Public Health Behavior Change Theory in Health Education and Promotion
by
Susan J. Curry, Robin J. Mermelstein
  • LAST REVIEWED: 15 June 2015
  • LAST MODIFIED: 22 April 2013
  • DOI: 10.1093/obo/9780199756797-0035

Introduction

The 20th century witnessed an extraordinary shift from infectious to chronic diseases as the leading causes of death. With greater understanding of the etiology of chronic disease, health behaviors have emerged as major contributors to premature morbidity and mortality. Thus, modifying health behaviors has tremendous potential to reduce the human and economic burdens of disease through prevention. Numerous studies have demonstrated that health behavior change including tobacco cessation, dietary modification with modest weight loss, and increased physical activity both prevents disease onset and improves the treatment and management of common diseases such as cardiovascular disease, cancers, and diabetes. Behavior change is complex and is most successful when resources align at the individual, interpersonal, and community levels. Health behavior change theory provides a roadmap to the major factors that influence behavior, articulates the relationships among the various factors, and considers when, where, and how these factors operate. This roadmap is critical for the development and implementation of effective approaches to health behavior change. Health behavior change theory and practice have evolved over time to focus on integrative models that examine the interplay of individual, interpersonal, social, cultural, and environmental factors. The following bibliography offers a collection of resources related to understanding, developing, testing, and applying health behavior theory at these multiple levels. It includes both early classic citations and recent theory formulations and applications. Many of the sources cited can be considered “metaresources,” as their coverage and references will lead the reader to more in-depth pursuit of specific topics.

General Overviews

Schroeder 2007 provides one of the most concise and compelling rationales for the importance of addressing health behaviors. Further detail is provided in Fisher, et al. 2011. The tables in Fisher, et al. 2011 provide detailed summaries of specific behavior–health linkages and of how behavior change interventions prevent disease, improve disease management, and improve quality of life and the overall health of the population. The slim volume Nutbeam, et al. 2010 manages to cover a broad range of theories and their application in less than one hundred pages. Three books provide more comprehensive overviews that can be used as textbooks in advanced and graduate-level courses. Included in Simons-Morton, et al. 2012 is useful coverage of theory-driven multilevel program planning. DiClemente, et al. 2013 covers multidisciplinary theories including behavioral economics, health communication, social marketing, and diffusion of innovations. Glanz, et al. 2008 is a one-stop resource for summaries of major health behavior theories and their application to intervention development and evaluation. The nine cross-cutting propositions outlined in the book’s final chapter are must-read guidance for the development, testing, and use of health behavior theory. In its critical appraisal of health behavior theory, Noar and Zimmerman 2005 argues for providing more consistency in theoretical constructs and highlights the need for more rigorous comparative theory testing.

  • DiClemente, R. J., L. F. Salazar, and R. A. Crosby. 2013. Health behavior theory for public health: Principles, foundations, and applications. Burlington, MA: Jones & Bartlett Learning.

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    Surveys major theoretical perspectives in health behavior theory. Provides an in-depth introduction regarding the importance of health behavior for achieving broad public health goals. Includes chapters that focus on measurement and evaluation of theory-based interventions.

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    • Fisher, E. B., M. L. Fitzgibbon, R. E. Glasgow, et al. 2011. Behavior matters. American Journal of Preventive Medicine 40.5: e15–e30.

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      Outstanding summary of the central role behavior plays in the etiology and management of chronic disease. Persuasive evidence-based documentation of why behavioral approaches need a central place in preventive medicine.

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      • Glanz, K., B. K. Rimer, and K. Viswanath, eds. 2008. Health behavior and health education: Theory, research, and practice. 4th ed. San Francisco: Wiley.

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        Seminal book with comprehensive coverage of health behavior theory. Includes individual, interpersonal, and community models. Also includes coverage of using theory in research and practice, including intervention design and evaluation. An adaptation from the third edition is available online as Theory at a glance: A guide for health promotion practice.

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        • Noar, S. M., and R. S. Zimmerman. 2005. Health behavior theory and cumulative knowledge regarding health behaviors: Are we moving in the right direction? Health Education Research 20.3: 275–290.

          DOI: 10.1093/her/cyg113Save Citation »Export Citation »E-mail Citation »

          Critiques the current direction of health behavior theory research, highlights the need for comparative theory studies, and suggests ways to accelerate the quality and impact of health behavior theory research.

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          • Nutbeam, D., E. Harris, and M. Wise. 2010. Theory in a nutshell: A practical guide to health promotion theories. 3d ed. Sydney, Australia: McGraw-Hill.

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            This brief book explores the main theoretical concepts and models in health promotion. The book covers theories at the individual, community, and organizational level. Focus is on practical application as well as theory, and includes innovations in theory-based approaches to health promotion such as evidence-based policymaking and health impact assessments.

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            • Schroeder, S. A. 2007. We can do better—Improving the health of the American people. New England Journal of Medicine 357:1221–1228.

              DOI: 10.1056/NEJMsa073350Save Citation »Export Citation »E-mail Citation »

              Taken from a Shattuck Lecture, covers the relative contributions of genetic predisposition, environmental exposures, social circumstances, health care, and behavioral patterns in premature death. Provides a cogent summary of the critical importance of addressing health behavior.

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              • Simons-Morton, B., K. R. McLeroy, and M. L. Wendel. 2012. Behavior theory in health promotion practice and research. Burlington, MA: Jones & Bartlett Learning.

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                Surveys major behavior theory with a focus on practical application for the improvement of population health. Each chapter includes clearly defined learning objectives and practical examples.

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                Journals

                There has been a rapid and dramatic expansion in the number of peer-reviewed journals that publish articles relevant to health behavior since the 1990s. Many of these journals are directly focused on health behaviors, such as Health Psychology or Annals of Behavioral Medicine. Other journals are behavior specific, including the Psychology of Addictive Behaviors. Journals covering the broad range of health behaviors tend to reflect the multidisciplinary characteristic of the field and represent disciplines such as psychology (Health Psychology Review), sociology (Journal of Health and Social Behavior), health promotion/public health (Health Education Research and Health Education and Behavior), and medicine (American Journal of Preventive Medicine). The journals highlighted below were selected based on their relative impact in the field of health behavior, their focus on emphasizing the role of theory in understanding and modifying health behaviors, and representation of international researchers in the articles they publish and on their editorial boards.

                Individual-Level Theories

                Early theories of health behavior focused primarily on the thoughts and actions of individuals as key determinants of motivation for and adoption of behavior changes. This section covers three major types of individual-level theories: decision theories, stages of change, and self-determination theory. This section includes articles with comprehensive overviews of the theoretical model, constructs, and measures as well as at least one example of the application of the model to a specific health behavior. Glanz, et al. 2008 (cited under General Overviews) includes chapters on the Health Belief Model, the Theory of Reasoned Action and Theory of Planned Behavior (see Decision Theories), Stages of Change and the Transtheoretical Model, and the Precaution Adoption Process Model (see Stages of Change).

                Decision Theories

                Among the earliest health behavior change theories are models that focused on individual beliefs and expectations as they influence the decision to change. The Health Belief Model originated in the 1950s and has been updated with reference to other emerging paradigms. Rosenstock, et al. 1988 describes an expanded Health Belief Model that includes concepts from Social Cognitive Theory. Champion and Skinner 2008 also provides comprehensive coverage of this theory. Sohl and Moyer 2007 shows the application of the Health Belief Model to interventions designed to increase compliance with mammography screening. The Theory of Reasoned Action and Theory of Planned Behavior are also widely applied to health behavior change. An introduction to each model along with a side-by-side comparison of the theories can be found in Madden, et al. 1992. Montano and Kasprzyk 2008 outlines an integration of the two models. A summary of the early application of the Theory of Reasoned Action to dietary behavior is in Shepherd and Towler 2007. Godin and Kok 1996 reviews studies guided by the Theory of Planned Behavior. The linkages and applicability of both theories remain the focus of some research. Hunt and Gross 2009 tests both models in a population of bariatric surgery patients with regard to physical activity.

                • Champion, V. L., and C. S. Skinner. 2008. The Health Belief Model. In Health behavior and health education: Theory, research, and practice. 4th ed. Edited by K. Glanz, B. K. Rimer, and K. Viswanath, 45–62. San Francisco: Wiley.

