• No results found

Instructional design strategies for health behavior change

N/A
N/A
Protected

Academic year: 2021

Share "Instructional design strategies for health behavior change"

Copied!
13
0
0

Loading.... (view fulltext now)

Full text

(1)

Patient Education and Counseling 56 (2005) 3–15

Review

Instructional design strategies for health behavior change

Mable B. Kinzie

Department of Leadership, Foundations and Policy, Curry School of Education, University of Virginia, P.O. Box 400265, Charlottesville, VA 22904-4265, USA

Received 19 August 2003; received in revised form 23 January 2004; accepted 20 February 2004

Abstract

To help health educators build upon the best of different health behavior change theories, this paper offers a unified set of instructional design strategies for health education interventions. This set draws upon the recommendations of Rosenstock (Health Belief Model), Bandura (Social Cognitive Theory), and Dearing (Diffusion Theory), and uses a modified Events of Instruction framework (adapted from Robert Gagne): gain attention (convey health threats and benefits), present stimulus material (tailor message to audience knowledge and values, demonstrate observable effectiveness, make behaviors easy-to-understand and do), provide guidance (use trustworthy models to demonstrate), elicit performance and provide feedback (to enhance trialability, develop proficiency and self-efficacy), enhance retention and transfer (provide social supports and deliver behavioral cues). Sample applications of these strategies are provided. A brief review of research on adolescent smoking prevention enables consideration of the frequency with which these strategies are used, and possible patterns between strategy use and behavioral outcomes.

© 2004 Elsevier Ireland Ltd. All rights reserved.

Keywords: Instructional design; Health education; Behavior change

1. Introduction

Individual behavioral factors, such as tobacco and alcohol use, diet, sexual behavior and avoidable injuries, contribute to significant suffering, premature death, and medical costs. Health education is an important tool in response—it can offer useful health enhancement strategies and encourage

voluntary informed behavior change [1,2]. While there are

a multitude of behavior change theories that instructional designers and health educators might draw upon for guid-ance, it is not altogether clear which to use, when. Glanz and her colleagues reviewed 536 journal articles on health education over a 2-year period in the 1990s, and found 66 different theories and models informing design efforts. The reviewers note:

Practitioners of health promotion and education at once benefit from and are challenged by the eclectic and deriva-tive nature of their endeavor: a multitude of theoreti-cal frameworks and models from the social sciences are available for their use, but the best choices and direct translations may not be immediately evident (pp. 30–1)

[1].

Tel.:+1-434-977-3314; fax:+1-434-924-1384. E-mail address: kinzie@virginia.edu (M.B. Kinzie).

After selecting a theory suited to guiding education for a particular health behavior change, the designer must de-termine how to translate theory into practice and identify specific instructional strategies to employ. Complicating this situation further, designers must frequently look to multi-ple theories for a full commulti-plement of instructional strategies.

For instance, the Health Belief Model[3] has strengths in

guiding information presentation (susceptibility/severity of condition, benefits of behavioral change) and ultimate per-formance (behavioral cues), while Social Cognitive Theory

[4]helps situate behavior in authentic social practice

(devel-opment of social proficiency and resilient self-efficacy). Be-cause behavior change is, after all, change, Diffusion Theory is eminently appropriate for introducing new behaviors to a

sometimes resistant population[5]. Health educators agree

with this assessment: These three models were among the top ten models employed across the research reviewed by Glanz et al.

The work reported here is an attempt to provide designers with a complete set of theory-driven instructional strategies for health education. Robert Gagne’s Nine Events of

In-struction were selected as a starting point. Gagne’s Events,

drawing on both behaviorist and cognitivist information processing theory, offer a framework for instructional design that has been employed by decades of instructional

design-ers. (Gagne’s well-regarded text, conditions of learning[6]

0738-3991/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2004.02.005

(2)

has been released in four editions and cited over 1490 times

in prominent journals between 1981 and early 2004[7].)

For ease of application in health promotion, the Nine

Events were condensed into five primary stages. This

frame-work was then populated with strategies developed from

those recommended by Rosenstock et al.[3], Bandura[4],

and Dearing et al.[8], for the design of AIDS prevention.

However, these strategies apply not only to prevention in-struction, but also to instruction to encourage any health be-havior change.

These strategies are presented in this paper, along with examples of how they inform instructional methods. The strategies are then used to guide a literature review target-ing research on adolescent smoktarget-ing prevention, to study the strategies implemented and to note patterns between strat-egy use and behavioral outcomes.

