No unified theory exists to provide direction in IHC application design and development. Rather, a variety of social science theories and models effectively describe how people think, reason, act, and make choices. These theories and models can help illuminate the processes related to health-related
behavior change and decisionmaking. They include: the theory of reasoned action (Ajzen and Fishbein, 1980; Ajzen, 1991); theories of learning (Bandura, 1986); group decisionmaking (Janis and Mann, 1977); transtheoretical stages of change (Prochaska et al., 1992; Prochaska et al., 1994); decision analysis (Weinstein et al., 1988; Mulley, 1989); and other theories and models (Rosenstock, 1974; Nisbett and Ross, 1980; Petty and Cacioppo, 1986; Locke and Latham, 1990; Strecher and Rosenstock, 1998).
Social science models that describe cognitive and behavioral concepts, and the relationships between these concepts, provide important orientation to designers of IHC applications. Listed below are selected psychosocial concepts with illustrative examples of IHC applications that may be of particular rel- evance to developers.
1. Outcome expectations associated with the behavior in question— Outcomes (both positive and negative) one expects as a result of engaging in a particular behavior.
Theories: (Rosenstock, 1974; Ajzen and Fishbein, 1980; Bandura, 1986; Weinstein, 1988; Ajzen, 1991; Prochaska et al., 1992; Strecher and Rosenstock, 1998)
IHC Applications: (Velicer et al., 1993; Campbell et al., 1994; Skinner et al., 1994; Strecher et al., 1994; Brug et al., 1996; Dijkstra et al., in press)
2. Self-efficacy expectations—Confidence in one’s ability to engage in a particular behavior.
Theories: (Bandura, 1986; Strecher et al., 1986)
IHC Applications: (Campbell et al., 1994; Dijkstra et al., in press) 3. Goal setting—Setting goals for change.
Theories: (Locke and Latham, 1990; Strecher et al., 1995) IHC Applications: (Strecher et al., 1995)
4. High-risk situations—Situations that trigger a particular behavior. Theories: (Shiffman, 1996)
IHC Applications: (Shiffman et al., 1997)
5. Attributions for previous failures—Interpretations one makes for the causes of previous failures in changing a particular behavior.
Theories: (Foersterling, 1986; Weiner, 1986) IHC Applications: (Strecher et al., 1994)
6. Stage of change—Degrees of motivation and current experience in changing a particular behavior, ranging from precontemplation, contemplation, preparation, and action to maintenance.
Theories: (Weinstein, 1988; Prochaska et al., 1992)
IHC Applications: (Velicer et al., 1993; Campbell et al., 1994; Skinner et al., 1994; Strecher et al., 1994; Brug et al., 1996; Dijkstra et al., in press)
7. Prescriptive decision theory—Use of explicit quantitative estimates of probabilities of good and bad outcomes, and the utilities of those outcomes from the decisionmaker’s perspective to inform a decision; and descriptive decision theory—Modeling decisions in the face of uncertainty in an attempt to predict actual behavior (e.g., prospect theory).
Theories: (Mulley, 1989)
IHC Applications: (Brennan, Moore et al., 1995; Gustafson, Hawkins et al., 1999)
Several psychosocial concepts that are particularly important in IHC ap- plication development are empowerment, self-efficacy, and motivation. Empowerment can be generally defined as the process that enables people to exert control over their lives and their destinies (Peterson and Stunkard, 1989; Feste and Anderson, 1995). It is closely related to health outcomes in that pow- erlessness has been shown to be a broad-based risk factor for disease. Studies demonstrate that people who feel “in control” in a health situation have better outcomes than those who feel “powerless” (Israel and Sherman, 1990; Ander- son et al., 1995). Empowerment can be enhanced by online support groups that allow patients to feel “connected” to others with a similar health condition (Gustafson et al., 1992; Pingree et al., 1993; Gustafson, Hawkins, Boberg, Bricker, Pingree et al., 1994). Interactive self-assessment tools can also help in this regard by helping individuals focus on central issues. Similarly, self-effi- cacy is a person’s level of confidence that he or she can perform a specific task or health behavior in the future (Bandura, 1977; Holman and Lorig, 1987; Lorig et al., 1989). Clinical studies show that self-efficacy is most predictive of im- provements in patients’ functional status (O’Leary, 1985; Cunningham et al., 1991). Perceived self-efficacy has been shown to play a significant role in smoking cessation relapse rates, pain management, control of eating and weight, success of recovery from myocardial infarction, and adherence to preventive health programs (Strecher et al., 1986; Mullen et al., 1987; O’Leary et al., 1988; Allen et al., 1990; Maibach et al., 1991).
Motivation is a major factor in explaining the effectiveness of any instruc- tional event, especially those that are voluntary and dependent upon intrinsic (as opposed to extrinsic) motivation as many IHC contexts are. Attribution theory states that the degree to which people attribute their own successes or failures to ability, effort, task difficulty, or luck differentially predicts whether, to what degree, and what kinds of subsequent learning opportunities they will
voluntarily seek (Dweck and Leggett, 1988). Differences in attribution (e.g., “I achieved because I made the effort” versus “I achieved because the test was easy”) explain why some people feel in control of their learning whereas oth- ers feel helpless in learning. For example, if when searching online to learn about treatment options, a person experiences difficulty, and he or she usually attributes success or failure to blind luck, the person may feel the task is just too difficult and/or his or her luck has run out. As a result, the person may give up and not seek online help again. On the other hand, another person may ex- perience the same difficulty, but because the person attributes his or her success to effort, this individual persists and continues to use online resources. One of the shortcomings with attribution theory and other motivation theories is that little is known about whether these are “trait” variables or “state” variables. Someone whose motivation might be quite low in a classroom context might be much more motivated by online instruction, indicating that their motivation is a “state” variable. On the other hand, some people are not motivated by any learning opportunity, indicating a “trait” variable. Attribution theory is related to the “confidence” factor in Keller’s ARCS model, which is designed to help developers be more attentive to the motivation aspects of their instruction (Keller and Suzuki, 1988).
Use of the above theories and models as the bases for IHC application development may also contribute to their further development. Interactive media may allow researchers to collect better and different kinds of data on behavior change processes—data that could lead to more refined or comprehensive theo- ries and models.