Thursday, July 2, 2009

An Excellent Adherence overview: Does health behavior theory "do" anything?

While looking for something else I came across this World Health Organization publication from 2003. It summarizes adherence literature on a variety of chronic diseases, including HIV/AIDS. One of the addenda has a very good review of Health Behavior theories.

The post title (or here) links to the publication.

A key issue in the overview is whether health behavior theory has been fruitfully applied to actual intervention or support programs for people with chronic diseases. The authors bemoan the relative lack of theory in program design, and the almost complete lack of theory-testing per se., but do conclude that health systems must be more attuned to behavioral theory.

However, from my read it is not clear that current health behavior theory & research is actually good for much other than describing - rather than changing - health behaviors. In the actual trenches social learning theory and simple information + skills provision seems out front; more complex theories of perceived vulnerability, stages of change, attitude models and the like all seem like fluff when thinking about actual health systems in an international context.

One interesting trend I noted in this review and another, very similar recent one is how "cognitive" our HB theories are. Lots of belief formation, attitudes, vulnerability judgments, efficacy expectations, but not much emphasis on motivation (Deci & Ryan are not even cited in these reviews). The strong cognitive bias in HB theories seems to assume that people are already motivated, and just need direction or self-efficacy.

As we keep finding out, when dealing with a public rather than clinical population motivation simply cannot be assumed. This is particularly the case for maintenance rather than initiation of behavior change.

The obvious path is the transition from extrinsic to intrinsic motivation that David F. is addressing in his paper. "How to motivate people" is really the core question: all the attitude and self-perception theories really just dance around this issue.

Self-determination theory is silent on how this happens, although Motivational Interviewing approaches do address it directly. It seems as though Carver's hierarchical perspective on values and goals may be relevant here: everyone (?) is intrinsically motivated to be healthy, but few are intrinsically motivated to actually get on a treadmill. The lower-level, more concrete behaviors that actually contribute to health are often extrinsically motivated, despite intrinsic motivation for the outcome.

The distinction between behaviors and outcomes is similar to what Eric is addressing in his dissertation in terms of high v. low levels of action identification. People must want not just to be healthier, but to actually exercise, eat dark green veggies, etc.

David F's paper, in process, will be addressing the transition from extrinsic to intrinsic motivation, for general and domain-specific self-schema (that is, larger values and actual behaviors). I would like us all to participate in that and make it more of a lab paper so we can collate more of our thoughts on these important topics.

David will send around a draft shortly. Everyone take a look at this overview and put on your thinking caps.