Victor J. Strecher

Social Learning Theory and the Health Belief Model

The Health Belief Model, social learning theory (recently relabelled social cognitive theory), self-efficacy, and locus of control have all been applied with varying success to problems of explaining, predicting, and influencing behavior. Yet, there is con ceptual confusion among researchers and practitioners about the interrelationships of these theories and variables. This article attempts to show how these explanatory fac tors may be related, and in so doing, posits a revised explanatory model which incor porates self-efficacy into the Health Belief Model. Specifically, self-efficacy is pro posed as a separate independent variable along with the traditional health belief var iables of perceived susceptibility, severity, benefits, and barriers. Incentive to behave (health motivation) is also a component of the model. Locus of control is not included explicitly because it is believed to be incorporated within other elements of the model. It is predicted that the new formulation will more fully account for health-related behavior than did earlier formulations, and will suggest more effective behavioral interventions than have hitherto been available to health educators.

The Role of Self-Efficacy in Achieving Health Behavior Change

The concept of self-efficacy is receiving increasing recognition as a predictor of health behavior change and maintenance. The purpose of this article is to facilitate a clearer understanding of both the concept and its relevance for health education research and practice. Self-efficacy is first defined and distinguished from other related concepts. Next, studies of the self-efficacy concept as it relates to health practices are examined. This review focuses on cigarette smoking, weight control, contraception, alcohol abuse and exercise behaviors. The studies reviewed suggest strong relationships between self-efficacy and health behavior change and maintenance. Experimental manipulations of self-efficacy suggest that efficacy can be enhanced and that this enhancement is related to subsequent health behavior change. The findings from these studies also suggest methods for modifying health practices. These methods diverge from many of the current, traditional methods for changing health practices. Recommendations for incorporating the enhancement of self-efficacy into health behavior change programs are made in light of the reviewed findings.

One size does not fit all: The case for tailoring print materials

Printed health education materials frequently consist of mass-produced brochures, booklets, or pamphlets designed for a general population audience. Although this one-size-fits-all approach might be appropriate under certain circumstances and even produce small changes at relatively modest costs, it cannot address the unique needs, interests, and concerns of different individuals. With the advent and dissemination of new communication technologies, our ability to collect information from individuals and provide feedback tailored to the specific information cellected is not only possible, but practical. The purpose of this article is to: (a) distinguish between tailored print communication and other common communication-based approaches to health education and behavior change; (b) present a theoretical and public health rationale for tailoring health information; and (c) describe the steps involved in creating and deliverin tailored print communication programs. Studies suggest computer tailoring is a promising strategy for health education and behavior change. Practitioners and researchers should understand the approach and consider the possibilities it presents for enhancing their work in disease prevention.

Improving dietary behavior: the effectiveness of tailored messages in primary care settings.

OBJECTIVES To achieve the Healthy People 2000 objectives, public health professionals must develop effective dietary interventions that address psychosocial and behavioral components of change. This study tested the effect of individually computer-tailored messages designed to decrease fat intake and increase fruit and vegetable intake. METHODS Adult patients from four North Carolina family practices were surveyed at baseline and then randomly assigned to one of two interventions or to a control group. The first intervention consisted of individually computer-tailored nutrition messages; the second consisted of nontailored nutrition information based on the 1990 Dietary Guidelines for Americans. Patients were resurveyed 4 months postintervention. RESULTS The tailored intervention produced significant decreases in total fat and saturated fat scores compared with those of the control group (P < .05). Total fat was decreased in the tailored group by 23%, in the nontailored group by 9%, and in the control group by 3%. Fruit and vegetable consumption did not increase in any study group. Seventy-three percent of the tailored intervention group recalled receiving a message, compared with 33% of the nontailored intervention group. CONCLUSIONS Tailored nutrition messages are effective in promoting dietary fat reduction for disease prevention.

The Health Belief Model and HIV Risk Behavior Change

The Health Belief Model (HBM) was initially developed in the 1950s by a group of social psychologists in the U.S. Public Health Service in an effort to explain the widespread failure of people to participate in programs to prevent or to detect disease (Hochbaum, 1958; Rosenstock, 1960, 1966, 1974). Later, the model was extended to apply to people’s responses to symptoms (Kirscht, 1974) and to their behavior in response to diagnosed illness, particularly compliance with medical regimens (Becker, 1974). Over three decades, the model has been one of the most widely used psychosocial approaches to explaining health-related behavior.

Computer-tailored smoking cessation materials: a review and discussion.

