Health and Behavior The Interplay of Biological, Behavioral, and Societal Influences (2001) / Chapter Skim
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From page 183... ...
This chapter aciciresses the models of behavior change anc3 interven' tions clesignec3 to influence incliviclual behaviors. It continues to explore the influence of family relationships on the management anc3 outcomes of chronic disease.
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From page 184... ...
I-earning an] Conditioning Among the oldest, most widely researched, anc3 yet most often misunclerstooc3 models of incliviclual behavior applied to behavior change are those that clear with fundamental associative or classical conditioning anc3 the related models of operant conditioning.
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From page 185... ...
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.
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Cognitive Social Learning Cognitive social-learning theory (e.g., Banclura, 1977, 1986, 1997) proposes that reinforcements are not the sole determinants of behavior, but that behavior changes with observations of others.
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Health Belief Mode! One of the earliest theoretical models clevelopec3 for unclerstancling health behaviors was the health belief model (HBM; Hochbaum, 1958~.
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Moreover, the HBM is more descriptive than explanatory anc3 floes not presuppose or imply a strategy for change (Rosenstock and Kirscht, 1974~. The preclictive utility of the HBM anc3 its applicability to behavior change can be improved by addling variables, such as self-efficacy, or by integrating it with other models.
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From page 189... ...
This model characterizes the continuum of steps that people take toward change anc3 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)
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From page 190... ...
Most behavioral research, however, has focused on incliviclual strategies to facilitate clesirec3 changes, anc3 less is known about how social anc3 other contextual factors can be mobilized to promote behavior change. Social-Action Theory specifies mediating mechanisms that link organizational structures to personal health anc3 incorporates key concepts from the earlier theoretical models, including self-efficacy anc3 outcome expectancies.
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From page 191... ...
Social Action Theory provides a promising way to integrate elements of several broac3 models in an attempt to account for health-relatec3 behavior change. INTERVENTIONS TARGETED AT INDIVIDUALS In response to mounting evidence that behaviors, such as cigarettesmoking anc3 consumption of high-fat diets, are risk factors for chronic diseases, several studies target interventions for medically at-risk inclivicluals.
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The role of behavioral interventions for improving adherence to treat' ment is cliscussec3 below. Interventions accessing behavioral anc3 psycho' social risk factors are also briefly reviewed.
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From page 193... ...
Insurance limits on reimbursement for treatments also can affect ac3herence. Nonadherence is more than failure to take medications as prescribed or to follow other recommendations for health behavior changes.
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The contributions of clinical behavioral anc3 psychosocial interventions to diabetes, cancer, anc3 heart disease are explored briefly. A recent chapter (Baum, 2000)
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From page 195... ...
There is evidence that psychosocial interventions can improve quality of life, psychological ac3 justment, health status, anc3 survival of can' cer patients (see reviews by Anclersen, 1992; Blake-Mortimer et al., 1999; Compas et al., 1998; Fawzy et al., 1995; Helgeson and Cohen, 1996; Meyer anc3 Mark, 1995, Montazeri et al., 19981. A meta~analysis of ll6 studies on the effects of psychoeclucational care proviclec3 to adult cancer patients concludes that interventions affect anxiety, depression, anc3 mooc3 (Devine anc3 Westlake, 1995~.
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of 23 clinical trials on coronary artery disease reported a similar significant reduction in morbidity anc3 mortality with psychosocial interventions, especially during the first 2 years. The interventions incluclec3 in the analysis by Linden et al.
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, indefinite clinical enclpoints, and lack of intention-to-treat analyses. To actress these limitations, a national multicenterec3 clinical trial has been initiated (Enhancing Recovery in Coronary Heart Disease [ENRICHD]
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From page 198... ...
Engaging busy practices to reach into new health promotion endeavors for which there is little eco' nomic reward is challenging, no matter how cleclicatec3 the leadership anc3 clinical staff (Fishman et al., 19971. Rising to such a challenge tests the leadership anc3 organizational adaptability of any practice that also must comply with innumerable legal, business, anc3 clinical regulations anc3 re' quirements.
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From page 199... ...
