Health Education Research Advance Access originally published online on January 4, 2005
Health Education Research 2005 20(3):291-293; doi:10.1093/her/cyg124
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Health Education Research Vol.20 no.3, © Oxford University Press 2004; All rights reserved
Commentary: It's a difference of opinion that makes a horserace...
1 John A. Burns School of Medicine, University of Hawai'i at M
noa, Honolulu, HI 96822 and 2 Pacific Telehealth & Technology Hui, Tripler AMC, Honolulu, HI 96859, USA
3 Correspondence to: C. R. Nigg; E-mail: cnigg{at}hawaii.edu
The authors of ‘Health behavior theory and cumulative knowledge regarding health behaviors: are we moving in the right direction’ (Noar and Zimmerman, 2005
) have taken a bold step by advocating for change in the field of change. The authors are correct when they note that our field should continually and critically reflect upon itself; however, it may be that our systems of funding, publication, peer review and specialization have made us too introspective, and discourage the types of innovation and risk-taking that could move our field to new esteem.
Herein, we provide some additional points for consideration in an effort to continue the dialogue initiated by Noar and Zimmerman (Noar and Zimmerman, 2005) and prompt further discussion by the research community. We applaud their provocative approach and look to complement their arguments, rather than critique their manuscript.
Distinguishing between health behavior theories, models, paradigms and frameworks is paramount to move this dialogue forward. In an attempt to clarify we provide the following:
- A theory is a system of assumptions and rules to describe predict and explain the nature of specified phenomena.
- A model is a description of a system that accounts for what is known.
- A framework is a set of assumptions, concepts, values and practices that constitutes a way of viewing reality.
- A paradigm is a common framework that is shared by a community.
These concepts need to be seen as an evolution of ideas—not as immutable systems of rules. Our field would be well served to contrast the value of comprehensive theories that attempt to identify all proximate influences on behavior change (or behavior) with more limited theories that describe the nature of causal relationships between two constructs (National Cancer Institute, 2004). In a similar vein, Noar and Zimmerman (Noar and Zimmerman, 2005) note that many health behavior theories are not falsifiable. Certainly, researchers are not able to conduct research at the level of Peter Weir's 1998 feature film, The Truman Show; however, is this the criteria to which we are holding ourselves before we will endorse a theory? A theory may not truly be falsifiable, but it can be tested to see if it is effective (or not) in eliciting behavior change.
Further along this same line of thought, the authors present health behavior theory alongside health behavior change theory without clear differentiation. To some, this may read as a semantic difference; however, we find a clear distinction between the two [e.g. (Glanz and Rimer, 1997)]. Describing and understanding behavior is not the same as changing it. Behavior theories identify why a behavior exists. Behavior change theories explain why and how changes come about, and later guide the development of interventions. Of course, we acknowledge the symbiotic nature of these two types of theories, but we cannot confuse the underlying ideology of each.
Perhaps a stronger call for theory-testing and comparison research from funding bodies and professional journals would prompt the acceptance and impetus for this type of research with the field. Researchers must be supported in order to explore potentially controversial research questions. Noar and Zimmerman (Noar and Zimmerman, 2005) describe in Table II of their manuscript 19 empirical comparisons of health behavior theories. Twelve of those are cross-sectional studies. We agree that it seems unlikely that this is the most appropriate method by which to examine a question with such broad implications. Further, are 3- or 6-month follow-ups sufficient tests of efficacy? We propose that the field would be better served by support for lengthier studies that make a serious attempt at theory comparison research.
It is important to note that the vast majority of theory refinement is undertaken by the originating research team, institution or center [e.g. the addition of perceived behavioral control to the Theory of Reasoned Action (Ajzen, 1985, 1991), and the addition of self-efficacy and decisional balance to the Transtheoretical Model (DiClemente et al., 1985; Velicer et al., 1985)]. This type of approach fosters incubation, but not necessarily collaboration. It was interesting to note from the data provided in Table II—a summary of studies that provided empirical comparisons of health behavior theories (Noar and Zimmerman, 2005)—that none of the authors listed were the originators of the model(s) being tested. Who is in the best position to ensure the fidelity of a theoretically based intervention if not the originators of that same theory? Perhaps we should call upon Drs Bandura, Deci, Fishbein, Prochaska, Schwarzer, Weinstein and others to further efforts in this regard.
