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Health Promotion by Social Cognitive Means
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144 Health Education Behavior April 2004,Supply Side Versus Demand Side Approaches. Current health practices focus heavily on the medical supply side The growing pres. sure on health systems is to reduce ration and delay health services to contain health. costs The days for the supply side health system are limited People are living longer. This creates more time for minor dysfunctions to develop into chronic diseases Demand. is overwhelming supply Psychosocial factors partly determine whether the extended life. is lived efficaciously or with debility pain and dependence 2 3. Social cognitive approaches focus on the demand side They promote effective self. management of health habits that keep people healthy through their life span Aging. populations will force societies to redirect their efforts from supply side practices to. demand side remedies Otherwise nations will be swamped with staggering health costs. that consume valuable resources needed for national programs. SOCIAL COGNITIVE THEORY, This article focuses on health promotion and disease prevention by social cognitive. means 4 5 Social cognitive theory specifies a core set of determinants the mechanism. through which they work and the optimal ways of translating this knowledge into effec. tive health practices The core determinants include knowledge of health risks and bene. fits of different health practices perceived self efficacy that one can exercise control over. one s health habits outcome expectations about the expected costs and benefits for differ. ent health habits the health goals people set for themselves and the concrete plans and. strategies for realizing them and the perceived facilitators and social and structural. impediments to the changes they seek, Knowledge of health risks and benefits creates the precondition for change If people. lack knowledge about how their lifestyle habits affect their health they have little reason. to put themselves through the travail of changing the detrimental habits they enjoy But. additional self influences are needed for most people to overcome the impediments to. adopting new lifestyle habits and maintaining them Beliefs of personal efficacy play a. central role in personal change This focal belief is the foundation of human motivation. and action Unless people believe they can produce desired effects by their actions they. have little incentive to act or to persevere in the face of difficulties Whatever other factors. may serve as guides and motivators they are rooted in the core belief that one has the. power to produce desired changes by one s actions, Health behavior is also affected by the outcomes people expect their actions to pro. duce The outcome expectations take several forms The physical outcomes include the. pleasurable and aversive effects of the behavior and the accompanying material losses. and benefits Behavior is also partly regulated by the social reactions it evokes The social. approval and disapproval the behavior produces in one s interpersonal relationships is the. second major class of outcomes This third set of outcomes concerns the positive and neg. ative self evaluative reactions to one s health behavior and health status People adopt. personal standards and regulate their behavior by their self evaluative reactions They do. things that give them self satisfaction and self worth and refrain from behaving in ways. that breed self dissatisfaction Motivation is enhanced by helping people to see how habit. changes are in their self interest and the broader goals they value highly Personal goals. rooted in a value system provide further self incentives and guides for health habits. Long term goals set the course of personal change But there are too many competing. Bandura Health Promotion 145, influences at hand for distal goals to control current behavior Short term attainable goals.