2. Instructional strategies for health behavior change As indicated, the starting point for this work was Gagne’s

Nine Events of Instruction, adapted to a five-stage

frame-work. Table 1 illustrates the correspondence between

Gagne’s original work and the adaptation.

The next step was to populate this framework with specific strategies for encouraging health behavior change, strategies based on the Health Belief Model, Social Cognitive Theory, and Diffusion Theory. To this end, recommendations made

by Rosenstock et al.[3], Bandura[4], and Dearing et al.[8],

for the design of AIDS prevention education were reviewed. Their recommendations were reduced to a bulleted list of generalized strategies and these strategies were then mapped onto the five stage framework.

For each learning situation (drug prevention, exercise pro-motion, etc.), designers will need to determine how best to implement the strategies. To provide some examples of how this may be done, education guidelines developed by the Centers for Disease Control (CDC) for adolescent smok-ing prevention are included, next to the strategies that

in-Table 1

Adaptation of Gagne’s nine events for a five-stage framework # Five stage framework # Corresponding Gagne events 1 Gain attention 1 Gain attention

2 Present stimulus material 2 Inform learners of objective 3 Stimulate recall of prior

learning

4 Present the stimulus 3 Provide learning guidance 5 Provide learning guidance 4 Elicit performance and

provide feedback

6 Elicit performance 7 Provide feedback 8 Assess performance 5 Enhance retention and

transfer

9 Enhance retention and transfer

form each [9]. Several strategies did not appear to inform

any CDC guidelines; in these cases, a recommendation was

drafted to complete the set (Table 2).

While these strategies are informed by theory and have informed practice, do they lead to the behavioral outcomes health educators hope for? In order to study the strategies used and the outcomes obtained, research done for a sin-gle application of health education—adolescent smoking prevention—was reviewed.

3. Literature review—method

The literature search was initially focused on health ed-ucation to prevent the risky health behavior of adolescents (MEDLINE search focusing on “health education and ado-lescent and risk)” and was then narrowed to interventions targeting smoking prevention. (This aspect of health edu-cation is extremely important, as tobacco use is the

“lead-ing cause of preventable death in the United States [9].”

Eighty-two percent of regular smokers began this habit

be-fore the age of 18[9]and in 1999, 35% of high school

stu-dents in this country reported smoking during the previous

month[10]. As many as 3000 young people begin smoking

each day[9].) To find additional research reports, reference

lists from identified publications were examined, as were a variety of on-line reference lists for adolescent health and smoking prevention.

Field trials for school-based interventions lasting over a year (producing potentially more powerful effects), or which were followed-up over a long term (providing information on the attenuation of desired behaviors over time) were se-lected for review. Eliminated from consideration were any studies that were not conducted in the United States within the last 20 years. Some of these trials were randomized and some were not, due to the difficulties associated with entire-school assignment to intervention and control groups. In all cases, intervention treatments were delivered to en-tire intact classes (as opposed to individualized instructional methods). Nine interventions remained after applying these selection criteria (school-based, long-term interventions or long-term follow-up, conducted in the United States within the last 20 years). There were no research reports lacking suf-ficient detail to apply these selection criteria. The outcomes from the nine selected interventions had been described in fifteen research reports (researchers published follow-up re-ports for some interventions).

To determine which of the strategies for health behavior

change might have been implemented for each intervention,

I used the authors’ description of the instructional meth-ods used. While these descriptions were necessarily brief due to the limits of publication, they did provide a way to identify the instructional methods the authors thought

were most salient for their interventions. Table 3uses the

strategies framework to describe the instructional methods

(3)

M.B. Kinzie / Patient Education and Counseling 56 (2005) 3–15 5

Table 2

Instructional strategies for health behavior change, with sample applications from CDC guidelines for adolescent smoking prevention[9]

Instructional strategies CDC strategy application

Gain attention

Convey threats to health (HBMa) Identify immediate and long-term undesirable physiologic, cosmetic, and social consequences of smoking

Fear arousal/health losses (to encourage health screening) (SCTb)

Perceived susceptibility and/or severity of ill-health condition (HBM)

Convey benefits to health (HBM) No related guideline

Health benefits (to encourage health behavior) (SCT) Benefits might involve athletic performance, feelings of physical well-being, and more money for hobbies/activities

Relative advantage, “the degree to which an innovation is perceived as being better than the idea it supercedes” (DOIc)

Present stimulus material

Tailor message to audience’s prior knowledge, values Decrease the social acceptability of tobacco use, highlight existing anti-tobacco norms, and help students understand that most adolescents do not smoke

Enhance perceptions of compatibility “with the existing values, past experiences, and needs of potential adopters” (DOI)

Tailor messages for socio-demographic differences in values (SCT), perceptions of threat, benefits, barriers (HBM) and self-efficacy (SCT/HBM)

Demonstrate observable effectiveness of desired behaviors No related guideline

Enhance perceptions of response efficacy (HBM) Show realistic outcomes associated with desired behavior: acceptable peer responses to refusal strategies, improved physiological outcomes, enhanced physical appearance (teeth color, breath odor), etc.