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                  Recaps the history of the Health Belief Model, defines core constructs and their measurement, and discusses challenges for future research based on the Health Belief Model.

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                  • Godin, G., and G. Kok. 1996. The theory of planned behavior: A review of its applications to health-related behaviors. American Journal of Health Promotion 11.2: 87–98.

                    DOI: 10.4278/0890-1171-11.2.87Save Citation »Export Citation »E-mail Citation »

                    Reviews fifty-six studies across seven health behavior categories and examines correlations among key constructs from the model with separate focus on behavioral intentions and actual behavior.

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                    • Hunt, H. R., and A. M. Gross. 2009. Prediction of exercise in patients across various stages of bariatric surgery: A comparison of the merits of the Theory of Reasoned Action versus the Theory of Planned Behavior. Behavior Modification 33.6: 795–817.

                      DOI: 10.1177/0145445509348055Save Citation »Export Citation »E-mail Citation »

                      Tests the two theories using multiple surveys conducted with 212 adults undergoing bariatric surgery. Concludes that perceived behavioral control is the most important predictor of exercise behavior.

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                      • Madden, T. J., P. S. Ellen, and I. Ajzen. 1992. A comparison of the theory of planned behavior and the theory of reasoned action. Personality and Social Psychology Bulletin 18.1: 3–9.

                        DOI: 10.1177/0146167292181001Save Citation »Export Citation »E-mail Citation »

                        Articulates differences between the Theory of Reasoned Action and the Theory of Planned Behavior and presents their application to ten behaviors. Argues for the importance of perceived behavioral control as a key construct.

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                        • Montano, D. E., and D. Kasprzyk. 2008. Theory of Reasoned Action, Theory of Planned Behavior, and the integrated behavioral model. In Health behavior and health education: Theory, research, and practice. 4th ed. Edited by K. Glanz, B. K. Rimer, and K. Viswanath, 67–92. San Francisco: Wiley.

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                          Recaps the historical development of the Theory of Reasoned Action and the Theory of Planned Behavior. Proposes an integration of the two theories and applies the integrated model to HIV prevention in Zimbabwe.

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                          • Rosenstock, I. M., V. J. Strecher, and M. H. Becker. 1988. Social learning theory and the Health Belief Model. Health Education and Behavior 15:175–183.

                            DOI: 10.1177/109019818801500203Save Citation »Export Citation »E-mail Citation »

                            Addresses the potential confusion among multiple models of health behavior change and revises the Health Belief Model to incorporate the concept of self-efficacy from social cognitive theory.

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                            • Shepherd, R., and G. Towler. 2007. Nutrition knowledge, attitudes and fat intake: Application of the theory of reasoned action. Journal of Human Nutrition and Dietetics 20:159–169.

                              DOI: 10.1111/j.1365-277X.2007.00776.xSave Citation »Export Citation »E-mail Citation »

                              Originally published in 1992 and reprinted in 2007, provides an example of cross-sectional surveys to test constructs in the Theory of Reasoned Action with specific reference to the associations among knowledge, beliefs, and intentions for dietary intake.

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                              • Sohl, J. S., and A. Moyer. 2007. Tailored interventions to promote mammography screening: A meta-analytic review. Preventive Medicine 45:252–261.

                                DOI: 10.1016/j.ypmed.2007.06.009Save Citation »Export Citation »E-mail Citation »

                                Reviews twenty-eight studies of interventions to promote mammography screening and concludes that interventions based on the Health Belief Model had the strongest effects.

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                                Stages of Change

                                The Stages of Change or Transtheoretical Model is among the most widely used theory of health behavior change. This model focuses on degree of motivation to change (i.e., how ready are individuals to change their behavior) and the cognitive and behavioral processes that individuals use to move through stages of readiness. Prochaska, et al. 1992 provides a detailed overview of the model. A more recent description can be found in Prochaska, et al. 2008. DiNoia and Prochaska 2010 and Garber, et al. 2008 cover the application of the model to dietary modification and physical activity, respectively. The Stages of Change or Transtheoretical Model has been used to develop tailored stage-based interventions. Cahill, et al. 2010 focuses on stage-based interventions for smoking cessation. The Precaution Adoption Process Model, articulated by Weinstein 1988 and Weinstein, et al. 2008 is an example of an alternative Stages of Change Model.

                                • Cahill, K., T. Lancaster, and N. Green. 2010. Stage-based interventions for smoking cessation. Cochrane Database of Systematic Reviews 11:CD004492.

                                  DOI: 10.1002/14651858.CD004492.pub4Save Citation »Export Citation »E-mail Citation »

                                  A recent Cochrane Collaboration review identified forty-one trials that either compared staged versus nonstaged interventions (n = 4) or staged versus no intervention (n = 37). Concludes that stage-based interventions work better than no intervention, but are comparable to non-stage based.

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                                  • DiNoia, J., and J. O. Prochaska. 2010. Dietary stages of change and decisional balance: A meta-analytic review. American Journal of Health Behavior 34.5: 618–632.

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                                    Examines the application of the stages of change to dietary modification with data from twenty-seven studies. Focuses primarily on the decisional balance (pros and cons) construct of the Stages of Change Model.

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                                    • Garber, C. E., J. E. Allsworth, B. H. Marcus, J. Hesser, and K. L. LaPane. 2008. Correlates of the stages of change for physical activity in a population survey. American Journal of Public Health 98.5: 897–904.

                                      DOI: 10.2105/AJPH.2007.123075Save Citation »Export Citation »E-mail Citation »

                                      Examines sociodemographic and health status correlates of stages of change for engaging in physical activity using Behavioral Risk Factor Surveillance System data for the state of Rhode Island.

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                                      • Prochaska, J. O., C. C. DiClemente, and J. C. Norcross. 1992. In search of how people change: Applications to addictive behaviors. American Psychologist 47.9: 1102–1114.

                                        DOI: 10.1037/0003-066X.47.9.1102Save Citation »Export Citation »E-mail Citation »

                                        A comprehensive overview and definitions of stages of change and their accompanying processes with historical perspective on the development of the model.

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                                        • Prochaska, J. O., C. A. Redding, and K. E. Evers. 2008. The Transtheoretical Model and Stages of Change. In Health behavior and health education: Theory, research, and practice. 4th ed. Edited by K. Glanz, B. K. Rimer, and K. Viswanath, 97–117. San Francisco: Wiley.

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                                          Describes and defines the core constructs related to stages and processes of health behavior change. Summarizes recent research applying the model to modifying multiple behaviors within a single intervention.

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                                          • Weinstein, N. D. 1988. The precaution adoption process. Health Psychology 7.4: 355–386.

                                            DOI: 10.1037/0278-6133.7.4.355Save Citation »Export Citation »E-mail Citation »

                                            Presents a new conceptualization of health behavior change in light of a critique of existing health behavior theories.

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                                            • Weinstein, N. D., P. M. Sandman, and S. J. Blalock. 2008. The Precaution Adoption Process Model. In Health behavior and health education: Theory, research, and practice. 4th ed. Edited by K. Glanz, B. K. Rimer, and K. Viswanath, 123–145. San Francisco: Wiley.

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                                              Articulates four underlying assumptions of all stage theories. Summarizes recent research based on the Precaution Adoption Process Model, including tests of matched and mismatched treatments.

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                                              Self-Determination Theories

                                              Deci and Ryan 1985 focuses on “why” individuals are motivated to change their behavior. Williams, et al. 2009 and Silva, et al. 2010 show the application of self-determination theory to tobacco cessation and physical activity and weight control, respectively. Curry, et al. 1991 and Curry, et al. 1997 expand on self-determination as one type of intrinsic motivation and introduce a four-dimensional intrinsic-extrinsic motivation model as originally applied to tobacco use cessation. Satia and Galanko 2007 illustrates the application of intrinsic and extrinsic motivation theory to changing eating behaviors. Although it may not be considered a “formal” self-determination theory, motivational interviewing is a leading paradigm for understanding and intervening for health behavior change. In Miller and Rose 2009, William Miller, the developer of motivational interviewing, proposes an “emergent theory” of motivational interviewing. This is an excellent example of the potential for theory development as a product of a mature intervention paradigm. The wide application of the motivational interviewing model to health behavior includes a number of studies on tobacco use cessation, which are reviewed in Lai, et al. 2010.

