Behavior does not occur in a vacuum. A variety of influences—from genetic to social—weighs in on behaviors. These influences create the reasons for behaviors. The accompanying chart lists many influences, but it’s far from comprehensive. The grouping of various influences into categories is subject to rearrangement based on the situation, behavior, or person. Interactions between influences mediate or exacerbate the effect of other influences. For example, the media may enhance a family influence in attitude about sports. The media can introduce a person to particular lifestyles, and then that person’s peer group might encourage an illegal behavior associated with a lifestyle. Different influences have different degrees of influence as well. For example, a strong genetic predisposition to alcoholism may overwhelm a family influence of abstinence from alcohol and a societal message of moderation.
A final mediator of influences on behavior is the level of personal control an individual exercises over that influence. For example, people cannot modify their genetics. However, a person who is genetically predisposed to develop heart disease might actively engage in behaviors that will decrease their risk of heart disease. Another level of control depends on social situation. An adult may decide to improve his or her diet as a result of influences, such as advice from healthcare professionals, educational opportunities, and the availability of a new local market. This person is in a position to modify his or her eating behavior. However, a child in this person’s home has very little control over what the family eats.
Adolescents do have control over many influences in their lives. In some cases, they don’t realize the extent to which they can modify their own behaviors. It’s important for adolescents to be able to
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In this curriculum supplement, students role-play behavioral clinicians in a scenario involving a patient with heart disease. Heart disease is a collection of conditions that limit the flow of blood to the heart muscle itself, including atherosclerosis, angina, and heart attack. Together, heart disease and stroke, which is a loss of blood flow to the brain, comprise the main components of cardiovascular disease (CVD). Over 930,000 people in the United States die annually as a result of cardiovascular disease, and 64 million Americans suffer from cardiovascular disease.7 CVD has traditionally been a disease of older people; however, recently, the incidence of heart disease in younger people has risen.
Heart disease and stroke share several of the same risk factors, many of which are preventable. These are the same factors that contribute to other chronic diseases, such as diabetes, which can complicate treatment and research. The CDC has identified a limited number of behaviors that are often established during adolescence and contribute to chronic diseases Americans face today:
Due to large-scale public education efforts, most people, even adolescents, are aware of the risks unhealthy behaviors pose to their health, yet they continue to engage in these behaviors.
Most people, even adolescents, are aware of the risks unhealthy behaviors pose to their health, yet they continue to engage in these behaviors.
A variety of influences contributes to an individual’s decision to engage in unhealthy behaviors or avoid them. Among these is an individual’s perception of long- and short-term health risks. Behaviors with short-term, or more immediate, health risks may be less appealing than behaviors with long-term risks. For example, while an individual might not refrain from overindulging in alcohol due to long-term consequences, such as addiction or liver disease, he or she might refrain to avoid being ill immediately.
Many people, especially adolescents, believe long-term health consequences can be avoided by a vague plan to change the behavior “later.” These expectations of changing behaviors can be unrealistic since changing behaviors is difficult. For example, 79 percent of smokers relapse after quitting.3
Behavioral and social science research contributes to health care by identifying potential health problems, studying risky behaviors, and evaluating the efficacy of treatments. The influences on the patient’s health-related behaviors are similar to the influences on any behavior. For example, genetics, family and cultural norms, and the media play roles in an individual’s behaviors.
Research in behavioral and social sciences examines healthcare data to determine the trends in health-related behaviors, including the prevalence of unhealthy behaviors and who is at risk. The research examines the influences that play major roles in these behaviors and that can enhance the effectiveness of prevention programs or medical treatments by determining how to reduce negative influences and enhance beneficial ones. This research can help the healthcare industry identify where to concentrate preventive efforts or how to prepare for upcoming health needs.
Epidemiological reports, such as the American Heart Association’s (AHA’s) annual report on CVD, reveal disease trends in the population.1 The AHA report, a statistical analysis of CVD in the United States, provides information on the incidence of CVD, treatments, and at-risk populations. Studies of risk behaviors can identify groups that are more likely to develop CVD. Another report examined the connection between smoking prevalence and levels of education and income.17
Healthcare workers with epidemiological information can target at-risk groups for maximal impact of preventive and early care. For example, a 1999 study showed that men whose parents suffered from CVD developed atherosclerosis at a high rate.27 This was not a surprise, based on genetics; however, the behavioral aspect of the research indicated that stress was a major factor in triggering atherosclerosis in these patients. The behavioral factor was unexpected and can be used to select appropriate preventive treatments for this group of patients.
When patients develop diseases with strong behavioral components, such as cardiovascular disease, behavioral interventions are often recommended in addition to medical treatments. In chronic diseases strongly affected by behavior, changing behavior can help control the disease. Behavioral and social science research has provided many new nondrug interventions for managing chronic diseases, thus preventing the development of new diseases and promoting healthy behaviors.22
Behavioral and social science research has provided many new nondrug interventions for managing chronic diseases.