Provide for observability, “the degree to which the results of an innovation are visible” (DOI)

Make desired behaviors easy-to-understand and to do Help students learn behavioral skills for resisting social influences, through

direct instruction, modeling, rehearsal, reinforcement

Enhance self-efficacy for preventive behavior (SCT) Help students develop ways to feel acceptance from peers, feel mature, and cope with stress, all without smoking

Present the innovation so that it is easy to understand and use (minimize complexity) (DOI)

Help students learn to recognize and refute tobacco-promotion messages from media, adults, peers

Provide learner guidance

Use trustworthy, knowledgeable models to demonstrate desired behavior Social modeling to develop self-protective skills (observe “models similar to themselves solve problems successfully with the modeled strategies”) (SCT)

No related guideline

Use instructional materials that show similar adolescents successfully employing smoking refusal strategies

If possible, use opinion leaders from the target population, to speed the diffusion process, or change agents who are “homophilous with the target audience,” are trustworthy and knowledgeable (DOI)

Use peer leaders to help counteract social pressures on youth to use tobacco

Elicit performance and provide feedback

Provide authentic practice and feedback to enhance trialability, develop proficiency, and enhance self-efficacy

(repeat from above) Help students learn behavioral skills for resisting social influences that promote tobacco use, through direct instruction, modeling, rehearsal, and reinforcement

“Opportunities for guided practice and corrective feedback” to enhance “social proficiency” and “resilient self-efficacy”: role playing, mental practice (SCT)

Provide for trialability, “the degree to which an innovation may be experimented with on a limited basis” (DOI)

Enhance retention and transfer

Develop social supports for desired behavior Coach students to help others develop skills for resisting social influences that promote tobacco use

Develop social structures (peer, community, etc.) to support personal change (SCT)

Deliver behavioral cues No related guideline

Provide brief, salient cues that stimulate a decision to act (HBM) Incorporate cues in school newspaper, bumper stickers/buttons, social events, and newsletter mailings. Involve local media

aHBM: Health Belief Model[3]. bSCT: Social Cognitive Theory[4]. cDOI: Diffusion of Innovations[8].

(4)

M.B. Kinzie /P atient Education and Counseling 56 (2005) 3–15 Table 3

Instructional strategies implemented

Gain attention Present stimulus material Provide guidance Elicit performance and

provide feedback

Enhance retention and transfer Convey threat: susceptibility,

potential loss (HBMa, SCTb)

Convey benefit; improvement over existing practice (HBM, SCT, DOIc)

Tailor message to audience’s prior knowledge, values, perceptions (DOI, SCT, HBM)

Demonstrate observable effectiveness of desired behaviors (DOI, HBM)

Make desired behaviors easy-to-understand and do (DOI, SCT, HBM) Use trustworthy, knowledgeable models to demonstrate desired behavior (SCT, DOI)

Provide authentic practice and feedback to enhance trialability, develop proficiency, and enhance self-efficacy (DOI, SCT)

Develop social supports for desired behavior (SCT)

Deliver behavioral cues (HBM)

Saskatoon: Denson and Stretch[11] Year 1

Films addressed chemical dependence, disease attributed to cigarette smoking Lecture on difficulties of smoking cessation Discussion of disease prevalence Year 2

Film presented lung cancer statistics

Demonstration of cancerous lung

Review of year 1 San Diego: Elder et al.[12]

Videotape on health consequences Antecedents and social consequences discussed

Overview of tobacco products

College undergrads as group leaders

Rehearsal: resisting peer pressure

Students trained to encourage others to quit

T-shirts with program logo

Possible addiction discussed Newsletters tailored so

smoking status

Smoking cessation tips Text-based celebrity endorsements of non-use

Practice: decision-making Parents received two newsletters

Newsletters (5) and phone calls (4) Estimation of personal health risk Presentation of opinion

polls on tobacco use

Skit perform. involving tobacco refusal Promotion of cessation hot line Letter-writing (tobacco comp’s, media) Opportunity to declare self-tobacco-free Tobacco issue debate Follow-up: Eckhardt et al.[13]

11th grade intervention 11th grade intervention: 11th grade intervention: 11th grade intervention:

Articles on effects of second-hand smoke

Tobacco Co. tactics explained

Legislation information (newsletter and phone call)

Newsletters (2) and phone call (1) Cessation advice

Waterloo: Flay et al.[14]

Grade 6 Grade 6 Grade 6

Personal beliefs elicited, discussed; supporting knowledge built by viewing videos, poster-making, discussions

Specific coping skills taught

Specific coping skills role-played and practiced

Students decided whether to smoke and why; made classroom announcement Grade 7

Students developed own prevention program and presented to classmates

(5)

M.B. Kinzie /P atient Education and Counseling 56 (2005) 3–15 7 Grade 8 Grade 8 Discussion of social benefits and consequences of smoking

Students presented on social benefits and consequences of smoking

Students engaged in decision-making process Follow-up study, no additional

intervention: Flay et al.[15] California and Oregon: Ellickson

and Bell[16]

7th grade 7th grade 7th grade: Teen Leader

Treatment

7th grade Students helped to

recognize the benefits of resisting drug use

Students learn how to say no to external and internal pressures

Teen leaders from neighboring schools used to deliver lessons

Students develop reasons not to use drugs, identify pressures to use them, counter pro-drug messages via small group activities, role play, and skills practice

8th grade 8th grade 8th grade 8th grade 8th grade

Booster of above Booster of above Booster of above Booster of above Booster (repeat

7th grade strategies) Minnesota: Hurd et al.[17]

Social pressures curriculum: Social pressures curriculum: Social pressures curriculum: Social pressures curriculum: Social pressures curriculum: Film followed by discussion

of dangers of smoking

Discussion of smoking prevalence in students’ own age group and in adults

Discussion of ways smoking starts, ways to avoid smoking College undergrads as group leaders Video demonstration of same-age individuals refusing to smoke, followed by role play of this behavior by students Students developed counter-arguments for smoking advertisements Plus personalization Plus commitment

Opinion leaders videotaped discussing smoking; Video used to spur discussion. (Video also shown in “Social Pressures only” school, but leaders were unknown)

Students decided why they would not smoke; made and viewed videotaped classroom announcement

Follow-up study, no additional intervention: Luepker et al.[18] Minnesota: Murray et al.[19]

Health influences intervention Lectures and activities on

long-term effects of smoking (but no fear arousal used)

Social influences intervention Social Influences

Intervention

Social Influences Intervention

Peer-Led Social Influences Intervention

Social Influences Intervention Lectures and activities on

short-term social and physiological effects

References made to students’ estimation of peer smoking rates; correction of students’ normative expectations

Social skills taught to resist pressures to smoke

Opinion leaders selected and trained to lead classroom activities

Social skills taught to resist pressures to smoke

Follow-up studies, no additional interventions (2) Murray et al.[20]

(3) Murray et al.[21] (4) Murray et al.[22]

(6)

M.B. Kinzie /P atient Education and Counseling 56 (2005) 3–15 Table 3 (Continued )

Gain attention Present stimulus material Provide guidance Elicit performance and

provide feedback

Enhance retention and transfer Convey threat: susceptibility,

potential loss (HBMa, SCTb)

Convey benefit; improvement over existing practice (HBM, SCT, DOIc)

Tailor message to audience’s prior knowledge, values, perceptions (DOI, SCT, HBM)

Demonstrate observable effectiveness of desired behaviors (DOI, HBM)

Make desired behaviors easy-to-understand and do (DOI, SCT, HBM) Use trustworthy, knowledgeable models to demonstrate desired behavior (SCT, DOI)

Provide authentic practice and feedback to enhance trialability, develop proficiency, and enhance self-efficacy (DOI, SCT)

Develop social supports for desired behavior (SCT)

Deliver behavioral cues (HBM)

Los Angeles: Johnson et al.[23]

Health Influences Intervention Health Influences Intervention

Health Influences Intervention

Social Influences Intervention

Both Social and Health Influences

Social Influences Intervention Behaviors that undermine

health were discussed

Behaviors that promote health were discussed

Students’ own risk behaviors were examined Social influences intervention

Students determined the extent to which smoking would interfere with their goals

Advertising techniques demonstrated; students criticized

Social skills taught to resist pressures to smoke

Opinion leaders selected to appear in videotapes. These peer leaders were

familiar in their own

schools, and unfamiliar in others

Students used a structured decision-making strategy for making a personal decision about smoking

Information presented on short-term and long-term health effects of smoking

Both social and health influences

Students presented arguments for why people should not smoke; these were videotaped. Kentucky: Noland et al.[24]