                                              • Curry, S. J., L. C. Grothaus, and C. McBride. 1997. Reasons for quitting: Intrinsic and extrinsic motivation in a population-based sample of smokers. Addictive Behaviors 22.6: 727–739.

                                                DOI: 10.1016/S0306-4603(97)00059-2Save Citation »Export Citation »E-mail Citation »

                                                Uses a validated Reasons for Quitting scale to assess the replicability of a four-construct intrinsic-extrinsic motivation model in smokers who have not self-selected for cessation treatment.

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                                                • Curry, S. J., E. H. Wagner, and L. C. Grothaus. 1991. Evaluation of intrinsic and extrinsic motivation interventions with self-help smoking cessation program. Journal of Consulting and Clinical Psychology 59.2: 318–324.

                                                  DOI: 10.1037/0022-006X.59.2.318Save Citation »Export Citation »E-mail Citation »

                                                  One of the earliest studies comparing computer-generated personalized feedback to enhance intrinsic motivation with financial incentives to enhance extrinsic motivation for use in self-help smoking cessation interventions.

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                                                  • Deci, E. L., and R. M. Ryan. 1985. Intrinsic motivation and self-determination in human behavior. New York: Plenum.

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                                                    A seminal book on self-determination with comprehensive coverage of motivational theories. The first part of the book (pp. 3–42) defines core constructs of intrinsic motivation and self-determination.

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                                                    • Lai, D. T. C., K. Cahill, Y. Qin, and J. L. Tang. 2010. Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews 1:CD00693.

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                                                      Meta-analysis based on fourteen studies involving over 10,000 smokers. Concludes that motivational interviewing can be effective when delivered by general practitioners and trained counselors.

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                                                      • Miller, W. R., and G. S. Rose. 2009. Toward a theory of motivational interviewing. American Psychologist 64.6: 527–537.

                                                        DOI: 10.1037/a0016830Save Citation »Export Citation »E-mail Citation »

                                                        Proposes theory of motivational interviewing based on two primary concepts: relational and technical. Theory development includes review of motivational interviewing research in addictive behaviors.

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                                                        • Satia, J. A., and J. A. Galanko. 2007. Intrinsic and extrinsic motivations for healthful dietary change in African Americans. American Journal of Health Behavior 31.6: 643–656.

                                                          DOI: 10.5993/AJHB.31.6.9Save Citation »Export Citation »E-mail Citation »

                                                          Application of the intrinsic-extrinsic motivation model to dietary change with specific focus on African Americans. Supports the applicability of motivationally tailored interventions to this population.

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                                                          • Silva, M. N., P. N. Vieira, S. R. Coutinho, et al. 2010. Using self-determination theory to promote physical activity and weight control: A randomized controlled trial in women. Journal of Behavioral Medicine 3:110–122.

                                                            DOI: 10.1007/s10865-009-9239-ySave Citation »Export Citation »E-mail Citation »

                                                            Tests a year-long weight management intervention with theory-driven components and assesses the impact of the intervention on self-determination constructs as well as weight loss and increased physical activity.

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                                                            • Williams, G. C., C. P. Niemiec, H. Patrick, R. M. Ryan, and E. L. Deci. 2009. The importance of supporting autonomy and perceived competence in facilitating long-term tobacco abstinence. Annals of Behavioral Medicine 37:315–324.

                                                              DOI: 10.1007/s12160-009-9090-ySave Citation »Export Citation »E-mail Citation »

                                                              Randomized-controlled trial with over 1,000 adults evaluating self-determination theory-based intervention and examining change in self-determination constructs as mediators of treatment effects.

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                                                              Interpersonal-Level Theories

                                                              Interpersonal-level theories of health behavior address how the social environment, ranging from more intimate relationships to larger social contexts including neighborhoods and media, may influence the development, maintenance, and change of health behaviors. Although the concept of social influence is core to several theoretical models that have been used both to predict health behaviors and to guide interventions, the conceptualization and measurement of social influence varies by theoretical model and may range from more objective, direct measures of social networks and interactions to more indirect and subjective measures of social perceptions and norms. This section covers three classes of theories: social cognitive theory, social relationships and social support, and stress and coping. Social influence models have also included highly influential theories of social relationships, including social network influences, social integration, and social support. At a more integrative level, theories related to stress and coping bring together constructs of cognitive appraisal of one’s environment and events and resources to cope or address these stressors, often incorporating the buffering effect of social support. The articles in the sections below include both theoretical reviews and specific applications of interpersonal-level theories to predicting and changing health behaviors.

                                                              Social Cognitive Theory

                                                              Bandura’s social cognitive theory, described in Bandura 1986, is the foundation for most interpersonal theories of health behavior and initially proposed that behavior can be influenced simply by observing others’ behavior, particularly others with strong personal attachments. Bandura 2004 provides a comprehensive guide for applying social cognitive theory to health behavior change at the population level. Chassin, et al. 1998 elegantly tests how parental modeling processes may influence children’s adoption of health behaviors (such as smoking), whereas Heatherton and Sargent 2009 provides an excellent example of how even more distal modeling influences, such as through movie figures, play a role in adolescent smoking. Another critical part of social cognitive theory is the concept of self-efficacy. Strecher, et al. 1986 provides an excellent review of the relationship between self-efficacy and several health behaviors, and Haaga and Stewart 1992 brings out the important conceptual issue that self-efficacy expectations that are too high may hinder long-term health behavior change. Elder, et al. 2007 shows how concepts from social cognitive theory inform intervention development, and O’Leary, et al. 2005 presents an example of examining whether changes in mediating constructs specified by social cognitive theory can explain intervention success.

                                                              • Bandura, A. 1986. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.

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                                                                The classic reference for Bandura’s comprehensive theory of human motivation and action addressing the reciprocal causation of cognitive, vicarious, self-reflective, and self-regulatory processes in psychosocial functioning and behaviors.

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                                                                • Bandura, A. 2004. Health promotion by social cognitive means. Health Education and Behavior 31.2: 143–164.

                                                                  DOI: 10.1177/1090198104263660Save Citation »Export Citation »E-mail Citation »

                                                                  A comprehensive discussion of the use of social cognitive theory for population-level health promotion. Provides a cogent description of common constructs across several major health behavior theories.

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                                                                  • Chassin, L., C. C. Presson, M. Todd, J. S. Rose, and S. J. Sherman. 1998. Maternal socialization of adolescent smoking: The intergenerational transmission of parenting and smoking. Developmental Psychology 34:1189–1201.

                                                                    DOI: 10.1037/0012-1649.34.6.1189Save Citation »Export Citation »E-mail Citation »

                                                                    Using a longitudinal, multigenerational design, this study examined whether maternal socialization of adolescent smoking would predict adolescent smoking both directly and indirectly by affecting peer affiliations, and it found strong evidence for the intergenerational transmission, including modeling and adolescents’ reports of parenting behavior.

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                                                                    • Elder, J. P., L. Lytle, J. F. Sallis, et al. 2007. A description of the social-ecological framework used in the trial of activity for adolescent girls (TAAG). Health Education Research 22:155–165.

                                                                      DOI: 10.1093/her/cyl059Save Citation »Export Citation »E-mail Citation »

                                                                      This paper describes the social-ecological framework used in the design of a multisite intervention trial to reduce the decline in physical activity for adolescent girls. The TAAG framework incorporates operant learning theory, social cognitive theory, organizational change theory, and the diffusion of innovation model in a multilevel model. A nice example of theory-based intervention.

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                                                                      • Haaga, D. A., and B. L. Stewart. 1992. Self-efficacy for recovery from a lapse after smoking cessation. Journal of Consulting and Clinical Psychology 60:24–28.

                                                                        DOI: 10.1037/0022-006X.60.1.24Save Citation »Export Citation »E-mail Citation »

                                                                        This study presents evidence that moderately high levels of self-efficacy, in contrast to very high levels of self-efficacy, may be more beneficial for maintaining abstinence, pointing to the potential risk of overconfidence.

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                                                                        • Heatherton, T. F., and J. D. Sargent. 2009. Does watching smoking in movies promote teenage smoking? Current Directions in Psychological Science 18:63–67.

                                                                          DOI: 10.1111/j.1467-8721.2009.01610.xSave Citation »Export Citation »E-mail Citation »

                                                                          Presents strong evidence across several studies that adolescents with high exposure to smoking in movies are more likely to try smoking or become smokers than those with low exposure, and considers possible mediators and moderators of this media social modeling effect.

