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NCBI Bookshelf. Human behavior plays a central role in the maintenance of health, and the prevention of disease. With an eye to lowering the substantial morbidity and mortality associated with health-related behavior, health professionals have turned to models of behavior change to guide the development of strategies that foster self-protective action, reduce behaviors that increase health risk, and facilitate effective adaptation to and coping with illness. Several decades of concerted effort to promote health and decrease risk through individual behavior change have produced successes, failures, and lessons learned.
This chapter addresses the models of behavior change and interventions deed to influence individual behaviors. It continues to explore the influence of family relationships on the management and outcomes of chronic disease. Human behavior plays a central role in the maintenance of health and the prevention of disease. Growing evidence suggests that effective programs to change individual health behavior require a multifaceted approach to helping people adopt, change, and maintain behavior.
For example, strategies for establishing healthy eating habits in children and adolescents might be quite ineffective for changing maladaptive eating behaviors—that is, when they are used to substitute one pattern for another—in the same population e. Similarly, maintaining a particular behavior over time might require different strategies than will establishing that behavior in the first place e.
Models of behavior change have been developed to guide strategies to promote healthy behaviors and facilitate effective adaptation to and coping with illness. Several models for individual behavior change are reviewed here. Among the oldest, most widely researched, and yet most often misunderstood models of individual behavior applied to behavior change are those that deal with fundamental associative or classical conditioning and the related models of operant conditioning. Classical conditioning, pioneered by Pavlov, modifies behavior by repeatedly pairing a neutral stimulus with an unconditioned stimulus that elicits the desired response.
Operant-conditioning builds on classical conditioning and focuses on the hypothesis that the frequency of a behavior is determined by its consequences or reinforcements; Skinner, Although learning theory has been criticized for treating behavior in simplistic and mechanistic stimulus response terms, modern learning theory addresses complex components, including environmental cues and contexts, memory, expectancies, and underlying neurological processes related to learning Rescorla, As Kehoe and Macrae note, today classical conditioning integrates cognition, brain science, associative learning, and adaptive behavior.
Classical conditioning introduced concepts that have been particularly important in the de of health-related interventions, such as reinforcement, stimulus—response relationships, modeling, cues to action, and expectancies. Relapse of extinguished behaviors is a major problem in health-related behavior change interventions, especially those that target alcohol use, smoking, and diet Dimeff and Marlatt, ; Marlatt and George, ; Perri et al. Extinction initially was conceptualized as a process in which original learning, and therefore behavior, was unlearned or destroyed.
That is, it was assumed that extinguished behavior would no longer be elicited by the environmental cues that originally evoked it. However, extensive research shows that extinction does not involve unlearning, but rather new learning that does not overwrite the original learning. Furthermore, the physical environment and social context in which extinction takes place, as well as such internal states as emotions, drug-related states, and time, will influence the process of extinction Bouton, Those findings have important implications for health-related behavior change.
Specifically, the effectiveness of an intervention to reduce or eliminate a health risk, such as cigarette-smoking, will be limited to the extent that it is bound to the context in which it is delivered. As noted Wm seeks a wf to model and keep lingerie Boutonp. One important implication of those findings is the importance of eliciting extinction in different contexts, including various physical environments, times, and emotional states. For example, extinction trials that are more widely spaced and in separate locations are more likely to be effective than core sessions that occur within short periods or in similar Wm seeks a wf to model and keep lingerie circumstances.
Behavior change efforts should recognize the possible influence of contextual cues, identify the cues that might be involved, and help people avoid or cope with the contexts connected with the original health-compromising Wm seeks a wf to model and keep lingerie, whether physical environments, interpersonal relationships, or negative emotional states.
The learning of the new behavior or extinction of the old should take place in the contexts in which the person will need it the most. There is another important difference between original learning and extinction, namely, that original learning of a behavior readily generalizes across contexts, whereas extinction does not Bouton,p.
One implication of this is that if we really want to reduce cardiovascular risk, we should arrange a world in which healthy behaviors are the first things, not the second things, learned. One way of thinking about research on behavior change is that the organism seems to treat the second thing learned about a stimulus as a kind of exception to a rule. It is as if the learning and memory system is organized with a default assumption that the first-learned thing is correct, and everything else is conditional on the current context, place, or time.
That perspective provides support for the importance of preventive interventions that promote health-enhancing behaviors, as opposed to interventions deed to treat or change health-compromising behaviors. The evidence that extinction depends on context is but one of several important from basic research on learning and conditioning with important implications for explaining health-related behavior change.
Cognitive social-learning theory e. According to cognitive social-learning theory, the most important prerequisite for behavior change is a person's sense of self-efficacy or the conviction that one is able successfully to execute the behavior required to produce the desired outcome.