, anc3 often emphasize peer consensus rather than outcome eviclence. Many focused interventions to encourage health-relatec3 behavior change would benefit from population databases that keep track of patients' medical histories, behaviors, and attitucles.
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changes in clinical practices that might support healthenhancing behavior change in defined populations. Future efforts shouIcl test various hypotheses that would encourage experimentation anc3 practice-leve!
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In abolition, because of the importance of accounting for the influence of secular trencis anc3 for other factors not associated with the intervention that could affect behavior change, the studies cliscussec3 here incluclec3 intervention anc3 control conditions alike. Finally, to narrow the field of potential studies, a focus was given to those interventions concluctec3 in the United States that targeted primary prevention of cancer or coronary heart disease, although the committee recognizes that considerable progress has been macle using community interventions to aciciress other public health problems.
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All targeted change in risk factors for coronary heart disease (CHD) , including high blood pressure, elevated blood cholesterol, cigarette-smoking, anc3 obesity.
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From page 203... ...
was a large-scale, 7-year demonstration project building on ranclomizec3 community-wicle intervention trials. The intervention was implemented in 17 states through a partnership among NCI, the American Cancer Society, state health clepartments, anc3 other organizations.
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In a move toward ensuring greater community input, the Kaiser Family Founciation's Community Health Promotion Grant Program (CHPGP) offered communities substantial flexibility in developing program targets that were responsive to local needs anc3 priorities.
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Many worksite trials have targeted cancer anc3 cardiovascular disease risk factors either as discrete trials (Byers et al., 1995; Emmons et al., 1999; Glasgow et al., 1995,1997; Heirich et al., 1993; Jeffery et al., 1993,1994; Salina et al., 1994; Sorensen et al., 1992, 1996,1999; Tilley et al., 1999) or within the context of larger community-wicle trials (Glasgow et al., 1996; Sorensen et al., 1993~.
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From page 206... ...
The poor scientific quality of the studies precludes judgment about whether such interventions can increase physical activity, anc3 the researchers concluclec3 that there is a need for studies that use valid designs anc3 methods. School Trials Over the past two clecacles, extensive attention has been paid to health promotion anc3 disease prevention among youth, particularly in schools.
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From page 207... ...
Such programs have been effective in reducing smoking prevalence throughout secondary school (Perry et al., 19921. A trial focusing on high-risk youths tested a combined program of mass media anc3 stanciarc3 school smoking prevention programs.
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In general, the studies found significant intervention effects for student knowledge anc3 for psychosocial factors related to physical activity. Significant positive behavior changes were less common, but they were clemonstratec3 in several studies (Dale et al., 1998; Homel et al., 1981; Killen et al., 1988; Leslie et al., 1998; Luepker et al., 1996; McKenzie et al., 1996; Sallis et al., 1999; Tell anc3 Vellar, 19871.
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From page 209... ...
in general, however, the interven' tions that were more broadly based and multifaceted were more likely to be effective. These challenges are not confined to advances in individual behavior change.
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That definition sets family relationships apart from other social relationships that provide "social support." It identifies the family as a unique setting with powerful continuing relationships that assume levels of complexity and organization that go beyond the individual people involved. Family members create a shared social reality that is linked to health (Kleinman et al., 1978; Reiss, 1981)
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From page 211... ...
, anc3 the resulting changes in hormonal, immunologic, anc3 neurochemical systems can influence the outcomes of chronic disease (Kiecolt-Glaser et al., 1997~. Family and Behavioral Risk Factors Behavior also defines the influence of family relationships on chronic cttsease.
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From page 212... ...
Three categories are used here anc3 clefinec3 in Table 5~2: psychoeclucational interventions to provide information about the disease anc3 methods for its management by multiple family members, mollified psychoeclucational interventions to strengthen anc3 improve family relationship quality anc3 functioning, anc3 family therapy. These are clescribec3 below with illustrative examples.
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· Cor~tirruir~g screening for patients and family members to detect depression, excessive anxiety, family conflict, and social isolation followed by secondary preventive interventions for individual family members, the family unit, or multifamily groups to prevent clinical dysfunction. · Family "support groups" with well-defined goals and protocols, including selfhelp and leaderless groups for primary prevention and professionally led groups for secondary and tertiary preventive interventions.
