BEHAVIOURALLY-BASED PRINCIPLES AS GUIDELINES FOR HEALTH PROMOTION. Christina Lee,* Neville Owen+

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1 VOLUME IX, NUMBER 2, 1985 BEHAVIOURALLY-BASED PRINCIPLES AS GUIDELINES FOR HEALTH PROMOTION Christina Lee,* Neville Owen+ * Lincoln Institute of Health Sciences, Carlton, Victoria, Foundation for Multidisciplinary Education in Community Health and University of Adelaide, Adelaide, South Australia Abstract Programmes to promote health, which appear with increasing frequency, should be based on sound principles. This paper deals with an approach to health promotion based on behavioural theories to explain the change and maintenance of habitual patterns of activity. It derives from work to determine programme guidelines and policy recommendations in the promotion of exercising, and is presented so as to have more general application to health-related behaviours. It describes some relevant theoretical approaches to behaviour change and maintenance, and outlines a set of principles which may be used as guidelines. This involves an account of stages of behaviour change, operant conditioning and associative learning theories, cognitivebehavioural and self-management theories, and social learning theory, and suggests judicious integration of these theories and the use of attitudinal theories. Eleven principles derived from these theories and from research on health behaviour change are described. These perspectives may be useful in work to influence the health-related behaviours of individuals, and as suggestions for the modification of some environmental and social factors which constrain individuals capacities to choose health promoting actions. Introduction There is an increasing emphasis in health services on efforts to change the behaviours of individuals in order to prevent disease. Epidemiological evidence shows associations between behaviours (for example, cigarette smoking, overeating and lack of exercise) and subsequent morbidity and premature mortality. I There is evidence of more widespread concern with good health and the prevention of illness,* and numerous large-scale interventions have attempted to reduce risks to health. The term health promotion is now used to describe many programmes, campaigns and policies, ranging from advice given by a health professional in a oneto-one setting, through courses for groups, mass media campaigns, and social and environmental legislation designed to alter habits considered to be deleterious to health.4 A major current concern is that health promotion is frequently conducted along pragmatic and ad hoc lines, with the implicit assumption that information and exhortation will automatically produce changes in behaviour. Interventions to promote health or to prevent disease will benefit from being based systematically in conceptual or theoretical frameworks.5 Such frameworks should provide a structure for considering health problems, and for the design and evaluation of interventions. However, such an ideal can be difficult to achieve. For example, a consideration of published material in the area of substance abuse makes it clear that basic theoretical developments and research on the one hand, and applications and policy on the other, are frequently not clearly linked.6. This paper proposes that behavioural theories of activity change can be useful in the understanding of issues in health promotion, and attempts to show how practical principles developed from these theories can be applied to guide and improve efforts to promote health. It is based on work commissioned by the Australian Sport and Recreation Ministers Council, examining psychological theories of behaviour change and research evidence relevant to the understanding of why people do and do not exercise. This also involved developing guidelines and recommendations for government involvement in the promotion of regular physical activity. A set of principles to guide the development of policies and programmes has been derived from this informtion. These principles are not specific to the promotion of physical activity, LEE & OWEN 131

2 but may be applied to a wide range of healthrelated behaviours, and can be seen as general principles for the design of strategies for health promotion. What follows is a brief outline of theoretical approaches to behaviour change, together with a description of the principles derived both from these theories and from research on the modification of health-related behaviours. A Behavioural Approach to Health Promotion The basis of this particular approach is a view of the prime task of health promotion as that of changing the personal, health-related behaviours of individuals. This includes the goal of altering the practices of those people who can influence the. environment. Health promotion should be concerned with practical guidelines for practitioners, and for policy-makers involved with the modifcation of social and environmental factors which constrain individual choice. Several related theoretical approaches to behaviour change will be considered, but first it is necessary to consider the nature of behaviour change itself. It is widely agreed that change is not a unitary phenomenon or a single event, but a process in which a number of stages may be identified. How these stages may be characterised will be considered first, and then the theories examined. Srages of behaviow change Different writers have characterised the stages