People can feel susceptible to an illness, expect to benefit if they change their behavior, and perceive their social environment as encouraging the change, but if they lack a belief that they can indeed change, their efforts are not likely to succeed. Substantial empirical evidence suggests that self-efficacy beliefs and the related concept of optimism are reliable predictors of behavior, and that they mediate the effects of intervention on behavior change, including a of health-related behaviors e.
A growing body of literature supports the importance of self-efficacy in initiation and maintenance of behavioral change Bandura,; Marlatt and Gordon, ; Strecher et al. Self-regulation is a concept that derives from cognitive social learning theory see Bandura, ; Baumeister et al.
Self-regulation can be critical in such health-protective and health-maintaining behaviors as eating a healthy diet, engaging in regular exercise, and managing stress. Conversely, the failure or breakdown of self-regulatory efforts can be crucial in some risky behaviors, such as smoking, poor dietary management, and a sedentary lifestyle.
Although much research supports the utility of Social Learning Theory, limitations have been noted. It is difficult to evaluate the efficacy of theory-based interventions because the studies have involved only small s of subjects and the intervention des have been very complex. In addition it is difficult to quantify and measure the conceptual elements of Social Learning Theory: self-efficacy, influence of observational learning, and emotional arousal.
One of the earliest theoretical models developed for understanding health behaviors was the health belief model HBM; Hochbaum, The model was developed in the s to explain why people did not engage in behaviors to prevent or detect disease early. It integrates elements of operant-conditioning and Cognitive Theory. Operant-conditioning theory focused on the hypothesis that the frequency of a behavior is determined by its consequences while Cognitive Theory gave more emphasis to expectations to explain behavior.
For example, the desire to avoid becoming ill is a value, and belief that a specific health behavior can prevent an illness is an expectancy. Perceived susceptibility is the perception of personal risk of developing a particular condition, and it involves a subjective evaluation of risk rather than a rigorously derived level of risk.
Perceived severity is the degree to which the person attributes negative medical, clinical, or social consequences to being Wm seeks a wf to model and keep lingerie with an illness. Together, perceived susceptibility and perceived severity provide motivation for reducing or eliminating such threats.
The type of action taken depends on perceived benefits beliefs about the effectiveness of different actions and perceived barriers potential negative aspects of particular actions. People are thought to weigh an action's effectiveness in reducing a health threat against possible negative outcomes associated with that action.
The HBM has been applied, among other things, to influenza inoculation, screening for Tay-Sachs disease, exercise programs, nutrition programs, and smoking cessation Strecher and Rosenstock, An important contribution of the model is the recognition that prevention requires people to take action in the absence of illness. This continues to be useful, for example, in explaining women's reluctance to perform breast self-examination or obtain mammograms Rimer, Perhaps the most critical of these is the lack of predictive value for some of its central tenets.
For example, the perceived severity of a risk does not reliably predict protective health behaviors Rimer, Moreover, the HBM is more descriptive than explanatory and does not presuppose or imply a strategy for change Rosenstock and Kirscht, The predictive utility of the HBM and its applicability to behavior change can be improved by adding variables, such as self-efficacy, or by integrating it with other models.
The Theory of Reasoned Action was first proposed by Ajzen and Fishbein to predict an individual's intention to engage in a behavior at a specific time and place. The theory was intended to explain virtually all behaviors over which people have the ability to exert self-control. Factors that influence behavioral choices are mediated through the variable of behavioral intent. In order to maximize the predictive ability of an intention to perform a specific behavior, it is critical that measures of the intent closely reflect the measures of Wm seeks a wf to model and keep lingerie behavior, corresponding in terms of action, target, context, and time.
Behavioral intentions are influenced by the attitude about the likelihood that the behavior will have the expected outcome and the subjective evaluation of the risks and benefits of that outcome. The predictive power of the model depends ificantly on the identification of most or all of the salient outcomes associated with a given behavior for any particular target population. This model characterizes the continuum of steps that people take toward change and includes the activities or processes to move people from one stage to another. The earliest stage of behavior change starts with moving from being uninterested, unaware, or unwilling to change precontemplation to considering a change contemplation.
This is followed by the decision to take action preparation and the first steps toward the behavioral change action. With determined action, the requirement for maintenance and relapses are recognized as part of the process. In addition to these temporal stages, the Transtheoretical Model encompassed the concepts of decision criteria, self-efficacy, and change processes consciousness-raising, relief from negative emotions associated with unhealthy behavior, self-reevaluation, environmental reevaluation, committing to change, seeking support, substituting healthier alternative behaviors, contingency management, stimulus control, and recognizing supportive social norms; Prochaska et al.
The Transtheoretical Model has been influential in research on smoking and was recently extended to other health risk behaviors Prochaska et al. The theoretical validity of the Stages-of-Change Model for behavior change is a matter of controversy Budd and Rollnick, ; Sutton, Although early cross-sectional studies provided support for the theory DiClemente et al. Furthermore, multivariate analyses of several behavioral predictors demonstrate that the stages are weak predictors of cessation Farkas et al. Variables from cognitive social learning—such as outcome expectancy, self-efficacy, and behavioral self-control—appear to be better predictors of change than are the stages and associated processes Bandura, ; Herzog et al.
