FOR THIS BOOK 33

Building on our distinctions among the type and degree of theory use (Glanz, 2002,

p. 546), our review of theory used from 2000 to 2005 classified articles that employed health

behavior theory along a continuum consisting of these four categories: (1) informed by theory:

a theoretical framework was identified, but no or limited application of the theory was used

in specific study components and measures; (2) applied theory: a theoretical framework was

specified and several of the constructs were applied in components of the study; (3) tested

theory: a theoretical framework was specified and more than half the theoretical constructs

were measured and explicitly tested, or two or more theories were compared to one another in

a study; or (4) building/creating theory: new or revised/expanded theory was developed using

constructs specified, measured, and analyzed in a study.

Of all the theories used in the sample of articles (n = 69 articles using 139 theories), 69.1 percent used theory to inform a study, 17.9 percent of theories were “applied,” 3.6 percent were

tested, and 9.4 percent involved building/creating theory (Painter et al., 2008). These findings

lead us to reaffirm calls by Noar and Zimmerman (2005) and Weinstein and Rothman (2005)

for thorough application and testing of health behavior theories to advance science and move

the field forward. Similar observations have been made by Michie and others (2014) as well.

Selection of Theories for This Book

Our selection of theories and models for inclusion in the fifth edition of Health Behavior:

Theory, Research, and Practice was based on the published information summarized above,

including an updated synthesis of reviews of theory use in the health behavior literature. Each

of the most often cited theories and models is the focus of a chapter in this volume. They

have been selected to provide readers with a range of theories representing different units

of intervention (e.g., individuals, groups, and communities). They were also chosen because

they represent, as in the case of Social Cognitive Theory, the Transtheoretical Model, and

the Health Belief Model, dominant theories of health behavior and health behavior change.

Others, like social marketing, Intervention Mapping and the PRECEDE/PROCEED Model,

and community organization, were chosen for their practical value in applying theoretical

formulations in a way that has demonstrated usefulness to professionals concerned with health

behavior change.

Our selection of theories also reflects some difficult editorial decisions. Three criteria

helped us to define our selection. First, we determined that, to be included, a theory must meet

basic standards of adequacy for research and practice, thus having the potential for effective

use by health education practitioners. Second, there must be evidence that the theory is being

used in current health behavior research. (That is why, e.g., we include the Health Belief Model

rather than Lewin’s Field Theory.) The third criterion is that there must be at least promising,

if not substantial, empirical evidence supporting the theory’s validity in predicting or changing

health behaviors. This does not preclude the possibility of mixed findings and critiques of the

evidence, which we believe are important to bring to light.

In the later sections of the book, a purpose, theme, or focus rather than a theory is

the identifying title for a chapter—as in the case of Chapter Thirteen, on interpersonalGlanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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34 CHAPTER 2: THEORY, RESEARCH, AND PRACTICE IN HEALTH BEHAVIOR

communication, which describes theories of interpersonal communication and social influence

and illustrates their utility for health behavior. Chapter Fifteen on community engagement

and community organization is named for this approach to intervention strategies rather than

for the convergent theoretical bases that form the foundation for community organization

work. Chapters in Part Five present the Intervention Mapping and the PRECEDE-PROCEED

Model for program planning, social marketing, and behavioral economics, each of which draws

on multiple theories to understand health behavior and assist in development of effective

intervention programs and strategies.

We recognize the lack of consensus regarding the definition and classification of theories.

We have taken a liberal, ecumenical stance toward theory. We concede that the lowest

common denominator of the theoretical models herein might be that they are all conceptual

or theoretical frameworks, models, or broadly conceived perspectives used to organize ideas.

Nevertheless, we have not abandoned the term theory, because it accurately describes the spirit

of this book and describes the goal to be attained for developing frameworks and tools for

refining health education research and practice.

Fitting Theory to Research and Practice: Building Bridges and Forging Links

Effective health behavior change depends on marshaling the most appropriate theory and

practice strategies for a given situation. Different theories are best suited to different units of

practice, such as individuals, groups, and organizations. For example, when one is attempting to

overcome women’s personal barriers to obtaining mammograms, the Health Belief Model may

be useful. The Transtheoretical Model may be especially useful in developing smoking cessation

interventions. When trying to change physicians’ mammography practices by instituting

reminder systems, dissemination and implementation science approaches are more suitable.

At the same time, physicians might use the Transtheoretical Model to inform their discussions

with individual patients about getting a first mammogram or annual screening. The choice

of a suitable theory or theories should begin with identifying the problem, goal, and units of

practice (Sussman & Sussman, 2001; van Ryn & Heaney, 1992), not with selecting a theoretical

framework because it is intriguing, familiar, or in vogue. As Green and Kreuter (2005) have

argued, one should start with a logic model of the problem and work backward to identify

potential solutions.