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                                                                          • O’Leary, A., C. C. Hoff, D. W. Purcell, et al. 2005. What happened in the SUMIT trial? Mediation and behavior change. AIDS 19 (Suppl. 1): S111–S121.

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                                                                            This study examined whether potential social cognitive theory mediators of behavior change in the Seropositive Urban Men’s Intervention Trial (SUMIT) were changed by the intervention. Presents a nice example of whether and how a social cognitive theory–based intervention works.

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                                                                            • Strecher, V. J., B. M. DeVellis, M. H. Becker, and I. M. Rosenstock. 1986. The role of self-efficacy in achieving health behavior change. Health Education Quarterly 13:73–92.

                                                                              DOI: 10.1177/109019818601300108Save Citation »Export Citation »E-mail Citation »

                                                                              This review covers studies of self-efficacy and cigarette smoking, weight control, contraception, alcohol abuse, and exercise, showing strong relationships between self-efficacy and health behavior change and maintenance, as well as suggestions that self-efficacy can be enhanced and can modify health practices.

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                                                                              Social Relationships and Social Support

                                                                              Social relationships can influence an individual’s health behaviors, and the effects of these relationships can be direct or indirect. Within the broad domain of social relationships, several conceptual distinctions are made, notably differentiating the constructs of social networks, social integration, and social support. Cohen 2004 provides an overview of the conceptual distinctions between the different social relationship constructs and how each might relate to health. Cohen 1988 is a classic paper that helps to clarify how different approaches to social support may influence different disease and health behavior parameters. Mermelstein, et al. 1986 examines how both behavior-specific social support for smoking cessation and general social support are related to cessation and maintenance and help to draw the important distinction between the different types and functions of social support across the health behavior change process. Based on correlational data suggesting links between social support and health behaviors, researchers developed interventions to enhance support for specific health behaviors or coping. Helgeson, et al. 2000 examines possible moderators to explain differential effects of social support interventions, and Westmaas, et al. 2010 provides a comprehensive review and model to help explain the discrepancies in the literature surrounding social support interventions. Beyond social support, social networks have also been considered in their links to health behaviors. Christakis and Fowler 2007 and Latkin, et al. 1995 provide excellent examples of the use of social network analysis to describe the spread of health-related behaviors throughout a network. Kobus 2003 provides a comprehensive analysis of several social relationship theories as they relate to adolescent smoking, drawing important distinctions about peer effects.

                                                                              • Christakis, N. A., and J. H. Fowler. 2007. The spread of obesity in a large social network over 32 years. New England Journal of Medicine 357:370–379.

                                                                                DOI: 10.1056/NEJMsa066082Save Citation »Export Citation »E-mail Citation »

                                                                                One of a series of studies using the Framingham Heart Study’s database for social network analysis. Shows that weight gain and obesity patterns over time are linked to social networks. An intriguing analytic approach that has spurred new interest in social network analysis.

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                                                                                • Cohen, S. 1988. Psychosocial models of the role of social support in the etiology of physical disease. Health Psychology 7:269–297.

                                                                                  DOI: 10.1037/0278-6133.7.3.269Save Citation »Export Citation »E-mail Citation »

                                                                                  Focuses on possible mechanisms linking social support to disease with recommendations for conceptual and methodological guidelines for research in this area.

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                                                                                  • Cohen, S. 2004. Social relationships and health. American Psychologist 59:676–684.

                                                                                    DOI: 10.1037/0003-066X.59.8.676Save Citation »Export Citation »E-mail Citation »

                                                                                    Discusses different aspects of social relationships (social support, social integration, and negative interaction) and how each is associated with different health outcomes. Suggests a framework for how to intervene in social networks to improve health, and the importance of understanding who benefits most and least from social connectedness interventions.

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                                                                                    • Helgeson, V. S., S. Cohen, R. Schulz, and J. Yasko. 2000. Group support interventions for women with breast cancer: Who benefits from what? Health Psychology 19:107–114.

                                                                                      DOI: 10.1037/0278-6133.19.2.107Save Citation »Export Citation »E-mail Citation »

                                                                                      Although focused on breast cancer and not specific health behaviors, the empirical approach to addressing the question of examining why social support interventions work for some individuals and not others is important in helping design future support interventions for health behaviors.

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                                                                                      • Kobus, K. 2003. Peers and adolescent smoking. Addiction 98 (Suppl. 1): 37–55.

                                                                                        DOI: 10.1046/j.1360-0443.98.s1.4.xSave Citation »Export Citation »E-mail Citation »

                                                                                        A critical review of both theoretical frameworks and empirical findings about peer influences on teen smoking. Social learning theory, primary socialization theory, social identity theory, and social network theory are discussed. Empirical support for differentiating between peer influence and peer selection is reviewed, as well as consideration of multiple relationships, including best friendships, romantic relationships, peer groups, and social crowds.

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                                                                                        • Latkin, C., W. Mandell, M. Oziemkowska, et al. 1995. Using social network analysis to study patterns of drug use among urban drug users at high risk for HIV/AIDS. Drug and Alcohol Dependence 38:1–9.

                                                                                          DOI: 10.1016/0376-8716(94)01082-VSave Citation »Export Citation »E-mail Citation »

                                                                                          This study examined the structural and relationship characteristics of the social networks of injecting drug users and the relation of social network characteristics to HIV infection risk behaviors (drug injection). A good example of how social networks can help to understand risk behaviors for HIV; the approach can be applied to other health behaviors.

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                                                                                          • Mermelstein, R., S. Cohen, E. Lichtenstein, J. S. Baer, and T. Kamarck. 1986. Social support and smoking cessation and maintenance. Journal of Consulting and Clinical Psychology 54:447–453.

                                                                                            DOI: 10.1037/0022-006X.54.4.447Save Citation »Export Citation »E-mail Citation »

                                                                                            This paper examines how both partner support, specific to smoking cessation, and more general social support, providing buffering against stress, both influence smoking cessation and maintenance. Evidence for both processes is found at different points in the cessation process, and the authors discuss the different processes for the different forms of social support.

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                                                                                            • Westmaas, J. L., J. Bontemps-Jones, and J. E. Bauer. 2010. Social support in smoking cessation: Reconciling theory and evidence. Nicotine and Tobacco Research 12:695–707.

                                                                                              DOI: 10.1093/ntr/ntq077Save Citation »Export Citation »E-mail Citation »

                                                                                              Reviews the empirical evidence for social support (notably partner support) interventions for smoking cessation and describes theoretical models that incorporate social support constructs in predicting success with smoking cessation. Helps to clarify mixed results for social support interventions.

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                                                                                              Stress and Coping

                                                                                              One of the oldest models in the field of health behavior involves the effects of stress on the development, maintenance, and change of health-promoting and health-compromising behaviors. A basic tenet is that stress may lead individuals to engage in deleterious behaviors (such as smoking, drinking, and overeating) as a way to cope with the negative affect arising from stress, and that stress may precipitate relapse following a successful health behavior change. Shiffman and Wills 1985 provides an excellent overview of the conceptual model linking stress, substance use, and coping behaviors. Marlatt and Donovan 2005 presents theoretical overviews, evidence, and intervention implications for preventing relapse, with examples of dynamic stress-coping processes in action across several addictive behaviors. Cohen and Wills 1985 is an impressive discussion of the theoretical foundations and evidence for the stress-buffering effects of social support in health behaviors. Braverman 1999 takes a developmental coping perspective in examining how resilience and coping resources may protect youth, in the face of life stressors, from developing deleterious health behaviors. Cohen and Lichtenstein 1990 and Block, et al. 2009 are good examples of empirical work longitudinally linking perceived stress with changes in two health behaviors, smoking and obesity. Minami, et al. 2011 provides an integrated and sophisticated methodological and analytic approach to examining the real-time dynamic relationships among coping, stress, negative affect, and smoking.

                                                                                              • Block, J. P., Y. He, A. M. Zaslavsky, L. Ding, and J. Z. Ayanian. 2009. Psychosocial stress and change in weight among US adults. American Journal of Epidemiology 170:181–192.

                                                                                                DOI: 10.1093/aje/kwp104Save Citation »Export Citation »E-mail Citation »

                                                                                                This paper analyzed a nationally representative longitudinal cohort of men and women to assess whether multiple domains of psychosocial stress were associated with weight gain. The paper is notable for its broad consideration of domains of stress, examination of sex differences, and implications for prevention of weight gain.