help people to succeed by enlisting effort and guiding action in the here and how. Personal change would be easy if there were no impediments to surmount The per. ceived facilitators and obstacles are another determinant of health habits Some of the. impediments are personal ones that deter performance of healthful behavior They form. an integral part of self efficacy assessment Self efficacy beliefs must be measured. against gradations of challenges to successful performance For example in assessing. personal efficacy to stick to an exercise routine people judge their efficacy to get them. selves to exercise regularly in the face of different obstacles when they are under pressure. from work are tired feel depressed are anxious face foul weather and have more inter. esting things to do If there are no impediments to surmount the behavior can be easy to. perform and everyone is efficacious, The regulation of behavior is not solely a personal matter Some of the impediments to. healthful living reside in health systems rather than in personal or situational impedi. ments These impediments are rooted in how health services are structured socially and. economically,Primacy of Efficacy Belief in Causal Structures. Self efficacy is a focal determinant because it affects health behavior both directly and. by its influence on the other determinants Efficacy beliefs influence goals and aspira. tions The stronger the perceived self efficacy the higher the goals people set for them. selves and the firmer their commitment to them Self efficacy beliefs shape the outcomes. people expect their efforts to produce Those of high efficacy expect to realize favorable. outcomes Those of low efficacy expect their efforts to bring poor outcomes Self efficacy. beliefs also determine how obstacles and impediments are viewed People of low efficacy. are easily convinced of the futility of effort in the face of difficulties They quickly give up. trying Those of high efficacy view impediments as surmountable by improvement of. self management skills and perseverant effort They stay the course in the face of. difficulties, Figure 1 shows the paths of influence in the posited sociocognitive causal model. Beliefs of personal efficacy affect health behavior both directly and by their impact on. goals outcome expectations and perceived facilitators and impediments. Overlap in Health Belief Models, There are many psychosocial models of health behavior They are founded on the. common metatheory that psychosocial factors are heavy contributors to human health. For the most part the models include overlapping determinants but under different. names In addition facets of a higher order construct are often split into seemingly differ. ent determinants as when different forms of anticipated outcomes of behavioral change. are included as different constructs under the name of attitudes normative influences. and outcome expectations Following the timeless dictum that the more the better some. researchers overload their studies with a host of factors that contribute only trivially to. health habits because of redundancy Figure 2 shows the factors the various health models. select and their overlap with determinants in social cognitive theory. Most of the factors in the different models are mainly different types of outcome. expectations Perceived severity and susceptibility to disease in the health belief model. are the expected negative physical outcomes The perceived benefits are the positive out. 146 Health Education Behavior April 2004, Figure 1 Structural paths of influence wherein perceived self efficacy affects health habits both.
directly and through its impact on goals outcome expectations and perception of. sociostructural facilitators and impediments to health promoting behavior. come expectations In the theory of reasoned action and planned behavior attitudes. toward the behavior and social norms produce intentions that are said to determine behav. ior Attitude is measured by perceived outcomes and the value placed on those outcomes. As defined and operationalized these are outcome expectations not attitudes as tradi. tionally conceptualized Norms are measured by perceived social pressures and one s. motivation to comply with them Norms correspond to expected social outcomes for a. given behavior Goals may be distal ones or proximal ones Intentions are essentially. proximal goals I aim to do x and I intend to do x are really the same thing Perceived con. trol in the theory of planned behavior overlaps with perceived self efficacy Regression. analyses reveal substantial redundancy of predictors bearing different names 6 For exam. ple after the contributions of perceived self efficacy and self evaluative reactions to. one s health behavior are taken into account neither intentions nor perceived behavioral. control add any incremental predictiveness, Most of the models of health behavior are concerned only with predicting health hab. its But they do not tell you how to change health behavior Social cognitive theory offers. both predictors and principles on how to inform enable guide and motivate people to. adapt habits that promote health and reduce those that impair it 4. Threefold Stepwise Implementation Model, The social utility of health promotion programs can be enhanced by a stepwise imple. mentation model In this approach the level and type of interactive guidance is tailored to. people s self management capabilities and motivational preparedness to achieve desired. changes The first level includes people with a high sense of efficacy and positive out. come expectations for behavior change They can succeed with minimal guidance to. accomplish the changes they seek, Figure 2 Summary of the main sociocognitive determinants and their areas of overlap in different conceptual models of health behavior. 148 Health Education Behavior April 2004, Individuals at the second level have self doubts about their efficacy and the likely ben. efits of their efforts They make halfhearted efforts to change and are quick to give up. when they run into difficulties They need additional support and guidance by interactive. means to see them through tough times Much of the guidance can be provided through. tailored print or telephone consultation, Individuals at the third level believe that their health habits are beyond their personal.