Tailored smoking cessation materials combine many of the interactive, diagnostic elements of a clinical encounter with the dissemination potential of mass media. In this article, the differences between general, targeted and tailored smoking cessation materials are discussed, and the impact of tailored versus the general or targeted modalities is examined. A review of ten randomized trials of tailored materials found a significant impact of these materials in a majority of the studies. Very few patterns, in terms of the characteristics associated with the tailored materials, subject recruitment, subject characteristics, or follow-up procedures were found when comparing positive versus negative trials. The two trials that combined tailored materials with nicotine replacement therapy found a strong impact on smoking cessation; studies that examine the combined effects of tailored behavioral and pharmacological interventions are suggested. Another notable finding was the effect tailored materials had among precontemplators. Most studies that included precontemplators found a significant positive impact of materials tailored to this group. Taken together, these findings suggest important new avenues for reaching smokers.

Web-Based Smoking-Cessation Programs : Results of a Randomized Trial

BACKGROUND Initial trials of web-based smoking-cessation programs have generally been promising. The active components of these programs, however, are not well understood. This study aimed to (1) identify active psychosocial and communication components of a web-based smoking-cessation intervention and (2) examine the impact of increasing the tailoring depth on smoking cessation. DESIGN Randomized fractional factorial design. SETTING Two HMOs: Group Health in Washington State and Henry Ford Health System in Michigan. PARTICIPANTS 1866 smokers. INTERVENTION A web-based smoking-cessation program plus nicotine patch. Five components of the intervention were randomized using a fractional factorial design: high- versus low-depth tailored success story, outcome expectation, and efficacy expectation messages; high- versus low-personalized source; and multiple versus single exposure to the intervention components. MEASUREMENTS Primary outcome was 7 day point-prevalence abstinence at the 6-month follow-up. FINDINGS Abstinence was most influenced by high-depth tailored success stories and a high-personalized message source. The cumulative assignment of the three tailoring depth factors also resulted in increasing the rates of 6-month cessation, demonstrating an effect of tailoring depth. CONCLUSIONS The study identified relevant components of smoking-cessation interventions that should be generalizable to other cessation interventions. The study also demonstrated the importance of higher-depth tailoring in smoking-cessation programs. Finally, the use of a novel fractional factorial design allowed efficient examination of the study aims. The rapidly changing interfaces, software, and capabilities of eHealth are likely to require such dynamic experimental approaches to intervention discovery.

Web-based Weight Management Programs in an Integrated Health Care Setting: A Randomized, Controlled Trial

Objective: To assess the efficacy of a Web‐based tailored behavioral weight management program compared with Web‐based information‐only weight management materials.

The role of engagement in a tailored web-based smoking cessation program: randomized controlled trial.

Background Web-based programs for health promotion, disease prevention, and disease management often experience high rates of attrition. There are 3 questions which are particularly relevant to this issue. First, does engagement with program content predict long-term outcomes? Second, which users are most likely to drop out or disengage from the program? Third, do particular intervention strategies enhance engagement? Objective To determine: (1) whether engagement (defined by the number of Web sections opened) in a Web-based smoking cessation intervention predicts 6-month abstinence, (2) whether particular sociodemographic and psychographic groups are more likely to have lower engagement, and (3) whether particular components of a Web-based smoking cessation program influence engagement. Methods A randomized trial of 1866 smokers was used to examine the efficacy of 5 different treatment components of a Web-based smoking cessation intervention. The components were: high- versus low-personalized message source, high- versus low-tailored outcome expectation, efficacy expectation, and success story messages. Moreover, the timing of exposure to these sections was manipulated, with participants randomized to either a single unified Web program with all sections available at once, or sequential exposure to each section over a 5-week period of time. Participants from 2 large health plans enrolled to receive the online behavioral smoking cessation program and a free course of nicotine replacement therapy (patch). The program included: an introduction section, a section focusing on outcome expectations, 2 sections focusing on efficacy expectations, and a section with a narrative success story (5 sections altogether, each with multiple screens). Most of the analyses were conducted with a stratification of the 2 exposure types. Measures included: sociodemographic and psychosocial characteristics, Web sections opened, perceived message relevance, and smoking cessation 6-months following quit date. Results The total number of Web sections opened was related to subsequent smoking cessation. Participants who were younger, were male, or had less formal education were more likely to disengage from the Web-based cessation program, particularly when the program sections were delivered sequentially over time. More personalized source and high-depth tailored self-efficacy components were related to a greater number of Web sections opened. A path analysis model suggested that the impact of high-depth message tailoring on engagement in the sequentially delivered Web program was mediated by perceived message relevance. Conclusions Results of this study suggest that one of the mechanisms underlying the impact of Web-based smoking cessation interventions is engagement with the program. The source of the message, the degree of message tailoring, and the timing of exposure appear to influence Web-based program engagement.

Self-related neural response to tailored smoking-cessation messages predicts quitting

Tailored health interventions can be more effective in eliciting positive behavior change than generic interventions, but the underlying neural mechanisms are not yet understood. Here, 91 smokers participated in a functional magnetic resonance imaging session and a tailored smoking-cessation program. We found that increases in activation in self-related processing regions, particularly dorsomedial prefrontal cortex, to tailored messages predicted quitting during a 4-month follow-up.