of behaviour change in a number of ways. DiClemente and Prochaska, for example, identify three stages: decision to change, active changing, and maintenance of the new behaviour.8 They argue, from work on smoking cessation, that different mechanisms are operating at these different stages, and that general education and specific information are most important in the first stage, and practical instruction more useful in the second and third. Abrams, Elder, Lasater, and Carleton consider stages from the point of view of programme design.9 They also argue for three stages: promotion of the new behaviour, skill development, and maintenance. Maccoby and Alexander propose five stages: agenda-setting; informing; training new behaviours; motivating and reinforcing the new behaviours; and maintenance training.10 This apparent variety of stages and labels appears to be based on a common underlying concept of change: that behaviour change requires a process of (i) producing awareness of the problem, then (ii) motivating people to change, followed by (iii) instruction on how to change and (iv) the initial adoption of the new behaviour, and consolidated by a final stage (v) assisting the maintenance of the new behaviour. It seems likely that different behaviour change techniques will be effective at different stages in the change process," and for this reason many writers have recommended a multiple approach in which all stages are addressed as targets. Rather than introducing the stages sequentially during a community intervention campaign, a variety of strategies focussing on different stages should be used throughout a campaign, so that individuals at all stages of readiness to change can be influenced. All of these approaches place considerable emphasis on maintenance, which is widely regarded as the most problematic aspect of behaviour change.12 Relapse rates following behaviour change show a similar pattern across a range of health-related activities,'j with less than 50 per cent of individuals making an initial change being able to maintain that change for twelve months. A number of psychological theories have addressed issues of habit change and of maintenance, and provide guidelines for the development of intervendons. These theories are outlined briefly in the following section. Behavioural theories of change to habitual patterns of activity Given the complex nature of behaviour change processes, the most appropriate theoretical approach is likely to be an integrative one, taking aspects from a number of mutually consistent frameworks. These are characterised by an emphasis on variables which can be defined explicitly, thus allowing objective assessment of outcomes.~4 Personality-trait formulations, which are not explicitly anchored to observations of behaviour, seem less useful. The focus of such theories is in general less on behaviour change processes and more on the assessment of behavioural stability. Mischel's review highlighting the paucity of evidence for cross-situational consistency in behaviour provides further argument, for the rejection of a personological approach, in favour of a specific consideration of aspects of settings and their interactions with patterns of behaviour.15 Recent theoretical developments in psychology are characterised by an emphasis on person-setting interaction,l6 which appears more useful in the present context. Personality-trait approaches do not provide strong or direct guidelines for the design of interventions for behaviour change, LEE & OWEN 132

3 because of their emphasis on behavioural stability, and on overall patterns of responding rather than on specific activities. Behaviour change theories, and theories developed from a general behavioural point of view, offer more directions for practical development and evaluation. Operant conditioning and associative learning theories These are strongly anchored in observable behaviours, and focus primarily on the effects of environmental cues, rewards, and punishment on actions. In situations where a considerable amount of control over settings and rewards is possible, these theories provide highly specific and accurate behaviour-change methods. In particular, they have been very effective in institutional settings, for example in the development of living and working skills in the intellectually handicapped.17 In the past twenty years, these conditioning approaches, with their emphasis on specific behaviours and their consequences, have been applied in an increasing range of clinical, educational, and institutional settings.19 In particular, recent work has focussed on the problem of maintaining newly acquired behaviours.ls A variety of techniques anchored in these theories has been developed, including the enhancement of naturally-occurring rewards, the training of family members to provide rewards, and the use of variable patterns of reward. Such strategies have been used successfully in attempts to modify health-related behaviours in controlled settingsi9 and, in combination, in community programmes.20 Their effective use in these comparatively unstructured settings often requires that they be combined with other approaches in which control over environmental influences and over incentives is less crucial. Cognitive-behavioural and self-management theories These are based on behavioural approaches but broadened to take into account the effects of individuals' thoughts and choices on their actions, and thus are more generally