How does health information influence health behavior change?
Jeffery Loo
Abstract
How does health information influence health behavior change?
My literature review explores this question from several research perspectives:
 information behavior and related behavior
 health behavior theory and counseling
 tailored health communication
 interactive technology for health behavior change and communication
Each review section addresses one of the above research topics.
In the end, an analytic framework will be developed. This will be used to conceptualize
the research addressing information, interactive technology and health behavior change.
Table of contents
1. Introduction ................................................................................................................. 3
1.1. Background .......................................................................................................... 3
1.2. Focus .................................................................................................................... 3
1.3. Purpose ................................................................................................................ 3
1.4. Health definitions .................................................................................................. 4
1.4.1. Health ............................................................................................................. 4
1.4.2. Health behavior .............................................................................................. 4
1.4.3. Health education / health promotion ............................................................... 4
1.4.4. Health behavior change ................................................................................. 5
1.5. Health behavior change ........................................................................................ 5
1.5.1. Importance of health behavior change ........................................................... 5
1.5.2. Environments for health behavior change ...................................................... 6
1.6. Perspectives on health ......................................................................................... 6
1.6.1. Rationale for the intrapersonal and interpersonal perspectives ...................... 7
2. Information behavior and related behavior .................................................................. 7
2.1. The ways information may shape our health behavior.......................................... 7
2.1.1. Background .................................................................................................... 7
2.1.2. Cultivating an understanding of health ........................................................... 8
2.1.3. Elucidating choices and options ..................................................................... 8
2.1.4. Shaping emotional issues .............................................................................. 8
2.1.5. Providing social support ................................................................................. 9
2.1.6. Promoting health awareness and self-care .................................................... 9
2.1.7. Activating good health behavior skills............................................................. 9
2.1.8. Motivating good health behavior .................................................................. 10
2.1.9. Empowering the individual ........................................................................... 10
2.1.10. Facilitating behavior change pathways ....................................................... 11
2.1.11. Limitations to the information-behavior link ................................................ 11
2
2.2. Information seeking for health decision making .................................................. 12
2.3. Information use and processing .......................................................................... 13
2.3.1. Effects on health behavior ............................................................................ 13
2.3.2. Understanding information processing ......................................................... 13
2.3.3. As a mechanism for reflective behavior change ........................................... 14
3. Health behavior theory and counseling ..................................................................... 14
3.1. Behavioral counseling interventions ................................................................... 14
3.1.1. Forms of interventions .................................................................................. 14
3.1.2. Expectations ................................................................................................. 15
3.1.3. Models.......................................................................................................... 15
3.2. Health behavior theory........................................................................................ 16
3.2.1. What is the value of theory? ......................................................................... 16
3.2.2. Overview of health behavior theories ........................................................... 17
3.2.3. Individual level theories ................................................................................ 18
3.2.3.1. Health Belief Model................................................................................ 18
3.2.3.2. Stages of Change (Transtheoretical) model .......................................... 19
3.2.3.3. Theory of Planned Behavior / Theory of Reasoned Action .................... 20
3.2.4. Interpersonal level theory: Social cognitive theory ....................................... 21
3.2.5. Community level theory ................................................................................ 22
3.3. Health behavior constructs ................................................................................. 22
4. Tailored health communication ................................................................................. 25
4.1. Definition............................................................................................................. 25
4.2. Example.............................................................................................................. 25
4.3. Value of tailored health communication .............................................................. 25
4.4. Variables for tailoring .......................................................................................... 26
5. Interactive technology for health behavior change and communication .................... 26
5.1. Background ........................................................................................................ 26
5.2. Example applications .......................................................................................... 27
5.2.1. Settings ........................................................................................................ 27
5.2.2. Uses and purposes ...................................................................................... 27
5.3. Value of interactive technology for health behavior change ................................ 28
5.4. Caveats of interactive technology ....................................................................... 29
5.5. Theoretical perspectives on interactive technologies.......................................... 30
5.5.1. Traditional health behavior theories ............................................................. 30
5.5.2. A conceptual framework for interactive technology for health promotion ..... 31
5.5.3. Information environments for health promotion ............................................ 32
6. Conclusion ................................................................................................................ 33
6.1. An analytical framework for information, interactive technology and health
behavior change ........................................................................................................ 33
6.2. Explanation of the framework ............................................................................. 34
6.3. Framework details .............................................................................................. 35
6.4. Further research ................................................................................................. 38
7. References ................................................................................................................ 39
3
1.