Negative consequences for using tobacco (undesirable social and immediate physical)

Training to recognize peer pressure

Trained peer leaders Student pledges not to use tobacco

Training on refusal skills, assertiveness

Training to recognize and counter appeals Washington State: Schinke et al.[25]

Skills and discussion groups Skills group Skills and discussion groups Skills and discussion group

Tobacco use information Problem-solving skills

presented to identify peer pressures and personal temptations; generate and select best solutions

Peer testimonials by older youths on alternatives to tobacco use

Debates weighing health, lifestyle and economic effects

Games and skits Homework presented in class

Skills group Practice refusing invitations to use tobacco; students coached and praised one another a HBM: Health Belief Model[3].

b SCT: Social Cognitive Theory[4]. c DOI: Diffusion of Innovations[8].

(7)

M.B. Kinzie /P atient Education and Counseling 56 (2005) 3–15 9 Table 4

Strategy and outcome overview

Authors Gain attention Present stimulus material Guide Perform Encourage retention and transfer Results

Threat Benefit Tailored

message

Effectiveness Easy-to-do Models Practice and

feedback Social supports Cues Denson and Stretch [11] varied

Prevalence, regular smoking

Trial 1 Immediate posttest: NSD Trial 2 Immediate posttest: NSD Trial 3 Immediate posttest

Intervention: 17.5%<control: 26.1 (P<0.05) Increase in prevalence Trial 3 Intervention: 4.0% <control: 17.5% (P<0.001) Elder et al. [12]

Prevalence, past-month smoking

Intervention: 13.2%<control: 19.8% (P<0.05) Eckhardt et al.[13] Continued intervention: 7.0%< continued control: 12.6% (P<0.05)

Lapsed vs.delayed intervention: NSD Flay et al. [14] Prevalence Baseline—Immediate posttest: intervention<control (P<0.03) (due to quitting of

treatment group smokers) Flay et al. [15] Baseline—End of grade 6: NSD Baseline—Beginning of grade 7: NSD Baseline—End of grade 7: intervention<control (P<0.002) (due to increased

smoking by control group [2.6 times])

Baseline—Grade 12: NSD Ellickson and

Bell[16] teen leader

treatment only

Non-users continuing to not smoke

Baseline—All posttests: NSD

Experimenters quitting (no smoking

for 1 year)

Teen educator, all periods: NSD Health educator > control

Baseline—3 months: NSD After 12 months (P<0.03)

After booster at 15 months

(P<0.006)

Experimenters decrease smoking

Teen educator, all periods: NSD Health educator > control

After 3 months, 12 months: NSD After booster at 15 months

(8)

M.B. Kinzie /P atient Education and Counseling 56 (2005) 3–15

Authors Gain attention Present stimulus material Guide Perform Encourage retention and transfer Results

Threat Benefit Tailored

message

Effectiveness Easy-to-do Models Practice and

feedback

Social supports

Cues

Experimenters increase smoking

After 3 months, 12 months: NSD After booster at 15 months

Monthly: Teen educator

<control (P<0.03)

Weekly: Teen educator

<control (P<006)

Daily: Teen educator<control (P<0.03)

Regular smokers increase smoking Teen educator > control

After 3 months: NSD After 12 months (P<0.052)

After booster at 15 months

(P<0.004)

Minnesota: Hurd et al.[17]

Decrease in numbers of non-smokers at all schools:

NSD

Increase in “regular smokers” Social pressures (48%), social

pressures plus (20%) <monitoring control (128%) (P<0.05) Follow-up: Luepker et al.[18] Decrease in numbers of non-smokers at all schools:

NSD Minnesota: Murray et al.[19] Social influences only Peer-Led social only Social influences only (1) Past-week smoking

Studies 1 and 2, immediate posttest results: NSD Pretest non-smokers only

All treatments

<non-equivalent control

(P<0.05)

Study 1, one-year follow-up Pretest non-smokers only

Peer-Led social

<Adult-Led social (P<0.01)

Pretest, experimental smokers: NSD Follow-up:

Murray et al.[20]

(2) Past-week smoking

Study 1, two- and three-year follow-ups: NSD Study 2, one-year follow-up,

baseline non-smokers

All treatments< non-equivalent control (P<0.05)

Study 2, two-year follow-up Baseline experimental smokers

Peer-Led<Adult-Led (P<0.05)

(9)

M.B. Kinzie /P atient Education and Counseling 56 (2005) 3–15 11 Ever smoking

Study 2, one-year follow-up, baseline non-smokers

Peer-Led<Adult-Led (P<0.05)