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                                                                                                • Braverman, M. T. 1999. Research on resilience and its implications for tobacco prevention. Nicotine and Tobacco Research 1 (Suppl. 1): S67–S72.

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                                                                                                  This review paper discusses the concept of resilience and protective factors that increase positive developmental outcomes for children who grow up in stressful or high-risk environments, and the implications for tobacco prevention. The paper presents a variety of methodological approaches to studying resilience and coping with tobacco use as one potential outcome variable.

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                                                                                                  • Cohen, S., and E. Lichtenstein. 1990. Perceived stress, quitting smoking, and smoking relapse. Health Psychology 9:466–478.

                                                                                                    DOI: 10.1037/0278-6133.9.4.466Save Citation »Export Citation »E-mail Citation »

                                                                                                    One of the first studies to provide evidence for the relationship between changes in perceived stress level and changes in smoking status; failure to quit was associated with high stress levels, whereas continuous abstinence was associated with decreased stress. The authors discuss the bidirectional nature of the stress-smoking relationship.

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                                                                                                    • Cohen, S., and T. A. Wills. 1985. Stress, social support, and the buffering hypothesis. Psychological Bulletin 98:310–357.

                                                                                                      DOI: 10.1037/0033-2909.98.2.310Save Citation »Export Citation »E-mail Citation »

                                                                                                      This classic paper presents one of the most comprehensive descriptions of the social-support stress-buffering hypothesis along with a review of empirical evidence supporting it.

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                                                                                                      • Marlatt, G. A., and D. Donovan, eds. 2005. Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. 2d ed. New York: Guilford.

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                                                                                                        Marlatt’s relapse prevention framework highlights the importance of coping during high-risk situations, including stress. This edited volume applies the relapse prevention model to a variety of addictive behaviors, addressing both conceptual and treatment issues.

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                                                                                                        • Minami, H., D. McCarthy, D. Jorenby, and T. B. Baker. 2011. An ecological momentary assessment analysis of relations among coping, affect, and smoking during a quit attempt. Addiction 106:641–650.

                                                                                                          DOI: 10.1111/j.1360-0443.2010.03243.xSave Citation »Export Citation »E-mail Citation »

                                                                                                          Example of the assessment of smoking, coping, and affect in near real-time with frequent ecological momentary assessment reports using electronic diaries. Findings about the links between coping and affect and their links to post-quit stress and smoking show the complicated relationships among these variables as well as differences by sex.

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                                                                                                          • Shiffman, S., and T. A. Wills, eds. 1985. Coping and substance use. New York: Academic Press.

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                                                                                                            An edited volume on coping and substance use, this is a comprehensive overview of the stress-coping model, along with several chapters describing both the negative affective links between stress and different substances and how coping resources may moderate use.

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                                                                                                            Community-Level Theories

                                                                                                            Because community environments influence health and health behavior, it is important for theoretical models to include community-level constructs that are amenable to change. This section presents theory-based papers that outline major constructs for understanding and modifying health behaviors at the community level. Although not all papers focus exclusively on health behavior change, they are included as useful examples of theory and research with broad applicability. The complimentary aspects of individual, social, and environmental models for health promotion are highlighted in Stokols 1996. Stokols, et al. 2003 further elaborates on two types of community-level constructs that focus on either social or environmental factors that influence health. Kawachi 1999 and Schulz and Northridge 2004 provide detailed summaries of social determinants of health, including the constructs of social capital and social inequalities. Parker, et al. 2010 provides a specific example of an intervention designed to increase community capacity to reduce environmental exposures that influence childhood asthma. There is increasing attention to the physical layout of communities as important determinants of health. Northridge, et al. 2003 outlines a framework for understanding the connections between the physical environment and health. Sallis and Glanz 2009 elaborates on two aspects of community environments (built environment and access to healthful foods) that influence obesity.

                                                                                                            • Kawachi, I. 1999. Social capital and community effects on population and individual health. Annals of the New York Academy of Sciences 896:120–130.

                                                                                                              DOI: 10.1111/j.1749-6632.1999.tb08110.xSave Citation »Export Citation »E-mail Citation »

                                                                                                              Review of concepts and research relating measures of social capital such as interpersonal trust and community norms of mutual social aid to health. Includes discussion of the relationship of social capital to reductions of high-risk behaviors among youth.

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                                                                                                              • Northridge, M. E., E. D. Scalr, and P. Biswas. 2003. Sorting out the connections between the built environment and health: A conceptual framework for navigating pathways and planning healthy cities. Journal of Urban Health 80.4: 556–568.

                                                                                                                DOI: 10.1093/jurban/jtg064Save Citation »Export Citation »E-mail Citation »

                                                                                                                Outlines multiple pathways for the influence of the built environment on health. Highlights the importance of close collaboration between urban planning and public health. Articulates methodological challenges in conducting research on health and built environment.

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                                                                                                                • Parker, E. A., L. K. Chung, B. A. Israel, A. Reyes, and D. Wilkins. 2010. Community organizing network for environmental health: Using a community health development approach to increase community capacity around reduction of environmental triggers. Journal of Primary Prevention 31:41–58.

                                                                                                                  DOI: 10.1007/s10935-010-0207-7Save Citation »Export Citation »E-mail Citation »

                                                                                                                  Example of qualitative research focusing on strategies and measurements to enhance community capacity related to reducing triggers to childhood asthma.

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                                                                                                                  • Sallis, J. F., and K. Glanz. 2009. Physical activity and food environments: Solutions to the obesity epidemic. The Milbank Quarterly 87.1: 123–154.

                                                                                                                    DOI: 10.1111/j.1468-0009.2009.00550.xSave Citation »Export Citation »E-mail Citation »

                                                                                                                    Provides a synthesis of recent literature reviews on how the food environment (e.g., availability of fresh fruits and vegetables) and the physical environment (e.g., opportunities for safe walking and exercise) influence eating and physical activity.

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                                                                                                                    • Schulz, A., and M. E. Northridge. 2004. Social determinants of health: Implications for environmental health promotion. Health Education and Behavior 31.4: 455–471.

                                                                                                                      DOI: 10.1177/1090198104265598Save Citation »Export Citation »E-mail Citation »

                                                                                                                      Outlines a conceptual framework focused on social processes that influence health and health disparities. Illustrates the applicability of the community-based model to environmental exposures and injuries.

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                                                                                                                      • Stokols, D. 1996. Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion 10.4: 282–298.

                                                                                                                        DOI: 10.4278/0890-1171-10.4.282Save Citation »Export Citation »E-mail Citation »

                                                                                                                        Comparison of three theoretical perspectives on health promotion: behavior change, environmental enhancement, and social ecological models. Includes discussion of future research needs.

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                                                                                                                        • Stokols, D., J. G. Grzwacz, S. McMahan, and K. Phillips. 2003. Increasing the health promotive capacity of human environments. American Journal of Health Promotion 18.1: 4–13.

                                                                                                                          DOI: 10.4278/0890-1171-18.1.4Save Citation »Export Citation »E-mail Citation »

                                                                                                                          Reviews literature and conceptually integrates two community-level frameworks. One framework emphasizes human resources (e.g., social capital); the other emphasizes material resources (e.g., built environment).

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                                                                                                                          Integrative Frameworks

                                                                                                                          Integrative frameworks bring together constructs from individual-, interpersonal-, and community-level models. One of the earliest comprehensive frameworks is Green and Krueter’s Precede-Proceed model, which organizes the multiple factors that contribute to health behaviors into predisposing, reinforcing, and enabling determinants. The model builds from the basic premise that because health behaviors are caused by multiple factors, health behavior change should be approached from multiple levels, as expressed in Green and Kreuter 2005. Most integrative frameworks reference the social ecological model. For example, the title of the most recent edition of Green and Kreuter 2005 includes the phrase “an educational and ecological approach.” This section includes several key references for the social ecological model, including McElroy, et al. 1988 as well as a more recent description in Sallis, et al. 2008. King, et al. 2008 provides an example of the application of an integrative ecological model to a specific health behavior (i.e., physical activity). Systems theory provides an additional integrative perspective as described in Best, et al. 2003 and Mabry, et al. 2008.

                                                                                                                          • Best, A., D. Stokols, L. W. Green, S. Leischow, B. Holmes, and K. Buchholz. 2003. An integrative framework for community partnering to translate theory into effective health promotion strategy. American Journal of Health Promotion 18.2: 168–176.