Introduction
1.1. Background
Health information is important to our health behavior. Information informs us of our
health choices and facilitates decision making for health actions. For these reasons,
effective information interventions that promote healthy lifestyle choices are an urgent
need (Latimer et al., 2005).
The health behavior impact of information is not explicitly studied in the information
science field. Instead, it is examined by different disciplines who regard information as
a secondary concept (e.g., health psychology, health behavior theory). Furthermore,
the notion of information is rarely examined in health-related studies (Kivits, 2004).
To illustrate the lack of information science research on this topic, consider these
figures. In a keyword search of articles published after 1970 in the Journal of the
American Society for Information Science and the Journal of the American Society for
Information Science and Technology, no articles were returned with the topical keyword
“health behavior”. Similarly, only two results were retrieved in the Journal of the Medical
Library Association and the Bulletin of the Medical Library Association (as searched in
PubMed).
In research that does examine health information, the studies typically center on the
medical power issue. The focus is on the construction and preservation of medical
knowledge by professionals (Turner, 1995 cited in Kivits, 2004). When the patient
perspective is examined, there is the notion of the “informed patient”, which has been
perceived as a challenge to medical authority (Hardey, 1999 cited in Kivits, 2004).
1.2. Focus
This literature review focuses on information, services and technology related to
behavior change at the intra- and interpersonal level.
The review will not explore acute health care situations (such as emergency or critical
incidents); instead it will focus on situations when there is greater personal health
control such as preventative care and self-monitoring/management.
1.3. Purpose
The purposes of this review are:
(1) To outline the ways that information shapes individual discretionary health
behavior change after examining relevant issues to cell phone eHealth;
(2) To develop an analytic framework for examining the research on information and
interactive technology for health behavior change.
4
1.4. Health definitions
1.4.1. Health
The constitution of the World Health Organization (WHO) defines health as "a state of
complete physical, mental and social well-being and not merely the absence of disease
or infirmity" (WHO, 2006).
1.4.2. Health behavior
Health behavior refers to “those personal attributes such as beliefs, expectations,
motives, values, perceptions, and other cognitive elements; personality characteristics,
including affective and emotional states and traits; and overt behavior patterns, actions,
and habits that relate to health maintenance, to health restoration, and to health
improvement” (Gochman, 1982 and Gochman, 1997 cited in Glanz et al., 2002).
Categories of overt health behaviors are outlined in Kasl and Cobb’s seminal articles
(1966a, 1966b cited in Glanz et al., 2002) which include:
 Preventive health behavior: when healthy and asymptomatic individuals engage
in activity to prevent or detect illness
 Illness behavior: when an individual who perceives themselves to be ill engages
in defining the state of their health or finding a remedy (1966a)
 Sick-role behavior: when people who perceive themselves to be ill engage in
activities to improve their health. This includes receiving medical treatments from
healthcare professionals (1966b).
Alonzo (1993) includes a fourth category to examine health behavior at the societal
level. He discusses “the protective behaviors to make environmental transactions safe
from disease, injury, defect and disability”.
1.4.3. Health education / health promotion
Health education and health promotion are terms used interchangeably in the US
(Breckon, Harvey and Lancaster, 1994 cited in Glanz et al., 2002). However, there are
subtle differences between them.
Health education is “any combination of learning experiences designed to facilitate
voluntary adaptations of behavior conducive to health” (Green et al., 1980 in Glanz et al.,
2002). It involves “the process of assisting individuals, acting separately or collectively,
to make informed decisions about matters affecting their personal health and that of
others” (National Task Force on the Preparation and Practice of Health Educators, 1985
cited in Glanz et al., 2002).
On the other hand, health promotion is “any combination of health education and related
organizational, economic, and environmental supports for behavior of individuals,
groups or communities conducive to health” (Green and Kreuter, 1999).
5
1.4.4. Health behavior change
Behavior change refers to any transformation or modification of human behavior
(Wikipedia, 2007).