applicable in situations where a large degree of personal choice is possible.21 Cognitive-behavioural techniques include the use of behavioural contracts and the public setting of goals, and have successfully been applied to health-related behaviours. For example, in exercise programmes, such techniques may be taught to trainees in order to develop skills in persisting with habits of regular physical activity. Behavioural self-control involves training individuals to observe their own behaviour, act to change their situation so that the desired actions become more convenient or pleasant, and reward themselves for appropriate activities. These techniques have been successful in community interventions focussing on health behaviours.22 Their advantage over behavioural approaches emphasising external cues and incentives is that they allow for individual choice and variation, and may promote independence and thus increase levels of maintenance. However, like the behavioural methods, self-management approaches may have limited application in the early stages of behaviour change, and are most useful in helping those who are already informed and motivated to learn new skills and make a change, while less so in motivating people or raising their awareness of problems. Social learning theories These focus on the interaction between the individual and the environment, rather than on a one-way influence of the environment on the person.23 The individual is seen as active in interpreting events and selecting a course of action on the basis of past experience, and through observation of others. Social learning theory, like the cognitive-behavioural approaches, maintains that it is necessary for people to makea permanent change in the way they think about themselves and their actions in order for them to make any lasting change in behaviour. Investigators have shown that combining the social-learning strategies of enhanced feedback and modelling with other behavioural techniques will improve adoptions and maintenance of health-related behaviours.24 The combined use of theories A combination of these three approaches is likely to be superior to any single technique. Because of the complexities of the individual's environment, both physical and social, and his or her work, family and leisure commitments, no single approach is likely to provide comprehensive guidelines for health promotion. But an integration of these approaches may be more effective by dealing more fully with the environmental, social and personal factors which are operating. Further, the addition of concepts derived from social psychological and attitudinal theories may be helpful in understanding and dealing with individual differences in response to programmes. Although a behavioural approach does not emphasise individual differences, and although it is not well established that people have LEE & OWEN 133

4 strong and consistent personality traits which will directly influence specific behaviours,ls individuals will differ in their cognitive orientation to situations as a result of differing experiences. Some recent attitudinal approaches can predict behaviour accurately by focussing on specific attitudes and thoughts concerning particular activities.25 These theories, emphasising knowledge and belief relating to specific relevant actions, may usefully be incorporated into an approach which focusses primarily on the alteration of particular sets of behaviours. Focussing on beliefs and knowledge about the behaviour of concern may be most appropriate in the early stages of behaviour change. It is clear that the issue of changing behaviour can be considered at many levels, and a number of specific integrative models have been proposed. While the explicit specification of particular target behaviours is generally viewed as important for interventions, any behaviour is part of a number of systems of behaviours, consequences, and social settings.26 Thus, a reliance on any one theoretical model is likely to produce a less than adequate framework. But a creative combination of several such models can be used to greater effect. Our research on physical activity for the Sport and Recreation Ministers Council reviewed experimental interventions, surveys, and health promotion campaigns based on the theories outlined above. It focussed on the problem of the development and maintenance of patterns of regular physical activity. From this review, eleven general principles were derived. These are presented here in a way which emphasises their broad applications to issues of health promotion. These principles may usefully be applied in the design of health-related interventions at a number of levels, including efforts to influence individuals in one-to-one, small group, and community settings, efforts to shape policy, or to provide opportunities and facilities for community use. Behaviourally-based Principles for Health Promotion In general, the research and theory on behaviour change and physical activity make clear the importance of situational and environmental factors in influencing the adoption and maintenance of new behaviours.7 Therefore, as well as ensuring access to appropriate information and instruction, it is important to provide opportunities for choice and to develop realistic, appealing and convenient alternatives to unhealthy behaviours. An awareness of how much can be achieved in any setting is also vital, given the constraints which result from the limitations of the environment, and the effects of structural variables in social and economic domains.27 The principles suggested as guidelines for work in health promotion are as follows. 