Study 2, one-year follow-up Baseline experimental smokers:

mixed results

Follow-up: Murray et al.[21]

(3) Past-week smoking

Study 1, five-year follow-up Pretest never- and ever-smokers:

NSD

Study 2, four-year follow-up Pretest never-smokers: NSD Pretest ever-smokers

Peer-Led, social influences (no video)<non-equivalent control (P<0.05)

Follow-up: Murray et al.[22]

(4) Past-week smoking

Study 1, six-year follow-up Pretest never- and ever-smokers:

NSD

Study 2, five-year follow-up Pretest never- and ever-smokers:

NSD Los Angeles: Johnson et al.[23] Health influences only Health influences only Social influences only Non-use to any-use Pretest—Immediate posttest: NSD Pretest—Year 2 Health (46%)<social (59%), within-school health and social controls (58% each) (P<0.03)

Pretest—Year 3: NSD

Experimental to regular or heavy use

Pretest—Immediate posttest: NSD Pretest—Year 2

Social (4%)<

within-school social control (9%) (P<0.02)

Pretest—Year 3: NSD

Regular to heavy use

Pretest—Immediate posttest: NSD Pretest—Year 2: NSD Pretest—Year 3: Social<health

(10)

M.B. Kinzie /P atient Education and Counseling 56 (2005) 3–15 Table 4 (Continued )

Authors Gain attention Present stimulus material Guide Perform Encourage retention and transfer Results

Threat Benefit Tailored

message

Effectiveness Easy-to-do Models Practice and

feedback Social supports Cues Kentucky: Noland et al.[24] Prevalence Year 1 follow-up Intervention 22.4%<control 28.1% (P<0.05) Year 2 follow-up Intervention 30.1%<control 37.9% (P<0.01) Washington State: Schinke et al.[25] Skills group only Both; skills group had more practice than discussion group Prevalence 6-Month follow-up Skills 5%<control 7% (P<0.05) Discussion: 6%: NSD 12-Month follow-up Skills 6%<discussion 8%, control 9% (P<0.05) 18-Month follow-up Skills 8%<discussion 10% control 11% (P<0.05) 24-Month follow-up Skills 7%<discussion 11% control 12% (P<0.05)

(11)

M.B. Kinzie / Patient Education and Counseling 56 (2005) 3–15 13

Fig. 1. Instructional strategies used across nine interventions reviewed.

described by the authors of each study were incorporated into the table.

Table 4presents a streamlined view of the use of the strate-gies, indicating with a bullet point which strategies were in-dicated in reports of the intervention design. Outcomes

ob-tained for each of the studies are also summarized inTable 4.

4. Literature review—results

4.1. Strategies emphasized in health education interventions

No one strategy was used in all interventions as is shown inFig. 1. The most prominently employed strategies (used in eight of the nine studies) involved conveying threats to health, making desired behaviors easy-to-understand and do, and providing authentic practice and feedback. Peer models to help guide and influence behavior were employed almost as often (seven of the nine interventions). Five of the nine interventions studied emphasized tailoring the message to fit the audience’s prior knowledge and values.

Surprisingly, few of the researchers reported an instruc-tional emphasis on health benefits, or on encouraging reten-tion and transfer (social supports for desired behavior and behavioral cues were each employed in only one of the nine interventions). None of the interventions reportedly empha-sized the observable effectiveness of the desired behaviors.

4.2. Strategies and behavioral outcomes

Were some of these interventions more effective than oth-ers? This is quite difficult to say. Not only did each study employ different instructional strategies and methods, each also employed a unique data collection and analysis method-ology. For all of the research reported, self-reports of recent smoking behavior were solicited; for seven of the nine

in-terventions, physiological samples (saliva sample, exhaled carbon monoxide) were collected prior to the self-report, both as a way of objectively validating students’ self-report, and as a way of encouraging the students to be more truth-ful (students were given an explanation of the purpose of these samples in advance of the measures); this is called the

“bogus pipeline” method[26].1

Eight of the interventions resulted in significant effects on some aspects of self-reported smoking behavior on the immediate posttest and, for some of the studies, for up to 3 years afterwards. (The ninth intervention, that studied by

El-lickson and Bell[16], required 12 and 15 months of elapsed

time before the effects of the health educator-delivered inter-vention were detected in decreasing “experimental smokers” cigarette use.) These effects, when studied over longer pe-riods of time through follow-ups do not seem to have been

durable. Murray, Johnson, Luepker and coworkers[17–23]

have studied the effects of a “social influences” interven-tion over time: While some positive effects persisted for 2 or 3 years, when studied for as long as 6 years, all positive effects had extinguished by year 5.