Skinner and Kreuter (1997) identify types of health behaviors amenable to change:
 Asymptomatic screening, e.g. pap smears, colorectal screening
 Lifestyle modifications, e.g. diet, exercise
 Cessations of addictive behaviors, e.g. alcohol and tobacco use
 Medical regimen compliance, e.g. medication adherence, glucose monitoring
 Precaution adoption, e.g. radon testing, smoke detector installation
1.5. Health behavior change
1.5.1. Importance of health behavior change
Currently in the US and other developed countries, chronic diseases are major causes
of death (National Center for Health Statistics, 2000 cited in Glanz et al., 2002).
Chronic diseases include heart disease, cancer and stroke. In addition, there has been
a resurgence of infectious diseases, such as foodborne illness and STDs – (Glanz and
Yang, 1996).
Human behavioral factors may trigger chronic diseases and may also serve as
predictors of outcome (Glanz et al., 2005). Increasingly, data show a link between
individual behaviors and the increased risk of morbidity and mortality (Glanz et al.,
2005). Among the ten leading causes of death in the US, 50% of these mortalities may
be traced to lifestyle behaviors (McGinnis and Foege, 1993). Behaviors with significant
health impact include tobacco use, diet and activity patterns, alcohol consumption, illicit
drug use, sexual behavior and avoidable injuries (McGinnis and Foege, 1993).
As our behavior has significant impact, health behavior change may be central to
combating chronic diseases. Researchers note the great potential that health behavior
change may have on reducing morbidity and mortality (Koop, 1996 cited in Whitlock et
al., 2002). Behavioral counseling is a key principle for preventive medicine and chronic
diseases management (Ockene and Camic, 1985). In addition, the federal government
endorses healthful behavior in its Healthy People 2010 initiative. This program
recommends behavior changes that include: (1) acquiring new behaviors (e.g., disease
screening, healthier diets), (2) modifying current behaviors (e.g., exercise), and (3)
stopping risky behaviors (e.g., unprotected sex, smoking, excessive drinking)
(Diclemente et al., 2001).
The notion of health behavior change matches the current climate of health care system
procedures. Among health organizations, there is a drive for shared decision making,
the respect for patients’ rights, and cost containment (Glanz et al., 2002). These
measures delegate greater responsibility to the patient, which may emphasize personal
health behavior change and decisions.
6
1.5.2. Environments for health behavior change
Health behavior change may occur in a number of different contexts and environments.
Six major settings for contemporary health education include: schools, communities,
worksites, health care settings, homes and the consumer marketplace (further details in
Glanz et al., 2002). These opportunities are applicable to a large cross section of
people.
1.6. Perspectives on health
An important health promotion paradigm is the ecological perspective of health
(National Cancer Institute, 2005). This model identifies three “levels of influence” in our
health: intrapersonal, interpersonal and community. In a health problem, these levels
interact with one another and are independent.
In order to fully understand health, environmental and behavioral components need to
be addressed together. This perspective asserts that: (1) “behavior both affects, and is
affected by, multiple levels of influence”; and (2) “individual behavior both shapes, and
is shaped by, the social environment (reciprocal causation)” (National Cancer Institute,
2005).
Table 1 outlines the three levels of influence in our health.
Table 1
An ecological perspective of health: levels of influences
excerpted from (National Cancer Institute, 2005)
Concept
Definition
Intrapersonal level
Individual characteristics that influence behavior, such as
knowledge, attitudes, beliefs, and personality traits
Interpersonal level
Interpersonal processes and primary groups, including
family, friends, and peers that provide social identity,
support, and role definition
Community level

Institutional factors
Rules, regulations, policies, and informal structures,
which may constrain or promote recommended
behaviors

Community factors
Social networks and norms, or standards, which exist as
formal or informal among individuals, groups, and
organizations

Public policy
Local, state, and federal policies and laws that regulate
or support healthy actions and practices for disease
prevention, early detection, control, and management
7
The three levels of influence shape and drive our health behavior. Within these levels,
other variables further shape our health and health decisions, such as age, gender, race,
ethnicity and socioeconomic status (Smedley and Syme, 2000).
When delivering social and behavioral health interventions, experts recommend
programs to take account of the levels of health influence (Smedley and Syme, 2000).
Therefore, health promotion may be seen as an instrument of personal, interpersonal
and social change that is mediated by policy, advocacy and organizational changes
(Glanz et al., 2002).
1.6.1. Rationale for the intrapersonal and interpersonal perspectives
This literature review focuses on intra- and interpersonal levels of influence for several
reasons.