control They need a great deal of personal guidance in a structured mastery program. Progressive successes build belief in their ability to exercise control and bolster their stay. ing power in the face of difficulties and setbacks Thus in the stepwise model the form. and level of enabling interactivity is tailored to the participants changeability readiness. The following sections are devoted to a more detailed consideration of how to enable peo. ple at these various levels of changeability to improve their health status and functioning. PUBLIC HEALTH CAMPAIGNS, Societal efforts to get people to adopt healthful practices rely heavily on public health. campaigns These population based approaches promote changes mainly in people with. high perceived efficacy for self management and positive expectations that the pre. scribed changes will improve their health Meyerowitz and Chaiken7 examined four pos. sible mechanisms through which health communications could alter health habits by. transmitting information on how habits affect health by arousing fear of disease by. increasing perceptions of one s personal vulnerability or risk or by raising people s. beliefs in their efficacy to alter their habits They found that health communications foster. adoption of healthful practices to the extent that they raise beliefs in personal efficacy. To help people reduce health impairing habits by health communications requires a. change in emphasis from trying to scare people into health to enabling them with the self. management skills and self beliefs needed to take charge of their health habits. In longitudinal analyses of community based health campaigns Rimal8 9 found that. perceived self efficacy governs whether individuals translate perceived risk into a search. for health information and whether they translate acquired health knowledge into health. ful behavioral practices Those of low self efficacy take no action even though they are. knowledgeable about lifestyle contributors to health and perceive themselves to be vul. nerable to disease Maibach and colleagues10 found that both people s preexisting self. efficacy beliefs that they can exercise control over their health habits and the self efficacy. beliefs instilled by a community health campaign contributed to adoption of healthy. eating habits and regular exercise Figure 3,Overprediction of Refractoriness. Our theories overpredict the resistance of health habits to change This is because they. are developed by studying mainly refractory cases but ignoring successful self changers. For example smoking is one of the most addictive substances It is said to be intractable. because it is compelled by biochemical and psychological dependencies Each puff sends. a reinforcing nicotine shot to the brain Prolonged use is said to create a relapsing brain. The problem with this theorizing is that it predicts far more than has ever been. observed More than 40 million people in the United States have quit smoking on their. own Where was their brain disease How did the smokers cure the disease on their own. Bandura Health Promotion 149, Figure 3 Paths of the influence of perceived self efficacy on health habits in community wide. programs to reduce risk of cardiovascular disease, NOTE The initial numbers on the paths of influence are the significant path coefficients for adop. tion of healthy eating patterns the numbers in parentheses are the path coefficients for regular exer. Superimposed on the 40 million self quitters the dismal relapse curves that populate our. journals are but a tiny ripple in the vast sea of successes Carey and his colleagues verified. longitudinally that heavy smokers who quit on their own had a stronger belief in their effi. cacy at the outset than did continuous smokers and relapsers 11 Successful self changers. combine efficacy belief with outcome expectations that benefits will outweigh. disadvantages of the lifestyle changes, The same is true for alcohol and narcotic addiction Lee Robins12 reported a remark.
ably high remission for heroin addiction among Vietnam veterans without the benefit of. treatment Vaillant13 has shown that a large share of alcoholics eventually quit drinking. without treatment assistance from self help groups or radical environmental change. Granfield and Cloud14 put it well when they characterized the inattention to successful. self changes in substance abuse as the elephant that no one sees. Enhancement of Health Impact by Interactive Technologies. The absence of individual guidance places limits on the power of one way mass com. munication The revolutionary advances in interactive technology can increase the scope. and impact of health promotion programs On the input side health communications can. now be personally tailored to factors known to affect health behavior Tailoring commu. nications does not necessarily guarantee better outcomes The benefits of individualiza. tion will depend on the predictive value of the tailored factors If weak or irrelevant fac. tors are targeted individualization will not provide incremental benefits Development of. measures for key social cognitive determinants known to affect health behavior can. provide guidance for tailoring strategies, On the behavioral adaption side individualized interactivity further enhances the. impact of health promotion programs Social support and guidance during early periods. of personal change and maintenance increase long term success Here too the impact of. social support will depend on its nature Converging evidence across diverse spheres of. functioning reveals that the social support has beneficial effects only if it raises people s. beliefs in their efficacy to manage their life circumstances 15 If social support is provided. in ways that foster dependence it can undermine coping efficacy Effective enablers pro. 150 Health Education Behavior April 2004, Figure 4 Paths of influences through which mass communications affect psychosocial changes. both directly and via a socially mediated pathway by linking viewers to social net. works and community settings, vide the type of support and guidance that is conducive to self efficacy enhancement for. personal success 5, Interactive computer assisted feedback provides a convenient means for informing. enabling motivating and guiding people in their efforts to make lifestyle changes The. personalized feedback can be adjusted to participants efficacy level the unique impedi. ments in their lives and the progress they are making The feedback may take a variety of. forms including individualized print communications telephone counseling and link. age to supportive social networks I shall describe shortly a self management system that. encompasses these various enabling features,Socially Mediated Pathways of Influence.