It is not surprising, then, that only one of these interven-tions emphasized retention and transfer strategies for the

health behaviors[12,13]. In their report on the “S.H.O.U.T.”

intervention, the researchers described incorporation of seven of the nine strategies. Not only did they design “booster” training that took place in the 11th grade, they creatively employed outreach materials such as newsletters, a cessation hot line, and a phone call from a health edu-cator over the middle- and high-school years. While these methods appear to have been successful in encouraging less smoking behavior, it must be noted that the research

1 This kind of procedure is not always necessary, however. Murray and Perry report that the “bogus pipeline” is valuable for encouraging valid disclosure when anonymity cannot be ensured, but if anonymity can be assured, self-report returns comparable data[27].

(12)

conducted on this intervention did not employ

physiologi-cal outcome measures (saliva or CO1 samples) to support

participants’ self-report of smoking.

5. Discussion

5.1. Practice implications

The Health Belief Model [3], Social Cognitive Theory

[4], and Diffusion of Innovation Theory[8]each have value

for informing the design of instruction to encourage health behavior change. The instructional strategies for health

be-havior change presented in this paper draw on the

recom-mendations of these theorists, and provide a unified frame-work from which to apply these theories in the design of health education.

The strategies appear to have been inconsistently applied in the adolescent smoking interventions reviewed, perhaps due in part to the separate nature of the different theories that have influenced researchers’ instructional designs. It is interesting to note that eight of the interventions reviewed (plus the guidelines from the CDC) focused on the nega-tive health effects of smoking but only two emphasized the benefits of not smoking. It is even more striking to observe the limited attention paid to encouraging the maintenance of non-smoking behavior through provision of social supports and on-going cues. Since extinguishing of healthy behav-iors can be an issue as children enter their teenage years, it seems essential to focus on ways to continue to support their tobacco-free behavior.

5.2. Limitations

There are limitations to inferring a product’s design from the research report describing it, and it may be that the apparent lack of emphasis on a strategy (for exam-ple, “demonstrate observable effectiveness”) is due to an incomplete description of the intervention in the research reports. It might be reasonable to expect that “demonstrable effectiveness” is something addressed in the course of mak-ing desired behaviors easy-to-understand and do, or in the context of a model demonstrating and guiding behaviors. This situation emphasizes the value of a thorough descrip-tion of intervendescrip-tions in published work—such descripdescrip-tions are critically important for interpreting the effectiveness of different instructional methods.

5.3. Future inquiries

Because the instructional strategies for health behavior

change are grounded in highly regarded behavioral theory,

they have the potential to positively influence the design of health education. It remains for health education researchers to fully test the strategies framework, particularly regarding the durability of health behavior change.

References

[1] Glanz K, Lewis FM, Rimer BK. The scope of health promotion and health education. In: Glanz K, Lewis FM, Rimer BK, editors. Health behavior and health education. 2nd ed. San Francisco: Jossey-Bass; 1997, p. 3–18.

[2] Glanz K, Lewis FM, Rimer BK. Linking theory, research, and prac-tice. In: Glanz K, Lewis FM, Rimer BK, editors. Health behavior and health education. 2nd ed. San Francisco: Jossey-Bass; 1997, p. 19–35.

[3] Rosenstock IM, Strecher VJ, Becker MH. The health belief model and HIV risk behavior change. In: DiClemente RJ, Peterson, John L, editors. Preventing AIDS: theories and methods of behavioral interventions. New York: Plenum Press; 1994, p. 5–24.

[4] Bandura A. Social cognitive theory and exercise of control over HIV infection. In: DiClemente RJ, Peterson, John L, editors. Preventing AIDS: theories and methods of behavioral interventions. New York: Plenum Press; 1994, p. 25–59.

[5] Rogers EM. Diffusion of innovations. 4th ed. New York: Free Press; 1995.

[6] Gagne R. The conditions of learning. 4th ed. New York: Holt, Rinehart, Winston; 1985.

[7] Thomson/ISI. Web of Science; 2004.

[8] Dearing JW, Meyer G, Rogers EM. Diffusion theory and HIV Risk Behavior Change. In: DiClemente RJ, Peterson, John L, editors. Preventing AIDS: theories and methods of behavioral interventions. New York: Plenum Press; 1994.

[9] CDC. Guidelines for school health programs to prevent tobacco use and addiction. Division of Adolescent and School Health (DASH), Centers for Disease Control and Prevention; 1994.

[10] CDC. Targeting tobacco use: the nation’s leading cause of death. Na-tional Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention; 2002.