First, I am concentrating on this perspective because of my dissertation topic: cell
phone eHealth, where I will be focusing on these two levels of influence.
Second, interactive information and communication technology presents unique
opportunities to study the individual. These technologies may “conduct individualized
behavioral diagnoses and deliver messages […] for a particular program user” and
“target health promotion messages to individual recipients” (Skinner and Kreuter, 1997).
Third, health promotion practice has typically relied on individual and interpersonal level
interventions and theory. In contrast, the community level theories and interventions
have served in changing our health environments (National Cancer Institute, 2005).
While the community level of influence is not addressed in this review, the analysis is
reserved for researchers in sociology, public health, health administration and public
policy who are better suited to the subject.
2.
Information behavior and related behavior
2.1. The ways information may shape our health behavior
This section explores information behavior and related behavior to identify the ways that
information may shape our health behavior.
2.1.1. Background
In health care environments, there is a notion that individuals need to act upon health
promotion information and to be informed. This expectation conveys a link between
information and our health behavior.
Consumer forces may be driving the importance of information for our health behavior.
Eng and Gustafson (Science Panel on Interactive Communication and Health, 1999)
8
have identified an increasing demand for health information and shared decision making.
They note trends in the health landscape such as:
 Recognition of patient preferences in the complex nature of medical decision
making
 Concerns regarding the financial motivations of medical decisions, which leads
some to seek second opinions and independent information
 Rising interests in self-care
 The “aging of America” along with the rise of chronic diseases, which may both
necessitate self-management as an efficient healthcare response
2.1.2. Cultivating an understanding of health
According to the common sense model, information and experiences shape our mental
models and representations of health, as well as our health outcomes (Severtson et al.,
2006). The health information we encounter may drive further information seeking,
cognitive processes and other experiences, which in turn, shape our health behaviors.
A study examined the health behavioral effects of information and experience with
arsenic risk representations, policy beliefs and protective behavior. A quantitative
survey was completed by 545 individuals who used well water with known arsenic levels
exceeding the maximum containment level (Severtson et al., 2006). Through structural
equation modeling, the study found that both external information and experiences (on
perceived water quality and arsenic-related health effects) had substantial effects on
health behavior. Those respondents who understood the problem with water quality
were more likely to engage in activities to reduce arsenic exposure.
2.1.3. Elucidating choices and options
Information may be critical to sound health-related decision making (Rudd and Glanz,
1990). It may elucidate the available health options and assist with the decision
process (see section 2.2. for further details). Quality information is also helpful by
stimulating accurate knowledge development, appropriate lifestyle choices, valuable
health care interactions and compliance with therapeutic advice.
2.1.4. Shaping emotional issues
Our experiences and attentional styles to health information may shape our emotional
state about health.
There are two attentional styles towards health information: (1) monitoring, where the
individual seeks information, and (2) blunting, where information is avoided (Miller, 1987
cited in Wenzel, 2002).
With monitors, information may satisfy certain needs to enhance active coping and
minimize their emotional and physical distress. On the other hand, monitoring may also
lead to excessive worry about health threats (Phipps and Zinn, 1986 cited in Wenzel,
2002). In some cases, these individuals may experience greater physical distress and
arousal during an invasive procedure (Miller and Mangan, 1983 cited in Wenzel, 2002).
9
The manner in which health information is framed may lead to different patient benefits
according to the disposition of the patient. In a study of cervical dysplasia screening
follow-ups, informational monitors experienced greater affective distress when the
health message was “loss framed”, emphasizing the costs rather than the benefits
(Miller et al., 1999 cited in Wenzel, 2002). The monitors experienced a heightened
sense of risk.
2.1.5. Providing social support
Social support is “the aid and assistance exchanged through social relationships and
interpersonal transaction” (Heaney and Israel, 2002). This type of support can be
important for individuals experiencing health conditions.
Of the four types of social support, two of them are related to information provision
(House, 1981 cited in Heaney and Israel, 2002):
 Emotional support: “expressions of empathy, love, trust, and caring”
 Instrumental support: “tangible aid and service”
 Informational support: “advice, suggestions, and information”
 Appraisal support: “information that is useful for self-evaluation” such as
constructive feedback, affirmation and validation
2.1.6. Promoting health awareness and self-care
Nearly half of American online health information seekers (48%) report that web
information has encouraged them to take better care of themselves (Fox et al., 2000
cited in Ybarra and Suman, 2005). Furthermore, nearly two-thirds of Internet users
report an improved understanding of health issues from reading online health resources
(Baker et al., 2003).