For theory comparison to advance, our science must examine the various ways in which we define a successful theory. Depending on our criteria for success, we may find different theories preferable. For example, let us compare five leading health behavior (change) model/theories: Health Belief Model, Theory of Planned Behavior, Transtheoretical Model, Social Cognitive Theory and Self-determination Theory. Would the same theory prevail if we evaluated statistically significant outcomes? Effect size? Parsimony? Clinical meaningfulness? Public health impact? Population or cultural specificity? Is our best theory one that exceeds in each category? Should we select the theory that performs best under certain circumstances or should we seek to merge those theories that are strong in certain areas, but weak in others? As we begin to foster a more multidisciplinary approach to behavior change science, it could be that future advancements will come from outside our current discipline by integrating and expanding our collective bases of knowledge.
The criticism that more theory-based research is being done, but not necessarily adding substantive knowledge, may not be correct. Ours is a relatively young discipline—the seminal theory articles upon which this discussion is based are less than 40 years old. Our field is developing by amassing information that can be further integrated and identifying areas that have not yet been addressed. This is happening to some extent with the recognition of the importance of multilevel models and the impact of the environment [e.g. (McLeroy et al., 1988)]. Potentially the most compelling rationale for simultaneously studying multiple theories may not be to hold experimental horseraces, but rather to empirically integrate salient components of theories in an effort to create a more complete or holistic theory of health behavior change (Nigg et al., 2002).
In our culture of technological expediency, we have come to expect immediacy from every aspect of our personal and professional lives. It is important to remember that the sciences with which we often compare ourselves have progressed over many hundreds of years. While we recognize that we are not operating in similar climate as Galileo, Brahe and others, we believe the field is evolving in the right direction at a pace that change allows.
 |
References |
|---|
 Top References |
|---|
Ajzen, I. (1985). From intentions to actions: a theory of planned behavior. In Kuhl, J. and Beckmann, J. (eds), Action-Control: From Cognition to Behavior. Springer, Heidelberg, pp. 11–39.
Ajzen, I. (1991) The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179–211.[CrossRef][Web of Science]
DiClemente, C.C., Prochaska, J.O. and Gibertini, M. (1985) Self-efficacy and the stages of self-change in smoking. Cognitive Therapy and Research, 9, 181–200.[CrossRef][Web of Science]
Glanz, K. and Rimer, B. (1997) Theory at a Glance: A Guide for Health Promotion Practice. NIH publ. no. 92-3316. National Cancer Institute, Bethesda, MD. Available: http://cancer.gov/cancerinformation/theory-at-a-glance (updated 27 February 2003); accessed: 3 June 2004.
McLeroy, K.R., Bibeau, D., Steckler, A. and Glanz, K. (1988) An ecological perspective on health promotion programs. Health Education Quarterly, 15, 351–377.[Web of Science][Medline]
National Cancer Institute (2004) Advanced training institute on health behavior theory: brief description. Syllabus provided to participants of the ATI, University of California, San Diego, July. Available: http://www.scgcorp.com/ati2004; accessed: 3 June 2004.
Nigg, C.R., Allegrante, J.P. and Ory, M. (2002) Theory-comparison and multiple-behavior research: common themes advancing health behavior research. Health Education Research, 17, 670–679.
Noar, S.M. and Zimmerman, R.S. (2005) Health behavior theory and cumulative knowledge regarding health behaviors: are we moving in the right direction? Health Education Research, 10.1093/her/cyg113.
Velicer, W.F., DiClemente, C.C., Prochaska, J.O. and Brandenburg, N. (1985) Decisional balance measure for assessing and predicting smoking status. Journal of Personality and Social Psychology, 48, 1279–1289.[CrossRef][Web of Science][Medline]
Received on July 14, 2004; accepted on September 8, 2004
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  S. Kobrin, K. L. Hall, and R. T. Croyle Advancing Theory in Cancer Screening and Beyond: A Conversation Across Fields Health Educ Behav, October 1, 2009; 36(5_suppl): 7S - 10S. [PDF]
|
|
|
|
 |
|
 J. R. Sorenson Theory and health behavior: are we making progress? Health Educ. Res., June 1, 2005; 20(3): 274 - 274. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||