                                                                                                                            DOI: 10.4278/0890-1171-18.2.168Save Citation »Export Citation »E-mail Citation »

                                                                                                                            Argues for the relevance and utility of system theories to health promotion (and, by extension, health behavior change). Applies system theory approaches to four integrative theories: social-ecological model, life course development theory, Precede-Proceed framework, and community partnering models.

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                                                                                                                            • Green, L. W., and M. W. Kreuter. 2005. Health program planning: An educational and ecological approach. 4th ed. New York: McGraw-Hill.

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                                                                                                                              In its fourth edition, one of the most comprehensive integrative frameworks that can be applied to understanding and intervening with health behaviors. Unique in its focus on identifying the desired endpoint of health outcomes as the starting place for identifying key constructs and potential avenues of intervention.

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                                                                                                                              • King, A. C., W. A. Satariano, J. Marti, and W. Zhu. 2008. Multilevel modeling of walking behavior: Advances in understanding the interactions of people, place and time. Medicine and Science in Sports and Exercise 40 (Suppl.): S584–S593.

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                                                                                                                                Applies the ecological framework to walking behavior and adds the dimension of time to individual, interpersonal, and environmental constructs. Applies sophisticated statistical analyses to theory testing and theory building and outlines future research directions.

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                                                                                                                                • Mabry, P. L., D. H. Olster, G. Morgan, and D. B. Abrams. 2008. Interdisciplinarity and systems science to improve population health: A view from the NIH Office of Behavioral and Social Sciences Research. American Journal of Preventive Medicine 35 (Suppl.): S211–S224.

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                                                                                                                                  Provides a clear description of systems science and theory. Brings the biological sciences perspective into an integrative, systems-theory approach to health and health behavior.

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                                                                                                                                  • McElroy, K. R., D. Bibeau, A. Steckler, and K. Glanz. 1988. An ecological perspective on health promotion programs. Health Education and Behavior 15:351–377.

                                                                                                                                    DOI: 10.1177/109019818801500401Save Citation »Export Citation »E-mail Citation »

                                                                                                                                    An original, defining article that outlined an “ecological model” that considered the interaction of individual-, interpersonal-, and community-level factors.

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                                                                                                                                    • Sallis, J. F., N. Owen, and E. B. Fisher. 2008. Ecological models of health behavior. In Health behavior and health education: Theory, research, and practice. 4th ed. Edited by K. Glanz, B. K. Rimer, and K. Viswanath, 465–486. San Francisco: Wiley.

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                                                                                                                                      Provides a detailed history of various ecological models. Describes recent applications of ecological models to several health behaviors. Also discusses methodological and logistical challenges to applying ecological models.

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                                                                                                                                      Special Populations

                                                                                                                                      Developing theories that are generalizable to diverse populations and that are sensitive to cultural contexts is challenging. Values and cultural orientation often play a role in selection of variables under consideration, and these may vary by socioeconomic status (SES), race and ethnicity, developmental stage of life, gender, or immigration status, among other factors. Theories need to consider whether health behavior in particular social and economic contexts is influenced by cultural norms and processes for given populations, and if so, how. Kline and Huff 2008 addresses multicultural issues for health promotion, including a chapter with specific focus on how current theories and models of behavior change relate to multicultural groups. Larkey and Hecht 2010 presents a conceptual and methodological approach to using narratives as a way to guide the development of culturally tailored interventions, and Resnicow, et al. 2009 is an excellent example of how cultural tailoring may improve intervention effectiveness. Krieger 2003 outlines key issues in addressing race and health and addresses the debate about whether race or socioeconomic status may account for health disparities. Wills, et al. 2007 presents a theoretical model and strong empirical test of how ethnic pride and coping skills relate to health behaviors in an African American population. Hamilton and Mahalik 2009 provides a clear discussion of the construct of minority stress and how that may play a role in health risk behaviors. Matthews, et al. 2010 provides an integrative overview and analysis of psychosocial mediators that may explain the health disparities related to socioeconomic status, and the authors make excellent suggestions for moving research forward in further clarifying these relationships. Frohlich and Potvin 2008 provides an intriguing cautionary note in the development of population-based interventions for health behavior, stressing the need to be sensitive to the multifactorial influences and leverage points for addressing health disparities. In examining the generalizability of theories and health behavior interventions and processes across populations, researchers need to consider conceptual equivalence of constructs across populations as well as measurement equivalence. The references in this section provide a general framework for considering cultural considerations as well as examples of cultural tailoring and testing.

                                                                                                                                      • Frohlich, K. L., and L. Potvin. 2008. The inequality paradox: The population approach and vulnerable populations. American Journal of Public Health 98:216–221.

                                                                                                                                        DOI: 10.2105/AJPH.2007.114777Save Citation »Export Citation »E-mail Citation »

                                                                                                                                        Uses the concept of vulnerable populations to examine how population approach interventions may exacerbate disparities in health, arguing for the need to engage with multiple societal sectors beyond the health sector to address health disparities and to use more participatory research and intervention development approaches.

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                                                                                                                                        • Hamilton, C. J., and J. R. Mahalik. 2009. Minority stress, masculinity, and social norms predicting gay men’s health risk behaviors. Journal of Counseling Psychology 56:132–141.

                                                                                                                                          DOI: 10.1037/a0014440Save Citation »Export Citation »E-mail Citation »

                                                                                                                                          This article addresses minority stress, social norms, and health behavior among men who have sex with men. It describes the minority stress perspective and addresses mechanisms linking minority stress to health behaviors.

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                                                                                                                                          • Kline, M. V., and R. M. Huff. 2008. Health promotion in multicultural populations: A handbook for practitioners and students. 2nd ed. Thousand Oaks, CA: SAGE.

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                                                                                                                                            This edited book addresses health behavior in multicultural populations, with primary focus on the United States. Includes important chapters on health disparities, ethics, and cross-cultural concepts of health and disease. Chapters on African American, American Indian and Alaskan Native, Hispanic/Latino, Asian American, and Pacific Islander populations include specific case studies and practical tips for working with each population.

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                                                                                                                                            • Krieger, N. 2003. Does racism harm health? Did child abuse exist before 1962? On explicit questions, critical science, and current controversies: An ecosocial perspective. American Journal of Public Health 93:194–199.

                                                                                                                                              DOI: 10.2105/AJPH.93.2.194Save Citation »Export Citation »E-mail Citation »

                                                                                                                                              A concise discussion of conceptual and methodological questions in addressing the concept of “race” and health. Addresses controversies about how to study the impact of racism on health and debates about whether racism or class underlies racial/ethnic disparities in health.

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                                                                                                                                              • Larkey, L. K., and M. Hecht. 2010. A model of effects of narrative as culture-centric health promotion. Journal of Health Communication 15:114–135.

                                                                                                                                                DOI: 10.1080/10810730903528017Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                The authors propose a model of culture-centric narratives in health promotion as a means of guiding the development and testing of psychosocial mediators of behavior change in a broad range of health behaviors. The authors suggest that culturally grounded narratives can help to shape health messages for specific audiences. The paper provides a useful framework for thinking about cultural tailoring.

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                                                                                                                                                • Matthews, K., L. C. Gallo, and S. E. Taylor. 2010. Are psychosocial factors mediators of socioeconomic status and health connections? A progress report and blueprint for the future. Annals of the New York Academy of Science 1186:146–173.

                                                                                                                                                  DOI: 10.1111/j.1749-6632.2009.05332.xSave Citation »Export Citation »E-mail Citation »

                                                                                                                                                  Comprehensive summary and critique of psychosocial mediators of the SES-health relationship, including negative emotions, stress, and resources, along with a blueprint for future research to help understand how SES influences health across the lifespan. Available online for purchase or by subscription.

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                                                                                                                                                  • Resnicow, K., R. Davis, N. Zhang, et al. 2009. Tailoring a fruit and vegetable intervention on ethnic identity: Results of a randomized study. Health Psychology 28:394–403.

                                                                                                                                                    DOI: 10.1037/a0015217Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                    This study points out the need to acknowledge the heterogeneity within ethnic groups and to incorporate individual difference variables, such as ethnic identity, into the design and tailoring of interventions for specific populations. The study results suggest that tailoring dietary messages based on ethnic identity within an African American population may improve intervention impact for some African American subgroups.