1. Appropriateness and convenience of settings The ease and convenience with which healthpromoting personal actions can be carried out is a strong predictor of their occurrence. For example, people are more likely to persist with an exercise programme if they find the exercise venue and class times convenient.28 It is therefore useful to decentralise facilities and to advertise their existence, or to provide appropriate channels for people to learn about and to develop new behaviour patterns at home or at work. 2. Stages of behaviour change Behaviour change, as already discussed, is best seen as a process rather than an event. It should be stressed that the raising of awareness or motivation concerning an issue does not automatically lead to the changing of behaviour, and also that short-term effects on behaviour are not necessarily maintained for any length of time. If the final aim is a lasting change in individuals, patterns of behaviour, it will be necessary to demonstrate and teach those desired behaviours, provide opportunities for them to occur, and continue to provide support and facilities for their maintenance. 3. Setting of realistic goals There is evidence that the selection of modest and realistic goals which can be achieved with moderate effort is a successful strategy for producing an initial change.29 If the goal of an intervention is very different from people s current actions, they can readily become discouraged. Promotion of a small change towards a new pattern of behaviour is most likely to be effective initially. For example, as over sixty per cent of adult Australians take almost no regular exercise,)o a goal of three bouts of vigorous running or swimming each week is so far removed from current exercise patterns that people may be reluctant even to try exercising. Promotion of lower-level activities, such as walking, may be more appropriate in motivating the sedentary to make at least some change. While these lower-level activities may not increase individuals aerobic LEE & OWEN 134

5 fitness, they can assist in weight control and in a general sense of well-being, and may be the first step towards more vigorous activity. 4. Specificity The more specific the aim of a message, intervention, or programme, the more likely it is to be successful. Providing people with specific information about a behaviour and exactly how and where they can do something to change is more likely to result in behaviour change than is the provision of a global message or exhortation only. 5. Variety Specific interventions are more effective than general exhortation, but any specific programme will only be appropriate for particular groups in particular circumstances; a range of such interventions will provide appropriate choices for a larger number, and will also suggest the existence of an even greater range of alternatives. 6. Multiple levels People are influenced by input at many levels, including mass media, groups, and one-to-one interactions. For maximum effectiveness, more than one channel of influence should be used.9 For example, a campaign to discourage adolescents from smoking might include television advertising, articles and advertisements in magazines, and teaching materials for use in schools. If people are receiving congruent messages from several sources, they are more likely to take notice. Interventions should focus not only on individuals, but also on the groups and communities which provide the social and physical environments in which individuals must act. 7. Use of social networks The use of existing social networks to disseminate information and organise groups and activities may be more effective than attempts to develop new structures and organisations. Healthy activities modelled by leaders of existing social groups are most likely to have an impact within those groups. Community organisations such as school parents' associations, church groups, and social clubs can be effective channels for specific interventions. If key people in such groups are assisted in setting up programmes tailored for their members, behaviour change programmes may have much higher maintenance rates. 8. Choice If people feel they have chosen an activity for themselves, they are more likely to persist with it than if they feel it has been forced on them.31 Provision of information to allow a reasoned choice is superior to simpleuyou should" messages, as people are likely to feel a stronger commitment to an action they have decided is best than to one in which they feel they have had no choice. Clear presentation of arguments for a particular target behaviour, and reasonable argument against objections to those behaviours, are essential. It is essential that arguments are kept simple and striking, but that they remain accurate representations of current knowledge. Persuasive attempts must be combined with an awareness of the practical and social constraints on particular individuals and community groups, so that realistic alternatives are presented. While it has been argued that social change may be best instituted through legislation, such an action can be counterproductive unless the issues have been debated publicly.