Interventions address self-efficacy or self-confidence issues, provide problem-solving skills, and promote the development of social support systems. Successful interventions take into account various influences in the patient’s life and involve individual, family, and community organizations in behavioral modification.10
Behavioral intervention is an approach to addressing a behavior that has poor health outcomes and replacing it with a more productive behavior. The primary care provider, such as a physician, nurse midwife, or nurse practitioner, works with the patient to design an initial behavioral intervention plan. First, the patient’s readiness for change may be assessed, as well as the patient’s views on how important the change is and how likely he or she is to succeed. The patient’s medical and behavioral history is reviewed to identify problem behaviors, such as smoking or not exercising. This process involves input by both patient and care provider, and leads to the development of a behavioral modification plan.9 The patient may be referred to behavioral therapists and other healthcare professionals as needed. Follow-up care with the primary care provider is an important part of treating any chronic disease.4
Studying how patients deal with chronic disease is an important component of developing effective medical and behavioral treatments. Hostility, depression, and stress play major roles in the progression of many chronic diseases.12 One important reason for a behavioral intervention approach is that the patient is largely responsible for the day-to-day treatment of chronic illness. This can be an overwhelming task without the proper preparation and support.
Although a patient may be highly motivated to change, many factors are involved in successful behavior change. In addition to learning about healthy and unhealthy behaviors, patients need to learn new skills and new behaviors, such as self-monitoring.26 Other important factors include social support and self-confidence.
Patients who have been diagnosed with chronic diseases react differently to sudden requirements to change lifelong behaviors. Some may succeed in changing their behaviors on their own; many others will be only partially successful or even fail completely. Behavioral and social science research can analyze these outcomes to determine what generates successes and failures, giving healthcare providers more information for successful treatment of their patients.
Approaches to changing behaviors include participating in formal programs or support groups and individualized therapy. Many health maintenance organizations (HMOs) and other healthcare groups provide classes, seminars, and printed materials to encourage healthy behaviors. Private groups offer programs designed to change specific habits, such as how to lose weight or stop smoking. One important aspect of behavioral intervention is having a long-term approach. Realistic goal setting, support from friends and family, and adding healthy behaviors before removing unhealthy behaviors all increase success rates.9, 10 The experience of “going cold turkey” may work for some individuals, but most need to pursue a more gradual approach.
Alternative treatments such as yoga, meditation, acupuncture, and biofeedback may be successful for some patients.14 Behavioral and social sciences research can be translated into effective behavioral interventions and thus complement or enhance the effectiveness of medical treatment of chronic disease.
Behavioral interventions can be provided as informational programs, behavioral and social interventions, or environmental and policy approaches.11 Because the response to behavioral treatments can vary among demographic groups, meta-analysis of programs is a useful tool. In meta-analyses, researchers compare the results of several similar studies or programs. This allows the researchers to draw conclusions about the general applicability of various approaches to determine whether one approach is more effective than another or whether effectiveness depends on the target audience.
Meta-analyses of risk factors and behavioral interventions provide a summary of findings for practitioners. For example, the Guide to Community Preventive Services offers continually updated summaries of a variety of public health interventions.11 Practitioners can look up the behavior of interest, see what programs have been scientifically tested for effectiveness, and determine which might be most appropriate for their community. A recent review examined the effectiveness of media campaigns and summarized the important points for an effective campaign based on a scientific analysis of this type of campaign.23 Meta-analysis ensures that evidence-based methods are available to practitioners, which reduces wasted time, effort, and money.
In addition to studying the effectiveness of programs, specifically whether or not the program resulted in the proposed outcomes, social science also examines feasibility of programs.2 This is particularly important for public health programs, in which a wide audience is targeted with limited funds. Social science research can provide information about which program is most likely to be effective in a particular community. For example, the Guide to Community Preventive Services offers information on effective interventions on a variety of levels, and also provides information about the cost-effectiveness of these programs.11 An affordable program may not be effective, or a very effective program may require high funding levels and, therefore, be impractical. In addition, information about the community to be served, such as local risk factors, community priorities, and local resources, is critical to ensure an appropriate choice for a given community.2
Another important consideration in developing behavioral health programs is cultural sensitivity.13 Effective programs must be culturally accessible, using people, language, and clothing with which the target audience can identify. In addition, a deeper sense of culture that takes into account traditions and history will increase the effectiveness of programs.24 For example, in one study on improving nutrition in a black population, the intervention was based in black churches. The churches proved to be an effective location for intervention efforts for this community.25
Effective programs must be culturally accessible, using people, language, and clothing with which the target audience can identify.
In this curriculum supplement, students are introduced to the complexities of studying behaviors. Learning how to understand behaviors on a scientific level and deriving practical healthcare applications is a complex but effective process. Through playing the roles of professionals, students should become aware that behaviors can be studied and that there is a scientific basis to behavioral intervention. They should also learn about the many influences on behavior and how an individual can modify behavior. Through their increased understanding of behavior, they should come to understand that changing behaviors “later” is not a good plan, or an easy task. In addition, they should become aware of the many factors that increase the likelihood of successful behavior changes. Students should be able to apply these behavioral and social science concepts to their own lives, thus improving their own chances of successfully practicing healthy behaviors.
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