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                                                                                                                                                    • Wills, T. A., V. M. Murry, G. H. Brody, et al. 2007. Ethnic pride and self-control related to protective and risk factors: Test of the theoretical model for the strong African American families program. Health Psychology 26:50–59.

                                                                                                                                                      DOI: 10.1037/0278-6133.26.1.50Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                      This study tested a theoretical model of how ethnic pride and self-control are related to risk (cigarette smoking, alcohol use, and sexual behavior) and protective factors (behavioral willingness, resistance efficacy, peer behavior). A good example of specifying pathways for examining ethnic factors.

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                                                                                                                                                      Constructs and Measurement

                                                                                                                                                      Health behavior theories contain a variety of constructs. Constructs refer to aspects of individuals or environments that are not directly observable, such as knowledge, emotions, or cultural norms. Clear conceptual definitions and measurement are vital elements in theory specification and testing. Although researchers may use the same words or constructs, operational definitions and measures often differ substantially. It is common to see mixed results for theories because constructs are differentially defined and measured across studies. At the individual level, valid measures of health behaviors such as individuals’ reports of what they eat, how often and what type of exercise they do, or whether they use tobacco are critical. Velicer, et al. 1992 is critical reading for further understanding some of the validity issues in selecting outcome measures for smoking cessation, and Tudor-Locke, et al. 2004 similarly discuss some of the psychometric issues with an objective measure of physical activity. Coverage of dietary assessment can be found in Thompson and Byers 1994. Stone, et al. 2007 discusses an alternative approach to retrospective self-reports of behavior and explanatory variables with its overview of the use of real-time data capture or ecological momentary assessment across a variety of health behaviors and populations. Also at the individual level, Wallston 2001 describes the operationalization of another core construct in health behavior theories, perceived control, along with considerations for its measurement. Two books provide thorough coverage of the key interpersonal constructs of stress and social support. Cohen, et al. 1995 is a comprehensive resource for understanding the conceptual and methodological issues in stress assessment, and similarly, Cohen, et al. 2000 achieves the same thorough presentation of the theoretical and measurement issues surrounding social relationships. Finally, at the community level, Carpiano 2007 covers the measurement of social capital.

                                                                                                                                                      • Carpiano, R. M. 2007. Neighborhood social capital and adult health: An empirical test of a Bourdieu-based model. Health and Place 13:639–655.

                                                                                                                                                        DOI: 10.1016/j.healthplace.2006.09.001Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                        Useful example of the use of population-level data to operationally define community-level constructs of social capital. Includes tables with specific survey items to enable replication of the measures.

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                                                                                                                                                        • Cohen, S., R. C. Kessler, and L. Underwood Gordon, eds. 1995. Measuring stress: A guide for health and social scientists. New York: Oxford Univ. Press.

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                                                                                                                                                          This book provides a comprehensive discussion of the conceptual and methodological issues in studying stress, clarifying differences across types of measures (e.g., life events scales, specific stressor scales, perceived stress), and highlights measures appropriate to specific types of empirical investigations.

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                                                                                                                                                          • Cohen, S., L. Underwood, and B. Gottlieb, eds. 2000. Social support measurement and interventions: A guide for health and social scientists. New York: Oxford Univ. Press.

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                                                                                                                                                            This book provides both a conceptual overview of different measures of social support, social networks, and social integration, as well as issues surrounding their measurement. Several empirically supported scales and measurement approaches to each construct are presented.

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                                                                                                                                                            • Stone, A. A., S. Shiffman, A. Atienza, and L. Nebeling, eds. 2007. The science of real-time data capture: Self-reports in health research. New York: Oxford Univ. Press.

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                                                                                                                                                              This book describes the use of ecological momentary assessments or real-time data capture as an approach to assessing both health behaviors and controlling variables in ecologically valid contexts. Advantages of this approach over traditional, retrospective self-reports of behavior are discussed across a variety of health behaviors.

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                                                                                                                                                              • Thompson, F. E., and T. Byers. 1994. Dietary assessment resource manual. The Journal of Nutrition 124 (Suppl.): 2245s–2317s.

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                                                                                                                                                                Comprehensive overview of the validity, strengths, and weaknesses of several methods of assessing dietary intake, including twenty-four-hour recall, food frequency questionnaires, and brief dietary assessments.

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                                                                                                                                                                • Tudor-Locke, C., J. E. Williams, J. P. Reis, and D. Pluto. 2004. Utility of pedometers for assessing physical activity: Construct validity. Sports Medicine 34:281–291.

                                                                                                                                                                  DOI: 10.2165/00007256-200434050-00001Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                  This article examines the validity of pedometer-assessed physical activity with a systematic literature review of articles examining the construct validity of pedometers in relation to age, anthropometric measures, and fitness and also examining the pattern of correlations across studies. The evidence presented supports the use of pedometers in both research and practice.

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                                                                                                                                                                  • Velicer, W., J. O. Prochaska, J. S. Rossi, and M. G. Snow. 1992. Assessing outcome in smoking cessation studies. Psychological Bulletin 111:23–41.

                                                                                                                                                                    DOI: 10.1037/0033-2909.111.1.23Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                    This paper presents a review of both self-report and biochemical verification measures of smoking cessation, discussing the issues involved in deciding which type of self-report measure to use and whether biochemical verification is necessary. The authors make an important distinction in considering type of study and demand characteristics in deciding upon outcome measures.

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                                                                                                                                                                    • Wallston, K. A. 2001. Conceptualization and operationalization of perceived control. In Handbook of health psychology. Edited by A. Baum, T. A. Revenson, and J. E. Singer, 49–58. Mahwah, NJ: Lawrence Erlbaum.

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                                                                                                                                                                      This chapter provides an excellent overview of conceptual definitions of perceived control, a core construct in several theories linking stress to health, issues in studying perceived control, measurement of the construct, its validity, and considerations for use of the construct in empirical work.

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                                                                                                                                                                      Theory Testing

                                                                                                                                                                      Theory testing is critical for the dynamic nature of theory development and improvement. Testing allows researchers to describe their constructs more clearly, to refine their construct measurements, and to clarify the relationship of constructs to each other. Theory testing is invaluable for the development of more effective interventions and for understanding why interventions may or may not work for given populations. The references in this section describe methodological issues in theory testing (Weinstein 2007) and considerations in examining the theoretical basis of interventions (Michie and Prestwich 2010) and also provide examples of empirical tests of theories (Weinstein 1993). As Noar and Mehrotra 2011 points out, a critical question to address in the field of health behavior change is whether changes in particular theory-based constructs lead to changes in health behavior, yet relatively few studies have appropriate designs to address this question appropriately. Stice, et al. 2010 and O’Leary, et al. 2008 provide an excellent model for testing mediators of intervention effects. Von Korff, et al. 1992 takes theory testing one step further to argue for the need to consider multilevel analyses in both theory development and testing. Considering the importance of testing theory through intervention designs, Bellg, et al. 2004 discusses the importance of monitoring and assuring treatment fidelity in intervention studies.

                                                                                                                                                                      • Bellg, A., B. Borrelli, B. Resnick, et al. 2004. Enhancing treatment fidelity in health behavior change studies: Best practices and recommendations from the NIH Behavior Change Consortium. Health Psychology 23:443–451.

                                                                                                                                                                        DOI: 10.1037/0278-6133.23.5.443Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                        Treatment fidelity is a foundational step in ensuring appropriate testing and application of theory-based interventions. Presents recommendations for best practices for monitoring and enhancing the reliability and validity of behavioral interventions to better evaluate intervention research.

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                                                                                                                                                                        • Michie, S., and A. Prestwich. 2010. Are interventions theory-based? Development of a Theory Coding Scheme. Health Psychology 29:1–8.

                                                                                                                                                                          DOI: 10.1037/a0016939Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                          Describes the development and use of the Theory Coding Scheme, a research tool that can reliably assess the extent to which behavioral interventions are theory based, an important methodological consideration in whether interventions are useful in theory testing or theory development.

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                                                                                                                                                                          • Noar, S. M., and Purnima Mehrotra. 2011. Toward a new methodological paradigm for testing theories of health behavior and health behavior change. Patient Education and Counseling 82:468–474.