* Individuals must be provided with an opportunity to make a considered choice, and must be able to take action on that choice in their current physical and social environment. The concept of "choice" here must be tempered by an understanding of issues of individual responsibility, equity of opportunity and facilities, and the avoidance of victim blaming.*' 9. Intrinsic value People are more likely to persist with activities beneficial to health if they find them enjoyable or interesting than if they see them as an unpleasant means to a desirable end. Effort should be expended on presenting such behanours in an enjoyable manner; for example, by providing group games in pleasant settings aa a way of increasing fitness. Individuals will differ m what they find enjoyable. For example, with exercise some enjoy competition and challenge, while others prefer relaxed, social, non-coinpetitive activities. Thus, provision of a range of activities (principle 5) from which people can ghoose (principle 8) wil enable individuals to select the programme which they will enjoy most. I0 Sound information and instruction Accurate information concerning the health benefits and risks of various activities, instruction on how to perform such activities, and information on resources and channels for social action need to be freely available so that people have the opportunities to make informed choices. In particular, efforts must be directed towards LEE & OWEN 135

6 ensuring that people directly involved in working with the public are provided with accurate and upto-date information. Health and welfare professionals, as well as individuals responsible for policy development and implementation, are vital targets for any health-related campaign, and require specifically tailored information and assistance. Exhortatory campaigns are likely to fail unless such knowledge and skill are readily available to the community. I I Independence Provision of information and opportunities to enable people to engage in new patterns of behaviour independently will enhance rates of adoption and maintenance. Dependence on any particular place or person reduces the individual s ability to continue with the activity pattern if the situation alters in any way. Thus, individuals should be taught skills in implementing new patterns of behaviour, in recognising when problems arise, and in seeking information and advice when it becomes necessary. Discussion This paper has briefly introduced a number of behaviour change theories and has suggested eleven principles which may be useful in the design of any intervention to promote change in behaviours influencing health. Although these principles were originally designed with the promotion of physical activity in mind, they may be applied more generally to the promotion of other health-related actions. The theoretical approaches used have been drawn from work which focusses explicitly on changes in individual behaviour. Other psychological theories might also be used for explanatory purposes in this type of work; however, there is a strong emphasis on conditioning and learning theories in recent behavioural-medicine and preventive-health research.32 Their specific focus on the observable and measurable gives them an advantage over some more metaphorical explanations of human behaviour. What has been presented here is a particular approach to health promotion, that of considering it in terms of the actions of individuals, as these relate to environmental and social variables. It can be argued that an emphasis on individual behaviours leads to a tendency to blame the victims of inequitable social arrangements and environments deleterious to health.27 There is evidence, for example, to suggest that socioeconomic status can influence the initiation or avoidance of preventivc health actions. With screening programmes for breast pathology, it has been found that, compared to those who attended screening, women who did not attend screening were more likely to be from lower socioeconomic strata, were more fearful about the possible outcomes of screening, and had different beliefs about practices which may or may not promote health. Attempts to change health related practices should take findings such as these into account, but should not view them only as data for pinpointing groups requiring cognitive and attitudinal change. Rather, such findings make clear that there will also be ethical and social decisions about the implementation of preventive programmes, especially in contexts where such programmes may cause distress and may be contrary to the beliefs and values of some sections of the population. It should be emphasised that the principles outlined above are intended to deal with the influence of the environment and of social arrangements, and are relevant to the process of influencing the actions of decision-makers who may be able to alter environmental conditions. However, the actions of decision-makers, particularly politicians and those responsible for framing social legislation, will not necessarily be determined by reasoned argument and rational knowledge. For example, the recent failure of the Western Australian government to pass legislation restricting the advertising of tobacco products can be attributed to the inability of scientists and health professionals to sustain their arguments in the public domain.34 It has been suggested that researchers and health practitioners may be more effective in influencing public policy if they are able to work at the levels of community lobbying and promotion of arguments through mass-media channels. The principles outlined in this article may usefully be applied to the preparation and presentation of arguments through these channels, so as to increase their impact with policy-makers. Reliance on professional authority, data from research, conceptual material, and logical argument may be insufficient in the domain of public debate. Data, concepts and logic may best be viewed as a necessary, but not sufficient, base for work in this area of health promotion. The behavioural theories described here give a prime emphasis to the role of the environment, and the social consequences of actions, in shaping the behaviour of individuals. This article therefore has emphasised such factors as: the setting of goals which acknowledge the circumstances of the LEE & OWEN I36