Despite questions about its theoretical validity, the model has contributed to the recognition that most potential recipients of health-related behavior change efforts are not motivated to change. That result draws attention to the potential of approaches that increase motivation for health promotion and illness prevention.
The development of innovative motivational programs to encourage less interested Wm seeks a wf to model and keep lingerie to consider healthier lifestyles represents a new direction in health and behavior change e.
One important example of a model that attempts to integrate individual psychological processes with social contextual factors is Social-Action Theory Ewart,which builds on Social Cognitive-Learning Theory, models of self-regulation, processes of social interdependence and social interaction, and underlying biological processes to predict health-protective behaviors and outcomes Ewart, It views the person as influenced by environmental contexts or settings to which he or she brings a particular temperament and biological context.
Thus, a person's capacity to practice healthy eating habits and to exercise is influenced by access to health-enhancing foods and safe places to exercise and by internal goal structures, self-efficacy beliefs, and problem-solving skills. In Social-Action Theory, biology and social and environmental contexts determine the success of interventions to promote individual behavior change Ewart, Most behavioral research, however, has focused on individual strategies to facilitate desired changes, and less is known about how social and other contextual factors can be mobilized to promote behavior change.
Social-Action Theory specifies mediating mechanisms that link organizational structures to personal health and incorporates key concepts from the earlier theoretical models, including self-efficacy and outcome expectancies. Some applications of social-action theory focus on the mechanisms and maintenance of behavior change Ewart,again placing the focus on the influence of context on individual behavior.
Social-Action Theory provides a framework for multilevel approaches to health promotion and illness prevention. It offers a theoretical rationale for intervening in health policy and for creating environments that are conducive to self-protective choices. It provides an approach for defining public health goals and modifiable social and personal influences that can be used to encourage individual health-related behavior change.
Social-Action Theory fosters interdisciplinary collaborations by incorporating and coordinating the perspectives of the biological, epidemiologic, social, and behavioral sciences. Strong conceptual models are available to guide the development, implementation, and evaluation of health-related behavior change interventions. While the models are useful constructs for thinking about behavioral change, they each have their limitations and each addresses different behavioral attributes.
Furthermore, only rarely have these models been appropriately applied to interventions IOM, The IOM report suggests that contextual and individual factors contributing to behavior should be fully surveyed and assessed from the perspective of the various models to gain insights from each as to pathways and barriers. It is prudent for researchers to look beyond specific models and to draw on general concepts of behavior change.
Recent advances in research on classical conditioning and self-regulation have important implications for establishing, reducing, and maintaining health-related behaviors. Establishing a stronger link with basic behavioral science promises to provide important directions for the continued development of health-related behavior interventions.
Social Action Theory provides a promising way to integrate elements of several broad models in an attempt to for health-related behavior change. In response to mounting evidence that behaviors, such as cigarette-smoking and consumption of high-fat diets, are risk factors for chronic diseases, several studies target interventions for medically at-risk individuals.
Trials also focus on psychosocial interventions after disease onset to improve treatment adherence and medical outcomes. Other interventions arise from the concept of population-attributable risk, which measures the amount of disease in the population that can be attributed to a given exposure Marmot, A large of people exposed to a small risk might generate more cases than will a small exposed to a high risk Rose,so that when risk is widely distributed in the population, small changes in behavior across an entire population can yield larger improvements in population-attributable risk than would larger changes among a smaller of highrisk individuals Marmot, ; McKinlay, ; Rose, Both approaches are described below.
Education and counseling can promote primary prevention measures reducing smoking and choosing a healthy diet. Interventions aimed at secondary prevention behaviors can influence early detection of illness. For instance, willingness to self-examine and participate in screening procedures is important Wm seeks a wf to model and keep lingerie detection and treatment of cancer.
Psychosocial interventions can improve people's coping skills and provide emotional support, thereby improving quality of life and medical outcomes among the chronically ill. The role of behavioral interventions for improving adherence to treatment is discussed below. Interventions addressing behavioral and psychosocial risk factors are also briefly reviewed. Adherence, the match between a patient's behavior and health care advice Haynes et al. For example, when treating bacterial infections, some patients stop taking antibiotics when symptoms stop, but before all the targeted bacteria are eradicated, resulting in relapse for the patient and the development of resistant bacteriological strains.
Failure to follow medical recommendations for treatment is a common problem that is not without controversy. The reasons are varied: Providers sometimes fail to describe the treatment regimen clearly, resulting in confusion on the part of the patient. Patients may also not Wm seeks a wf to model and keep lingerie appreciate the consequences of nonadherence. Some regimens interfere with daily activities, particularly those requiring multiple doses each day, or those with special instructions regarding meals e.Wm seeks a wf to model and keep lingerie
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