2.1.7. Activating good health behavior skills
Health information may encourage beneficial health behaviors.
According to the IMB model for AIDS prevention, information, motivation and behavior
are linked. The key determinants of AIDS preventive behavior include AIDS-prevention
information, motivation and behavioral skills (Fisher et al., 1994).
Preventive behavior results from the activation of behavioral skills. In the instance of
AIDS, these skills include proper use of condoms, communication about sexual history,
and turning away from an unsafe sex situation. According to IMB, three factors activate
the behavioral skills leading to the preventive behavior: (1) knowledge of AIDS
transmission and prevention, (2) the receipt of such information, and (3) motivation to
engage in preventive behavior (as diagrammed in Figure 1).
10
Figure 1 IMB model (Fisher et al., 1994)
Information and motivation are conceived as independent factors.
Fisher et al.’s study (1994) surveyed these three model components among gay males
and heterosexual university students. Structural equation modeling found that
information, motivation and behavioral skills factors accounted for a significant
proportion of the variance in AIDS-preventive behavior (35% for gay men, and 10% for
heterosexual university students).
2.1.8. Motivating good health behavior
Information, such as test results indicating a health condition, may motivate good health
behavior.
From a study of cigarette smokers, the knowledge of a genetic predisposition to
developing emphysema (a genetic AAT deficiency) led to greater efforts in smoking
cessation attempts (Carpenter et al., 2007). The researchers tested smokers for their
AAT genotype, and found that those who tested severely AAT deficient were more likely
to report a 24 hour quit attempt (59%) than those who tested normal (39%). In general,
there is a 34% quit attempt rate among smokers.
2.1.9. Empowering the individual
Information may empower individuals in the health domain. For instance, the availability
and use of online health information suggests of the “informed patient”, who are
perceived as “empowered through information acquisition” (Kivits, 2004). Being
informed could balance the asymmetrical doctor-patient relationship, where physicians
have traditionally yielded greater informational power and access.
One of the six types of power in health educator-client relationships is informational
power (van Ryn and Heaney, 1997 cited in Lewis et al., 2002). Health educators exert
this power when providing access to information which is conveyed in a clear and
persuasive way (Lewis et al., 2002). Accessibility to this information may lead to healthpromoting beliefs and behaviors. While informational power is one component of
behavior change, by itself it is not sufficient.
11
2.1.10. Facilitating behavior change pathways
From tailored health communications research, a behavior change pathway has been
hypothesized (Rimer and Kreuter, 2006) (Figure 2, see further details in section 4. ).
Figure 2 Behavior change pathway (Rimer and Kreuter, 2006)
According to the pathway, “greater perceived relevance and salience increase
motivation to process information and enhance message receptivity, information
processing, and behavior change” (Rimer and Kreuter, 2006).
Therefore, the characteristics and framing of health information may shape the behavior
change pathway.
2.1.11. Limitations to the information-behavior link
While health information is an important component to health behavior change, its
influence alone is not sufficient. For example, a majority of smokers are aware of the
detrimental health effects of their habit, yet they continue to smoke (Thomas and Larsen,
1993 cited in Noell and Glasgow, 1999).
Information is one of many important determinants of health behavior. Other variables
may be more important than information access and use, such as health care access
and structural barriers (Rimer and Kreuter, 2006).
In addition, people who “live” in different information milieus may exhibit different health
knowledge and behavior traits (Ginman and Eriksson-Backa, 2001). Our personal
information preferences and our access to health information affect our health behavior.
The same health message may be processed and used differently according to our
information behavior traits. Veazie and Cai (2007) hypothesize that the manner which
we take in health information is influenced by our sense of uniqueness and our personal
experiences. For example, if people perceive themselves different from the majority,
they may find statistically-based health information less applicable.
An overabundance of health information may impede our ability to process, judge and
make use of it. Bruhn (1988 cited in Alonzo, 1993) suggests that inconsistencies and
conflicts in the evidence base may be a `formidable” barrier to the recognition and
acceptance of accurate health information.