7 individual; the use of explicit education and instruction, rather than simple exhortation; the provision of adequate social settings and social incentives for change; the use of social support and appropriate conditions for self-help; and the recognition that behaviour change is often a difficult and complex process. The principles are presented as some potential guidelines, and the theories as some potential conceptual anchors, for dealing with the range of behaviours which health promotion attempts to confront. Acknowledgement The authors wish to thank the Australian Sport and Recreation Ministers' Council for their grant which supported the project on which this article is based. I. Carleton RA, Lasater TM. Coronary heart disease and human behaviour. Prev Med 1983; 12: Wood PD. Calijiirnia diet and exercise program. Sydney: Bay Books, Stamler J. Primary prevention of coronary heart disease: The last 20 years. Am J Cardiol 1981; 47: Haggerty RJ. Changing lifestyles to improve health. Prev Med 1977; 6: Gottfredson GD. A theory-ridden approach to program evaluation. Am Psychol 1984; 39: Wilson GT. Expectations and substance abuse: Does basic research benefit clinical assessment and therapy? Addict Behav 1981; 6: Owen N, Lee C. Why people do and do not exercise.,adelaide: Department of Recreation an& Sport, DiClemente CC, Prochaska 30. Self-change and therapy change of smoking behaviour: A comparison of processes of change in cessation and maintenance. Addict Behav 1982; 7: Abrams DB, Elder JP, Lasater TM, Carleton RA. Social learning theory principles for community health promotion: An integration across levels of intervention. Paper presented at the 16th Annual Convention of the Association for Advancement of Behavior Therapy, Los Angeles, November, Makoby N, Alexander J. Use of media in lifestyle programs. In: Davidson PO, Davidson SM eds. Behavioural Medicine: Changing health lifestyles. New York: Brunner/ Mazel, I. Dishman RK. Complianceiadherence in health-related exercise. Health Psychol 1982; 1: Karoly P, Steffen J. Improving the longterm effects of psychotherapy. New York: Gardner Press, References 13. Hunt WA, Barnett LW, Branch LA. Relapse rates in addiction programs. J CIin Psychol 1971; 27: Wilson GT, Franks CM. Contemporary behavior therapy: Conceptual and empirical foundations. New York: Guilford Press Mischel W. Personality and assessment. New York: Wiley, Woodward WR. The "discovery" of social behaviorism and social learning theory, Am J Psychol 1982; 37: Ayllon T, Azrin NH. The token economy: A motivational system for therapy and rehabilitation. New York: Appleton- Century-Crofts, Stokes TF, Baer DM. An implicit technology of generalisation. J Appl Behav Anal 1977; 10: Allen ID, lwta BA. Reinforcing exercise maintenance using existing high-rate activities. Behav Mod. 1980; 4: Owen N, Ewins A, Bullock M, Lee C. Adherence, relapse, and health-related behaviours. In: Sheppard JL ed. Advances in behavioural medicine, Vol. 2. Sydney: Cumberland College, 1982; Goldfried MR, Merbaum M. eds. Behavior change through self-control. New York: Holt, Rinehart and Winston, Oldridge NB, Jones NL. Improving patient compliance in cardiac exercise rehabilitation: Effects of written agreement and self-monitoring. J Cardiac Rehab 1983; 3: Bandura A. Social learning theory. Englewood Cliffs, New Jersey: Prentice- Hall, Dubbert PM, Martin JE, Raczynski J, Smith PO. The eflects of cognitivebehavioral strategies on the maintenance of exercise. Paper presented at the Third Annual Meeting of the Society for LEE & OWEN 137

8 Behavioral Medicine, Chicago, March Berkowitz L. Cognitive theories in social psychology. London: Academic Press, Winkler RC, Winett RA. Behavioral interventions in resource conservation: A systems approach based on behavioral economics. Am Psychol 1982; 37: Brown ER, Margo GE. Health education: Can the reformers be reformed? Int J Health Serv 1978; 8: Andrew GM et al. Reasons for dropout from exercise programs in post-coronary patients. Med Sci Sports Exerc 1981; 13: Bandura A, Schunk DH. Cultivating competence, self-efficacy, and intrinsic interest through proximal self-motivation. J Pers Soc Psychol 1981; 41: National Heart Foundation of Australia. Risk factor prevalence study. Canberra: Thompson CE, Wankel LM. The effects of perceived activity choice upon frequency of exercise behavior. J Appl Soc Psychol 1980; 10: Gentry WD. Handbook of behavioral medicine. New York: Guilford Press, Maclean U, Sinfield D, Klein S, Harnden B. Women who decline breast screening. J Epidemiol Community Health 1984; 38: Peachment A. Usable knowledge and expertise: Setting the agenda for tobacco reform. Community Health Stud 1984; 8: LEE & OWEN 138