There is another way in which the power of population based approaches to health. promotion can be strengthened There is only so much that large scale health campaigns. can do on their own regardless of whether they are tailored or generic There are two. pathways through which health communication can alter health habits Figure 4. In the direct pathway media promote changes by informing modeling motivating. and guiding personal changes In the socially mediated pathway the media link partici. pants to social networks and community settings These places provide continued per. sonalized guidance natural incentives and social supports for desired changes The. major share of behavioral changes is promoted within these social milieus 16. Psychosocial programs for health promotion will be increasingly implemented via. interactive Internet based systems People at risk for health problems typically ignore. preventive or remedial health services For example young women at risk of eating disor. ders resist seeking help But they will use Internet delivered guidance because it is readily. accessible convenient and provides a feeling of anonymity Studies by Taylor and col. leagues17 attest to its potential Through interactive guidance women reduced dissatis. faction with their weight and body shape altered dysfunctional attitudes and rid. themselves of disordered eating behavior, Interactive technologies are a tool not a panacea They cannot do much if individuals. cannot motivate themselves to take advantage of what they have to offer These systems. need to be structured in ways that build motivational and self management skills as well. Bandura Health Promotion 151, as guide habit changes Otherwise those who need the guidance most will use this tool. Promoting Society Wide Changes by Serial Dramas, The social linking function via the media is illustrated in global applications of serial. television dramas founded on social cognitive theory that address some of the most. urgent global problems 18 They include the soaring population growth and transmission. of AIDS Hundred of episodes in these long running serials get people deeply involved in. the lifestyle changes being modeled The serials dramatize the everyday problems people. struggle with model solutions to them and provide people with incentives and strategies. for bettering their lives The story lines model family planning women s equality envi. ronmental conservation AIDS prevention and a variety of life skills. It is of limited value to motivate people to change if they are not provided with appro. priate resources and environmental supports to realize those changes The dramatiza. tions therefore link people to community resources where they can receive a lot of con. tinued supportive guidance Worldwide applications in Africa Asia and Latin America. are raising people s efficacy to exercise control over their family lives enhancing the sta. tus of women and fostering the adoption of contraceptive practices to lower the rates of. childbearing, A controlled study in Tanzania compared changes in family planning and contracep. tion use in half the country that received a dramatic series with the rest of the country that. did not 19 Compared to the control region more families in the broadcast area went to. family planning clinics and adopted family planning and contraceptive methods Fig. ure 5 The dramatic series produced similar changes later when they were broadcast in. the former control region of the country, Some of the story lines centered on safer sexual practices to prevent the spread of.