12
Finally, health information may lead to negative health behavior outcomes. While online
health information may motivate some to seek medical attention (Azocar et al., 2003),
concerns arise that increased information access may delay or impede medical care
(Cline and Haynes, 2001). For instance, individuals may rely on the information they
find to self-diagnose, provide self-care or pursue alternative pathways.
2.2. Information seeking for health decision making
Informed decision making is generally desired when medical uncertainty is encountered
(Glanz et al., 2002). Being informed helps to identify and validate the best available
option.
When a patient is informed, shared decision making with health care providers is
possible. Studies suggest that such a cooperative relationship improve health
outcomes and patient satisfaction (Frosch and Kaplan, 1999).
Information seeking is also an important antecedent to patient health-related decisions
and health behavior (Lenz, 1984). Searching for information may lead to important
cognitive and behavioral outcomes toward decision making. In Lenz’s seminal article
(1984), she explores information seeking for health behavior, with a focus on
discretionary health behaviors. These are behaviors that rely on the ability for personal
judgment and decision making.
According to Lenz’s model (1984), the information search process consists of six steps:
“(1) stimulus, (2) goal setting, (3) a decision regarding whether to seek information
actively, (4) search behavior, (5) information acquisition and codification, and (6) a
decision regarding the adequacy of the information acquired”.
Information seeking may affect the “scope and nature of information acquired, the
repertoire of alternative courses of action known to the searcher, and ultimately, the
action taken” (Lenz, 1984). This hypothesis is substantiated by: (1) consumer decision
theory, which values information towards the decision making process, and (2) theories
of health care utilization, which consider information seeking as an intervening variable
between socioeconomic status and the utilization of health services (Lenz, 1984).
The influence of information seeking to health decision-making centers on cognitive and
behavioral search outcomes (Lenz, 1984):
 Cognitive outcomes include: “an information repertoire about possible
alternatives”; and changes in perceptions, opinions, attitudes or beliefs that may
be conducive to healthy behavior.
 The behavioral outcomes center on lifestyle and behavioral changes as the result
of a conscious choice, informed by the information search.
From Lenz’s perspective, different information seeking styles may explain the variation
in health-related decisions and discretionary health behavior. However, a caveat: this
perspective is limited to health behavior due to rational and purposeful decisions. The
relevance of these cognitive and behavioral outcomes was not explored for non-
13
discretionary illnesses and conditions such as developmental disabilities and mental
health conditions.
Further research is necessary to empirically ground Lenz’s postulations and to identify
the mechanism linking information seeking with health behavior.
2.3. Information use and processing
2.3.1. Effects on health behavior
Information use and processing (such as reflection, relating information, comparing
experiences) develop knowledge for preventive and other practices for optimal health
(Rudd and Glanz, 1990). It has been postulated that this knowledge is crucial to health
promotion actions by consumers (Rudd and Glanz, 1990).
Information processing is particularly important during health decision-making and at the
moment when individuals receive health information (Castells, 1993).
2.3.2. Understanding information processing
Theories of Consumer Information Processing (CIP) offer a framework for: (1) the
attention people pay to health information, (2) their understanding of this information,
and (3) the application of it (Rudd and Glanz, 1990).
According to the CIP model, health consumer decision-making is a “multistage process
in which information is acquired and processed (search), a decision is made and acted
upon (choice and purchase), and the quality of the decision is evaluated (use)”. This
process is diagrammed in Figure 3.
14
Figure 3
Consumer Information Processing Model of Choice
(Bettman, 1979 as excerpted in Rudd and Glanz, 1990)
This model is useful for emphasizing information processes that lead to learning for
decision-making and proper health behavior. Health is a complex subject, and this
model recognizes our limits for information processing (e.g., short term memory).
Empirical tests were conducted for the CIP model. It was found to be useful for
explaining the impact of nutrition labeling for food choices and the use of quality of care
information when selecting health care providers (Rudd and Glanz, 1990).
2.3.3. As a mechanism for reflective behavior change
The increased motivation for information processing may lead to behavior change.
Fazio’s MODE model supports this view (Fazio & Towles-Schwen, 1999). MODE is an
acronym for motivation and opportunity as determinants of the path which attitudes
influence behavior. According to the model, when there is personal motivatation and
information processing opportunities exist, people engage in a more thoughtful and
deliberative process of health behavior decision-making (Rimer and Kreuter, 2006).
