Health behavior is central to disease prevention, detection, and treatment management. The leading contributors to disease and death in the United States and globally are behavioral factors, including tobacco use, diet and activity patterns, alcohol consumption, sexual behavior, adherence to medical treatment, and avoidable injuries. Among the most important challenges we face is to understand health behavior and to transform knowledge about behavior into effective strategies for health enhancement. Health behavior research ultimately will be judged by its contributions to improving the behavior and health of populations.1
Over the past three decades, experts increasingly have agreed that public health and preventive medicine interventions that are based on social and behavioral science theories are more effective than those lacking a theoretical base. During this period, researchers, practitioners, public health organizations, and funding agencies have come to accept that a theory or theories should be the foundation for well-conceived and effective intervention strategies. The extensive literature in health behavior includes numerous applications of health behavior theory. Thus, we can examine which theories have been most often used over time, and whether use of theory has improved the effectiveness of interventions. Further, systematic reviews and meta-analyses—and systematic reviews of meta-analyses—are available to synthesize the current evidence on theory use and behavior change.2–4
This chapter provides an overview of the state-of-the-science of theory use for designing and conducting public health and health promotion interventions. Influential contemporary perspectives stress the multiple determinants and multiple levels of determinants of health and health behavior. We briefly describe selected often-used theories and their key concepts—including the ecological model, health belief model, theory of planned behavior (TPB), transtheoretical model, and social cognitive theory (SCT). This is followed by a review of evidence about patterns and effects of using theory in health behavior intervention research.
EVOLUTION AND TRENDS IN USE OF HEALTH BEHAVIOR THEORIES AND MODELS
The earliest known applications of health behavior theory were the result of social psychologists working in the U.S. Public Health Service in the 1950s trying to understand how to increase participation in programs designed to prevent and detect disease, such as offering chest x-rays to detect tuberculosis.5 Today, theories have been applied to the development and evaluation of behavioral interventions for many behaviors, for example, adherence to poorly controlled diabetes and hypertension, sun protection and skin self-examination, cancer screening, and oral health promotion (tooth brushing, flossing). Theories have been used to understand and change many behaviors that have emerged more recently or been tied to personal and public health, such as cell phone use while driving, sugar-sweetened beverage consumption, m-health interventions in low- and middle-income countries, promoting HIV serostatus disclosure to sex partners, and climate change risk perceptions. Theory application is also called for in cases where theories have not been used or tested, due to the widely perceived promise of their usefulness.