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Each failed to show reclucec3 patient distress, although the parents were less clistressec3 in the study by Jay and Elliott (19901. There have been two studies of family-focusec3 interventions for chilciren with congenital heart disease.
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Six- month follow- up data were collected but have not been reportecl. r~rerver~tior~s Affecting Family Relationship Quality arid Fur~ctior~ir~g This type of intervention focuses on family relationships anc3 includes various methods to foster emotional expressiveness, reduce social isolation, prevent disease from dominating family life, help clear with loss, promote collaboration among family members, improve empathy, clear with stigma, reinforce developmental family roles, anc3 resolve intrafamily conflict.
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From page 216... ...
Interventions that affect family relationship quality anc3 functioning in chilc3hooc3 asthma include those shown in a study by Hughes anc3 colleagues (1991) , in which 89 families hac3 monthly sessions focused on supportive parent/chilc3 relationships anc3 asthma management.
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Screening programs can detect families in which serious psychological dysfunction predates the dis' ease or complications of the chronic disease already constitute disorders r to target tor more intensive intervention. A randomized trial of family therapy (n = 25)
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In contrast, improvement in family communication anc3 parental discipline was clocumentec3 with preintervention anc3 postintervention assessments of an intensive rehabilitation program that used family therapy anc3 education for chilciren with severe asthma (Weinstein et al., 19921. Interventions for Adults and the Elderly with Chronic Disease Chronic diseases of aclulthooc3 have received the least systematic attention with respect to family-focusecl interventions.
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From page 219... ...
Several descriptive studies indicate that spouse support is crucial for optimal risk reduction anc3 management of existing heart disease. Family studies show that counseling about diet anc3 exercise cleliverec3 to both marital partners reclucec3 risk for both spouses over time (Family Heart Study Group, 1994; Knutsen anc3 Knutsen, 19911.
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From page 220... ...
Helping family members manage stress by preventing the disease from dominating family life anc3 sacrificing normal developmental anc3 personal goals is also important. Interventions help the family clear with the losses that chronic disease can create, mobilize the family's natural support system, provide education and support for family members, and reduce the social isolation and the resulting anxiety and depression accompanying disease management.
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From page 221... ...
. Brief family interventions to improve family communication and cooperation regarding diabetes management.
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Health Education and Behavior, 24, 652-666.
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From page 223... ...
American Journal of Public Health, 86, 206-213. Bruvold, W.H.
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(1995~. The Pawtucket Heart Health Program: Community changes in cardiovascular risk factors and projected disease risk.
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(1998) A randomized controlled trial of the effects of group psychological therapy on survival in women with metastatic breast cancer.
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(1999) A metaanalysis of psychoeduational programs for coronary heart disease patients.
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(1990~. A social problem-solving approach to behavior change in coronary heart disease.
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(1993) Survival of breast cancer patients receiving adjunctive psychosocial support therapy: A 10-year follow-up study.
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American Journal of Preventive Medicine, 4, S101-S107. Greer, A.L.
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Health Education Quarterly, I I, 1-47.
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(1970~. Coronary heart disease in seven countries.
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II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering.
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American Journal of Health Promotion, 7, 452 464. McKenzie, T.L., Nader, P.R., and Strikmiller, P.K.
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(1985~. Evaluation of family health education to build social support for long-term control of high blood pressure.
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Health Education Quarterly, 16, 171-180. Perry, C.L., Story, M., end Lytle, L.A.
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(1983~. Change in risk factors for coronary heart disease during 10 years of a community intervention programme (North Karelia project)
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American Journal of Health Promotion, 10, 55-62. Sorensen, G., Lando, H., and Pechacek, T
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Health Education Quarterly, 16, 155-169. Stone, Ed., McKenzie, T.L., Welk, Gil., and Booth, M.L.
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(1995~. Serum total cholesterol and long-term coronary heart disease mortality in different cultures.
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From page 240... ...
Health Education Quarterly, 19, 157-175. Wamboldt, M.Z.
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