[11] Denson R, Stretch S. Prevention of smoking in elementary schools. Can J Public Health 1981;72:259–63.

[12] Elder JP, Wildey M, deMoor C, Salllis JF, Eckhardt L, Edwards C, et al. The long-term prevention of tobacco use among junior high school students: classroom and telephone interventions. Am J Public Health 1993;83:1239–44.

[13] Eckhardt L, Woodruff SI, Elder JP. Relative effectiveness of contin-ued, lapsed, and delayed smoking prevention in senior high school students. Am J Health Promotion 1997;11:418–21.

[14] Flay BR, Ryan KB, Best JA, Brown KS, Kersell MW, d’Avernas JR, et al. Are social-psychological smoking prevention programs effective? The Waterloo study. J Behav Med 1985;8:37–59. [15] Flay BR, Koepke D, Thomson SJ, Santi S, Best JA, Brown KS.

Six-year follow-up of the first Waterloo school smoking prevention trial. Am J Public Health 1989;79:1371–6.

[16] Ellickson PL, Bell RM. Drug prevention in junior high: a multi-site longitudinal test. Science 1990;247:1299–305.

[17] Hurd PD, Johnson CA, Pechacek T, Bast LP, Jacobs DR, Luepker RV. Prevention of cigarette smoking in seventh-grade students. J Behav Med 1980;3:15–28.

[18] Luepker RV, Johnson CA, Murray DM, Pechacek T. Prevention of cigarette smoking: three-year follow-up of an education program for youth. J Behav Med 1983;6:53–62.

[19] Murray DM, Luepker RV, Johnson CA, Mittelmark MB. The preven-tion of cigarette smoking in children: a comparison of four strategies. J Appl Social Psychol 1984;14:274–88.

[20] Murray DM, Richards PS, Luepker RV, Johnson CA. The prevention of cigarette smoking in children: two- and three-year follow-up comparisons of four prevention strategies. J Behav Med 1987;6:595– 611.

[21] Murray DM, Davis-Hearn M, Goldman AI, Pirie PL, Luepker RV. Four- and five-year follow-up results from four seventh-grade smok-ing prevention strategies. J Behav Med 1988;11:295–405.

(13)

M.B. Kinzie / Patient Education and Counseling 56 (2005) 3–15 15

[22] Murray DM, Pirie PL, Luepker RV, Pallonen U. Five- and six-year follow-up results from four seventh-grade smoking prevention strate-gies. J Behav Med 1989;12:207–18.

[23] Johnson CA, Hansen WB, Collins LM, Graham JW. High-school smoking prevention: results of a three-year longitudinal study. J Behav Med 1986;9:439–52.

[24] Noland MP, Kryscio RJ, Riggs RS, Linville LH, Ford VY, Tucker TC. The effectiveness of a tobacco prevention program with ado-lescents living in a tobacco-producing region. Am J Public Health 1998;88:1862–5.

[25] Schinke SP, Gilchrist LD, Schilling RF, Senechal VA. Smoking and smokeless tobacco use among adolescents: trends and intervention results. Public Health Rep 1986;101:373–8.

[26] Evans RI, Hansen WB, Mittelmark MB. Increasing the validity of self-reports of smoking behavior in children. J Appl Psychol 1977;62:521–3.

[27] Murray DM, Perry CL. The measurement of substance use among adolescents: when is the “bogus pipeline” method needed? Addictive Behav 1987;12:225–33.

References

Related documents

(Circle if updated within the past 35 years) Electrical Heating Plumbing Roof Loc Bldg Address:. Zip

Until 1987- 1988, it was mainly the structural disequilibria that characterised the Bulgarian economy that were stressed, and only during the closing two or three years that the

Numeral incorporation in American Sign Language (ASL) is a complex process which combines a numeral handshape with a base representing a noun using.. simultaneous morphology as

Despite early efforts at tackling issues concerning food security, it seems the problem still stares the world in the face as little progress has been made in that

To determine whether, or not, consumers’ purchase intention would be predicted by shopping orientations, perceived behavioral control, demographic characteristics, and online

This paper outlines the theoretical foundations for this workshop, with an overview of two publications: one that categorizes the way engineers work with the people they serve

This paper highlights further problems with the Health Belief Model (HBM, Becker &amp; Rosenstock, 1987), the Theory of Reasoned Action (TRA, Fishbein &amp; Ajzen, 1975),

A cytokine secretion analysis in monocytes of young healthy controls revealed that increased frequencies of cells producing the proinflammatory cytokines TNF and IL-23 and