The adequacy of a theory is most often assessed in terms of three criteria: (1) its logic, or

internal consistency, in not yielding mutually contradictory derivations; (2) the extent to which

it is parsimonious, or broadly relevant, while using a manageable number of concepts, and (3)

its plausibility in fitting with prevailing theories in the field (McGuire, 1983).

Theories are also judged in the context of practitioners’ and researchers’ activities.

Practitioners may apply the pragmatic criterion of usefulness to a theory and thus be concerned

with its consistency with everyday observations. Researchers make scientific judgments of a

theory’s ecological validity, or the extent to which it conforms to observable reality when

empirically tested (McGuire, 1983). We should test our theories iteratively in the fieldGlanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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FITTING THEORY TO RESEARCH AND PRACTICE: BUILDING BRIDGES AND FORGING LINKS 35

(Rosenstock, 1990) as well as in more controlled settings. When we do so, theory, research,

and practice begin to converge.

Researchers and practitioners of health behavior change benefit from and are challenged

by the multitude of theoretical frameworks and models from the social sciences available for

their use, because the best choices and direct translations may not be immediately evident. The

inherent danger in a book like this is that one can begin to think that the links between theory,

research, and health outcomes are easily forged. They are not. For the unprepared, the choices

can be overwhelming, but for those who understand the commonalities and differences among

theories of health behavior and health education, the growing knowledge base can provide a

firm foundation upon which to build. We find that one of the most frequent questions students

around the world ask is, “What theory should I use?” It is an important question, whose

answer, we believe, will be found not just in the readings contained in this book but also in the

experience and judgment that equip readers to apply what is learned here: theory into practice

and research. We hope that Health Behavior: Theory, Research, and Practice will provide and

strengthen that foundation for readers.

Science is, by definition, cumulative, with periods of paradigm shifts that come more rarely

as a result of crises when current theories fail to explain some phenomena (Kuhn, 1962).

This applies as well to the science base that supports long-standing as well as innovative

health behavior interventions. More research is needed at all points along the research

continuum—more basic research to develop and test theories, more intervention research

to develop and test evidence-based interventions, more implementation science research and

more practice to understand and apply the processes of implementation, and more concerted

attention to dissemination of evidence-based interventions (Institute of Medicine, 2002; Rimer

et al., 2001; Rohrbach et al., 2006; Weinstein, 2007).

Moreover,thehealthbehaviorresearchandpracticecommunitiesaresorelyinneedofmore

rigorandprecisionintheorydevelopmentandtesting—inmeasures,inassessmentofmediating

variables, and in specification of theoretical elements (Rejeski et al., 2000). We encourage more

care and attention to how theories are tested, and especially to the way variables are measured

and analyzed. Building a solid, cumulative base of theory development is very difficult when one

researcher’s findings cannot be compared to another’s. However, we also caution that while

rigor is critically important in the verification of the component parts of theories and in testing

hypotheses, we eschew a one-size-fits-all approach to rigor. As Potter and Green (2012) have

cautioned: the social and behavioral sciences continue to fall short in the theories and methods

they bring to the systems needs identified by public health today; many of their methods and

theories have been dominated by psychology and have not dealt adequately with the broader

ecological understanding of causal webs and systems interventions that we seek today.

The gift of theory is that it provides the conceptual underpinnings for well-crafted research

and informed practice. “The scientist values research by the size of its contribution to that

huge, logically articulated structure of ideas which is already, though not half built, the most

glorious accomplishment of mankind” (Medawar, 1967).

In this book, we aim to demystify theory and to communicate theory and theoretically

inspired research alongside their implications for practice. We encourage informed criticism ofGlanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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36 CHAPTER 2: THEORY, RESEARCH, AND PRACTICE IN HEALTH BEHAVIOR

theories. Only through rigorous scrutiny will theories improve. The ultimate test of these ideas

and this information rests on its use over time, critical assessment, refinement, and application.

The process is circular in that it doesn’t end with publication of a particular study. The goal

of a theory, for a small number of people, may be proof of that theory. But for most readers

of this book, it will be improved health. Theory, then, is a tool for improving health outcomes.

Thus we should think about theory and practice, not theory or practice. Green (2006) said it

well: the translational gap between research and practice has long been discussed, often as a

one-way street—get practitioners to recognize and utilize the research that is being conducted.

While that is important, equally important is the reverse—integrating practice-based evidence

and context into the research conducted. We need a bridge between the two, not a pipeline.