AIDS Infection rates are high among long distance truckers and prostitutes at truck. stops The dramatic productions focused on self protective and risky sexual practices and. modeled how to curb the spread of HIV infection Compared with residents in the control. region those in the broadcast region increased belief in their personal risk of HIV infec. tion through unprotected sexual practices talked more about HIV infection reduced the. number of sexual partners and increased condom use 20 21 The greater the exposure to the. modeled behavior the stronger the effects on perceived efficacy to control family size and. risky sexual practices,SELF MANAGEMENT MODEL, Health habits are not changed by an act of will It requires motivational and self. regulatory skills Self management operates through a set of psychological subfunctions. People have to learn to monitor their health behavior and the circumstances under which. it occurs and how to use proximal goals to motivate themselves and guide their behavior. They also need to learn how to create incentives for themselves and to enlist social sup. ports to sustain their efforts, DeBusk and his colleagues22 have developed a self management model for health pro. motion and disease risk reduction founded on the self regulatory mechanisms of social. cognitive theory This self management model combines self regulatory principles with. computer assisted implementation Figure 6 It includes exercise programs to build car. 152 Health Education Behavior April 2004, Figure 5 Mean number of new family planning adopters per clinic in the Ministry of Health. Clinics in the broadcast region and those in the control region. NOTE The period 1990 to 1992 is the prebroadcast baseline The values for 1993 to 1994 are the. family planning adoption levels in the broadcast region solid line and the control region dotted. line The values for 1995 to 1996 are the adoption levels when the serial was aired in the previous. control region solid line 20, diovascular capacity nutrition programs to reduce dietary fat to lower risk of heart dis. ease and cancer weight reduction programs and smoking cessation programs. For each risk factor people are provided detailed guides on how to improve their. health functioning They monitor their health habits set themselves short term goals and. report the changes they are making The computer mails personalized reports that include. feedback of progress toward subgoals The feedback also provides guides on how to man. age troublesome situations and new subgoals to realize Efficacy ratings identify areas in. which self regulatory skills must be developed if beneficial changes are to be achieved. and maintained A single implementer assisted with a computerized implementation sys. tem provides intensive individualized guidance in self management to large numbers of. In tests of the preventive value of this self management system employees in the. workplace lowered elevated cholesterol by altering eating habits high in saturated fats. Figure 7 They achieved even larger reductions if their spouses took part in the program. The more room for dietary change the larger the reduction in plasma cholesterol A sin. gle nutritionist implemented the entire program at minimal cost for large numbers of. Nonadherence to drug therapies is a pervasive serious problem It worsens health con. ditions and raises medical costs Moreover it may lead physicians to prescribe stronger. medications or more drastic interventions in response to the seeming failure of the pre. Bandura Health Promotion 153, Figure 6 Computer assisted self regulatory system for altering health habits.
Figure 7 Levels of reduction in plasma cholesterol achieved with the self regulation system. NOTE The panel on the left summarizes the mean cholesterol reductions achieved in applications. in the workplace by participants who used the self management system either by themselves or. along with their spouses or did not receive the system to provide a control baseline The right panel. presents the mean cholesterol reductions achieved with the self management system by partici. pants whose daily cholesterol and fat intake was high or relatively low at the outset of the program. 154 Health Education Behavior April 2004, Figure 8 Enhancement of perceived self regulatory efficacy and reduction of sodium intake. through the aid of the self management system, scribed treatment A major public health nightmare is that excessive use of drugs and. erratic compliance will breed hardier strains of pathogens that render existing medica. tions ineffective The success of the self management system in promoting adherence is. shown in a program by West and his colleagues23 to reduce sodium intake in patients suf. fering from heart failure Figure 8 It strengthened patients efficacy to adhere to a low. sodium diet They achieved substantial reduction in sodium intake and maintained it dur. ing a 6 month period At each time point the higher the perceived self efficacy the. greater the sodium reduction, Haskell and his associates24 used the self management system to promote lifestyle. changes in patients suffering from coronary artery disease This places them at high risk. of heart attacks At the end of 4 years those receiving medical care by their physicians. showed no change or they got worse In contrast those aided in self management by. nurse implementers achieved big reductions in multiple risk factors They lowered their. intake of saturated fat lost weight lowered their bad cholesterol raised their good cho. lesterol exercised more and increased their cardiovascular capacity Figure 9. The program also altered the physical progression of the disease Those receiving the. self management program had 47 less buildup of plaque on their artery walls Figure. 10 They also had fewer coronary events fewer hospitalizations and fewer deaths. The success of the self management system has been compared in five hospitals to the. standard medical postcoronary care in patients who have already suffered a heart attack. At the end of the 1st year the self management system is more effective in reducing risk. factors and increasing cardiovascular functioning than the standard medical care. The self management system is well received because it is individually tailored to. people s needs It provides continuing personalized guidance that enables people to exer. cise control over their own change It is a home based program that does not require any. special facilities equipment or group meetings plagued with high drop out rates It can. serve large numbers of people simultaneously under the guidance of a single imple. menter It is not constrained by time and place It combines the high individualization of. the clinical approach with the large scale applicability of the public health approach It. provides valuable health promotion services at low cost. In the present applications the computer is used as a coordinating and mailing system. to guide self directed change and to provide feedback of progress By linking the interac. Figure 9 Reduction in multiple risk factors by patients with coronary atherosclerosis depending on whether they received the usual care from their physicians or. training in self management of health habits,SOURCE Plotted from data of Haskell et al 24. 156 Health Education Behavior April 2004, Figure 10 Differences in the number of cardiac deaths hospitalizations for nonfatal myocardial.