For example, health information that is relevant and accessible may increase one’s
motivation as well as the opportunities for information processing. This combination
may make ideas more compelling and influence future behavior (Rimer and Kreuter,
2006).
3.
Health behavior theory and counseling
3.1. Behavioral counseling interventions
Behavioral counseling interventions in clinical care are “activities delivered by […]
clinicians and related healthcare staff to assist patients in adopting, changing, or
maintaining behaviors proven to affect health outcomes and health status” (Whitlock et
al., 2002). Typically, these interventions focus on smoking cessation, healthy diet,
regular physical activity, appropriate alcohol use, and contraception use.
3.1.1. Forms of interventions
Interventions take many forms and may involve:
 a set of healthcare team members (e.g., clinicians, nurses, health educators,
pharmacists) (Whitlock et al., 2002)
 different media and communication channels (e.g., telephone counseling
(Fleming et al., 1997), video or computer-assisted interventions (Stevens et al.,
2002), self-help guides (Curry, 2000 cited in Whitlock et al., 2002), and tailored
mailings (Kreuter et al., 1999)
15

multiple interactions between the health professional and patient (Fiore et al.,
2000 cited in Whitlock et al., 2002)
3.1.2. Expectations
Both patient and healthcare professional expect behavioral interventions in the clinicalpatient relationship. In one survey, over 90% of adult HMO members had expectations
for advice and assistance from the healthcare system on key behaviors such as diet,
exercise and substance use (Vogt et al., 1998). In turn, healthcare providers generally
accept and value a role in motivating health promotion and disease prevention (Whitlock
et al., 2002).
3.1.3. Models
An organizational construct for clinical counseling highlights the value of information for
health behavior change. The Five A’s construct has been applied to a number of
behaviors (Ockene et al., 1995). It was adapted by Whitlock et al. (2002) from
constructs developed by the National Cancer Institute for smoking cessation
interventions (Glynn and Manley, 1989 cited in Whitlock et al., 2002). The Five A’s
consists of the following elements:
 Assess for risks and factors influencing behavior change goals and methods
 Advise: provide “clear, specific, and personalized behavior change advice,
including information about personal health harms and benefits”
 Agree: the collaborative selection (with the patient) of goals and methods for
behavior change
 Assist: employ behavior change techniques to help patients reach their goals; the
methods should address the cognitive, social, affective and behavioral domains
of behavior change
 Arrange: provide ongoing assistance, such as follow-up appointments
In this paradigm, information advises patients on the benefits of behavior change. This
motivates and helps patients decide upon appropriate behavior change goals and
methods (as signified by the Advise construct preceding the Agree phase).
PRECEDE/PROCEED is another model for health promotion program planning. It is a
useful framework for identifying and analyzing health behavior determinants and for
implementing behavior change plans accordingly (Green and Kreuter, 1991 cited in
Skinner and Kreuter, 1997). See Figure 4.
16
Figure 4
The PRECEDE-PROCEED Model
(Green and Kreuter, 1999 as excerpted in National Cancer Institute, 2005)
An optimal health promotion program plan would include all phases in the model. Steps
1 through 5 correspond to an assessment phase. The remaining protocol addresses
program implementation and evaluation.
Of note, there are three influencing factors of behavior:
 Predisposing factors that help or hinder the motivation to change (e.g.,
knowledge, attitudes, values and beliefs)
 Enabling factors that support or hinder efforts in behavior change (e.g., skills,
resources and barriers)
 Reinforcing factors that encourage or discourage the continuation of behaviors
(e.g. feedback)
It may be postulated that information shapes factors that predispose, enable and
reinforce behavior change. For example, information may build knowledge and shape
attitudes; information may instruct users on behavioral skills; and health feedback, such
as progress reports or test results, may reinforce new behaviors.
3.2. Health behavior theory
3.2.1. What is the value of theory?
Examining health behavior theory may shed light on the role of information in shaping
and influencing behavior.
Health behavior theory is a good source to examine. Public health researchers and
practitioners encourage theory use for the design and evaluation of health promotion
interventions (National Cancer Institute, 2005). In line with evidence based practice,
theories also serve as useful “road maps” for research and practice. They provide
17
frameworks for understanding health problems; help explain the underlying factors and
dynamics in health behavior; and help identify indicators by which to monitor and
evaluate patient outcomes (National Cancer Institute, 2005).