Achieving this vision, as would be the case for sustaining any health behavior, will require

social support, supportive environments, and periodic reinforcement. The beneficiaries will be

practitioners, researchers, and participants in health education programs.

As this chapter and the preceding one demonstrate, health behavior is a concern of ever-

increasing importance to the well-being of humankind worldwide. As scholars, researchers,

and practitioners, we grapple with the complexities of human beings in populations and

societies. We press forward within the limits of current methodologies while striving to build

a cumulative body of knowledge in a fast-changing world. Our efforts do not always achieve

successful results, but this should motivate, not deter, us in pursuing high-quality work.

Continual dialogue between theory, research, and practice involves compromise, creativity,

healthy criticism, appreciation of others’ skills, and a willingness to cooperate to learn and

to set high standards. “We must learn to honor excellence in every socially accepted human

activity, however humble the activity, and to scorn shoddiness, however exalted the activity.

An excellent plumber is infinitely more admirable than an incompetent philosopher. The

society that scorns excellence in plumbing because plumbing is a humble activity and tolerates

shoddiness in philosophy because it is an exalted activity will have neither good plumbing nor

good philosophy. Neither its pipes nor its theories will hold water” (Gardner, 1984).

Limitations of This Book

No text can be all inclusive nor can it meet the needs of all potential audiences, and that is

true for this book as well. Some theories and frameworks presented in previous editions of this

book do not appear in this edition: consumer information processing (Rudd & Glanz, 1990),

Multiattribute Utility Theory (Carter, 1990), Attribution Theory (Lewis & Daltroy, 1990), media

advocacy (Wallack, 1990), organizational change (Butterfoss, Kegler, & Francisco, 2008), and

the Precaution Adoption Process Model (Weinstein, Sandman, & Blalock, 2008). These theories

and frameworks remain important, but they are less widely used than those included in this

edition. We did not update the chapters in the third edition on communication technology

and health behavior change (Owen, Fotheringham, & Marcus, 2002) and applying theory to

culturally diverse and unique populations (Resnicow, Braithwaite, DiIorio, & Glanz, 2002).

Rather, these issues are woven throughout various chapters in this edition. Interested readers

should refer to the first, third, and fourth editions of this book for coverage of these frameworks.Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2015). Health behavior : Theory, research, and practice. Retrieved from http://ebookcentral.proquest.com Created from waldenu on 2019-08-28 04:37:37.

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REFERENCES 37

Other important theories and conceptual frameworks could not be included because of

space limitations. These include Self-Regulation Theory (Leventhal, Zimmerman, & Gutmann,

1984), Protection Motivation Theory (Rogers, 1975), and more familiar classical theories such

as Field Theory (Lewin, 1935) and cognitive consistency (Festinger, 1957). Some of these are

described as part of the historical origins of the various theories discussed in this book. Others

are discussed in the introductory chapters. Some are summarized in Michie and others’ recent

book (2014).

This book is not a how-to guide or manual for program planning and development in

health education and health behavior. Other books in health education, nursing, medicine,

psychology, and nutrition serve that purpose, and readers should seek out key sources in

each discipline for more on the nuts and bolts of practice. This volume will be most useful

when it is included as part of a problem-oriented learning program, whether in a formal

professional education setting or continuing education venues. Besides using search engines,

there are a number of useful sources of evidence reviews that include assessments of the use

of theory on various health outcomes. These include the Guide to Community Preventive

Services (www.thecommunityguide.org) and the Cochrane Collaborative (www.cochrane.org).

For specific programs and tools, see, for example, Cancer Control P.L.A.N.E.T. (cancer

controlplanet.cancer.gov) and the National Cancer Institute’s Research-Tested Intervention

Programs (rtips.cancer.gov/rtips/index.do), which provide information relevant to cancer

prevention and control. The National Registry of Evidence-Based Programs and Practices

(nrepp.samhsa.gov) is a searchable, online registry of mental health and substance abuse

interventions that have been scientifically tested and can be readily disseminated.

The editors intend that readers emerge with a critical appreciation of theory and with the

curiosity to pursue not only the theories presented in this book but other promising theories

as well. Thus Health Behavior: Theory, Research, and Practice should be regarded as a starting

point, not the end.

Theories—or conceptual frameworks—can be and are useful because they enrich, inform,

and complement the practical technologies of health promotion and education. Thus the

readers of this book should “pass with relief from the tossing sea of Cause and Theory to the

firm ground of Result and Fact” (Churchill, 1898). As the ocean meets the shore, so we hope

you will find that theory, research, and practice can converge in a single landscape of improved

health for all.

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