infarction and other cardiac events for patients who received the usual care from their. physician or training in self management of health habits. SOURCE Plotted from data of Haskell et al 24, tive aspects of the self management model to the Internet one can vastly expand its avail. ability to people wherever they may live at whatever time they may choose to use it. Health Promotion in Children Through Interactive Media. The interactive capabilities of electronic technologies are beginning to be creatively. enlisted for health promotion A company in Silicon Valley is developing interactive. video games that raise children s perceived self efficacy and enable them to manage. chronic health conditions 25, In a role playing video game for diabetic children they win points depending on how. well they understand the diabetic condition and regulate the diet insulin and blood sugar. levels of two wacky diabetic pachyderms Packy and Marlon They set out to retrieve the. food and diabetes supplies snatched by pesky enemy critters in a diabetes summer camp. To succeed children have to boost the elephants health by managing their diabetes as. they fight off the pesky critters using their trunks as water cannons and peanut launchers. The better the children manage the meals blood glucose and insulin dosage of the pachy. derm duo to stay in the safe zone the more points the children win. Children love the video game They quickly become experts in how to manage diabe. tes Figure 11 In assessments conducted 6 months later 26 the interactive role playing. raises the children s self care efficacy They talk more freely about their diabetes and. their feelings about it They adopt dietary and insulin practices to keep their blood sugar. level under control They reduce urgent doctor visits for diabetes emergencies by 77. Control children who played a video game unrelated to health decreased their self care. and increased emergency doctor visits by 7, Asthmatic children learn how to manage their condition by helping an asthmatic dino. saur named Bronchiasaurus stay strong and healthy while on a risky mission in an envi. ronment riddled with allergens In the interactive game children learn how to avoid. asthma triggers to keep the air free of respiratory irritants to track peak flow and to take. medication The video game improves knowledge about asthma enhances perceived effi. Bandura Health Promotion 157, Figure 11 Changes exhibited in a 6 month follow up in perceived self efficacy to manage differ. ent aspects of diabetes child initiated discussions about diabetes level of diabetes. self care and number of emergency doctor visits by children who had the benefit of. the role playing video game and diabetic control children who played other entertain. ment video games 26, cacy to avoid things that trigger asthma attacks and improves use of emergency medica.
Children with cystic fibrosis are taught how to deal with their lung problem by using. medications and physical therapy to keep the lungs of a virtual puppy clear Another. interactive video game discourages children from smoking promoted by the Blackburn. Tobacco Company A daring surgeon enters the body in microscopic size with lasers to. repair the damage done by smoking to save the smoker s life He clears phlegm from the. bronchial tubes removes tar deposits and precancerous cells from the throat and lungs. removes plaque and a deadly blood clot in the arteries and enters the brain to conquer nic. otine addition The children become experts in the harmful effects of smoking They lose. any appetite for it, These health promoting videos are being widely distributed to families by pediatri. cians This is but the beginning in the creative use of the interactive video technology to. promote childhood health,Childhood Health Promotion Models. Many of the lifelong habits that jeopardize health are formed during childhood and. adolescence For example unless youngsters take up the smoking habit in their teens. they rarely become smokers in adulthood It is easier to prevent detrimental health habits.


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