                                                                                                                                                                            DOI: 10.1016/j.pec.2010.11.016Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                            Introduces the multi-methodological theory-testing framework for testing health behavior theory to go beyond correlational designs and to consider integration of randomized lab and field experiments, mediation analyses of theory-based interventions, and meta-analyses.

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                                                                                                                                                                            • O’Leary, A., L. S. Jemmott, and J. B. Jemmott. 2008. Mediation analysis of an effective sexual risk-reduction intervention for women: The importance of self-efficacy. Health Psychology 27 (Suppl. 2): S180–S184.

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                                                                                                                                                                              Presents a strong examination of which theory-based factors that were addressed in an intervention to reduce risk for HIV/STD were associated with treatment success. Good description of social cognitive theory mediators and testing.

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                                                                                                                                                                              • Stice, E., P. Rhode, J. R. Seeley, and J. M. Gau. 2010. Testing mediators of intervention effects in randomized controlled trials: An evaluation of three depression prevention programs. Journal of Consulting and Clinical Psychology 78:273–280.

                                                                                                                                                                                DOI: 10.1037/a0018396Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                Provides an excellent model for testing mediators hypothesized to account for the effects of an intervention program. Although addressing depression prevention, the methodological approach is directly applicable to health behavior interventions.

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                                                                                                                                                                                • Von Korff, M., T. Koepsell, S. Curry, and P. Diehr. 1992. Multi-level analysis in epidemiologic research on health behaviors and outcomes. American Journal of Epidemiology 135:1077–1082.

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                                                                                                                                                                                  Presents an overview of multilevel analysis in understanding both the individual and environmental contributions to understanding health behaviors, and argues for the importance of considering multilevel analyses in both theory testing and development.

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                                                                                                                                                                                  • Weinstein, N. 1993. Testing four competing theories of health-protective behavior. Health Psychology 12:324–333.

                                                                                                                                                                                    DOI: 10.1037/0278-6133.12.4.324Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                    Reviews similarities and differences among Health Belief Model, Theory of Reasoned Action, Protection Motivation Theory, and Subjective Expected Utility Theory, as well as the data and analyses needed to compare them. Problems in theory development and testing are discussed.

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                                                                                                                                                                                    • Weinstein, N. 2007. Misleading tests of health behavior theories. Annals of Behavioral Medicine 33:1–10.

                                                                                                                                                                                      DOI: 10.1207/s15324796abm3301_1Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                      Discusses the problems associated with correlational designs for testing cognitively oriented theories of health behavior, noting that these designs often lead to overestimation of the predictive accuracy of these theories. Ideas for alternative testing strategies are presented.

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                                                                                                                                                                                      Theory-based Intervention Development

                                                                                                                                                                                      Theory-based intervention design involves a strategic set of decisions regarding key constructs, target outcomes, and intervention components that influence both constructs and the ultimate behavioral change objective. Practical guides for translating theory into actual interventions are important. Bartholomew, et al. 1998 provides an early description of intervention mapping; Glanz and Bishop 2010 and Bowen, et al. 2009 provide more-recent overviews and examples of theory-based interventions. Guidelines specifically for individual-level intervention development can be found in Curry, et al. 2009. Interpersonal interventions based on theoretical constructs of social support and interpersonal influence are illustrated in Hennrikus, et al. 2010 and Koning, et al. 2011. Translation of the integrative social-ecological model is described in Elder, et al. 2007. Although not explicitly theory based, Navarro, et al. 2007 summarizes recommendations for community-based interventions from a national panel of experts.

                                                                                                                                                                                      • Bartholomew, L. K., G. S. Parcel, and G. Kok. 1998. Intervention mapping: A process for developing theory and evidence-based health education programs. Health Education and Behavior 25.5: 545–563.

                                                                                                                                                                                        DOI: 10.1177/109019819802500502Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                        Outlines a multistep framework that includes explicit focus on when and how to use theory appropriately in the development of health behavior and health promotion interventions.

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                                                                                                                                                                                        • Bowen, D. J., C. Moinpour, B. Thompson, M. R. Andersen, H. A. Meischke, and B. Cochrane. 2009. Creation of a framework for public health intervention. In Handbook of cancer control and behavioral science. Edited by S. M. Miller, D. J. Bowen, R. T. Croyle, and J. Rowland, 43–55. Washington, DC: American Psychological Association.

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                                                                                                                                                                                          Describes a three-step model for developing theory-driven interventions. Includes a table that delineates the inclusion of seven theoretical constructs across a variety of individual- and community-level health behavior theories.

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                                                                                                                                                                                          • Curry, S. J., D. W. Wetter, L. C. Grothaus, J. B. McClure, and S. H. Taplin. 2009. Designing and evaluating individual-level interventions for cancer prevention and control. In Handbook of cancer control and behavioral science. Edited by S. M. Miller, D. J. Bowen, R. T. Croyle, and J. Rowland, 61–84. Washington, DC: American Psychological Association.

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                                                                                                                                                                                            Provides conceptual and methodological guidance for theory-based intervention development and evaluation. Highlights the importance of consistency of theoretical constructs across intervention goals, intervention components, measurement, and data analysis.

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                                                                                                                                                                                            • Elder, J. P., L. Lytle, J. F. Sallis, et al. 2007. A description of the social-ecological framework used in the trial of activity for adolescent girls (TAAG). Health Education Research 22.2: 155–165.

                                                                                                                                                                                              DOI: 10.1093/her/cyl059Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                              Example of use of an integrative theoretical model to design an intervention. Blends constructs from individual, social, and community levels to create intervention goals and components.

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                                                                                                                                                                                              • Glanz, K., and D. P. Bishop. 2010. The role of behavioral science theory in development and implementation of public health interventions. Annual Review of Public Health 31:399–481.

                                                                                                                                                                                                DOI: 10.1146/annurev.publhealth.012809.103604Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                Overview of the state of the science of theory use in public health interventions. Includes an overview of commonly used theories and specific examples of theories applied in large-scale public health interventions.

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                                                                                                                                                                                                • Hennrikus, D., P. Pirie, W. Hellerstedt, H. A. Lando, J. Steele, and C. Dunn. 2010. Increasing support for smoking cessation during pregnancy and postpartum: Results of a randomized controlled pilot study. Preventive Medicine 50:134–137.

                                                                                                                                                                                                  DOI: 10.1016/j.ypmed.2010.01.003Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                  Describes an intervention targeted at helping pregnant women obtain and benefit from social support to quit smoking during pregnancy. Notable for its inclusion of identified supports in the delivery of the intervention.

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                                                                                                                                                                                                  • Koning, I. M., R. J. van den Eijnden, J. E. Verdurmen, R. Engles, and W. A. Vollebergh. 2011. Long-term effects of a parent and student intervention on alcohol use in adolescents: A cluster randomized controlled trial. American Journal of Preventive Medicine 40.5: 541–547.

                                                                                                                                                                                                    DOI: 10.1016/j.amepre.2010.12.030Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                    Developed a parent-directed intervention designed to provide social influence on their children’s alcohol use and compared it to an individual-level intervention based on the Theory of Planned Behavior. Good example of theory-based intervention design and evaluation that crosses individual and interpersonal levels.

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                                                                                                                                                                                                    • Navarro, A. M., K. P. Voetsch, L. C. Liburd, H. W. Giles, and J. L. Collins. 2007. Charting the future of community health promotion: Recommendations from the National Expert Panel on Community Health Promotion. Preventing Chronic Disease: Public Health Research, Practice and Policy 4.3: 1–7.

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                                                                                                                                                                                                      Summarizes eight recommendations for community health promotion from a national panel of experts that include an emphasis on research, surveillance, and community-based participatory research.

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                                                                                                                                                                                                      Evaluation of Theory-based Interventions

                                                                                                                                                                                                      Building an evidence-base of effective, theory-driven interventions requires rigorous evaluation. Typical behavior change interventions include multiple components that can be evaluated collectively or disaggregated in comparison studies. Collins, et al. 2005 describes methods for strategically selecting different intervention components in order to optimize a final intervention strategy. Many individual-level interventions are offered and evaluated in group settings. Pals, et al. 2008 outlines appropriate analytic models for group randomized trials. Because not all interventions are amenable to evaluation in randomized controlled trials, alternative rigorous designs are important. Biglan, et al. 2000 and Hawkins, et al. 2007 describe interrupted time-series and multiple baseline designs. Glasgow, et al. 1999 is included because it provides an important framework for considering the potential population-level impact of a broad range of theory-based interventions.

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