Theory helps us understand phenomena. It is “a set of concepts, definitions, and
propositions that explain or predict [...] events or situations by illustrating the
relationships between variables” (National Cancer Institute, 2005).
An important element of theory is constructs. These are the key concepts of a theory.
Additionally, there are variables, which define how a construct may be measured, and
thus serve as the operational forms of constructs (National Cancer Institute, 2005).
There are two types of health behavior theories: explanatory and change theory.
Explanatory theory describes why a problem exists. Alternatively, change theory acts
as a guide for developing interventions, serving to identify important concepts for
program delivery and to suggest evaluation methods. This review focuses on
explanatory theories.
In addition, health behavior theories may be differentiated by the level of its examination.
Derived from the ecological perspective of health, there are three echelons of
interacting levels of influences: (1) individual or intrapersonal, (2) intrapersonal, and (3)
community level (National Cancer Institute, 2005). This review focuses on the first two
levels.
Conducting a behavioral diagnosis may identify the best applicable theory to an
individual health situation. Before deploying an intervention, researchers recommend
studying the behavior type and its determinants (Skinner and Kreuter, 1997). This may
suggest a theoretical framework to guide the behavior change program.
3.2.2. Overview of health behavior theories
Prominent health behavior theories are reviewed in this section. The theories are
popular and highly regarded amongst researchers and practitioners in academic and
public health agencies.
Table 2 summarizes the theories that will be explored.
18
Table 2
Six most commonly cited behavior change models/theories and constructs – focus and key concepts
(excerpt from Whitlock et al., 2002)
3.2.3. Individual level theories
These theories examine how knowledge, attitudes, prior experiences and personality
affect health behavioral choices.
3.2.3.1. Health Belief Model
The Health Belief Model (HBM) is one of the most recognized theories in health
behavior. It originated in the 1950’s when American health professionals were trying to
explain why the public were not going to neighborhood screening units for tuberculosis
diagnosis (Hochbaum, 1958; Janz and Becker, 1984; Kirscht and Rosenstock, 1979 –
all cited in Skinner and Kreuter, 1997).
The HBM model focuses on the motivations for making health decisions. Our readiness
to take action with our health behaviors is influenced by six main constructs (National
Cancer Institute, 2005; Skinner and Kreuter, 1997):
1. perceived susceptibility to the health condition
2. perceived severity of the consequences of the health condition
3. perceived benefits that taking action would reduce susceptibility to or severity of
the condition
19
4. perceived barriers, which are the beliefs about the material and psychological
costs relative to the benefits
5. cues to action, which are the exposure factors that prompt action; such as,
experiencing symptoms, witnessing another person's experience, viewing a
television commercial on the subject
6. other variables including demographic variables and self-efficacy, which is the
confidence in one’s ability to take action
Information may help develop the knowledge, attitudes and beliefs that shape our
perceptions of health, which in turn motivate our health actions.
HBM factors are shaped by information in a number of ways. For example (National
Cancer Institute, 2005):
 Risk information may form the perceived susceptibility, severity and benefits of
health actions
 Misinformation or the lack of information may result in perceived barriers.
 Information (such as self-care instructions) and information behavior (such as
searching for health information) may serve as cues to action (Johnson, 1997).
Few health behavior theories have addressed these constructs as cues to action.
3.2.3.2. Stages of Change (Transtheoretical) model
The stages of change (also known as the transtheoretical) model explains our readiness
to change or attempt to change health behavior. It asserts that behavioral modification
is a circular progression through a number of stages. Change is ongoing and
individuals may quit, relapse or start the process again from any stage (National Cancer
Institute, 2005; Skinner and Kreuter, 1997).
The model was developed by Prochaska and DiClemente (1983) for conceptually
understanding the smoking cessation procedure. Since that time, it has been used to
model other health behaviors including: alcohol abstinence, sunscreen use, dietary
change, and contraceptive use (Skinner and Kreuter, 1997).
According to the model, there are five stages in health behavior change (adapted from
Skinner and Kreuter, 1997; National Cancer Institute, 2005):
1. precontemplation, which considers making a change (within the next 6 months)
2. contemplation, which considers taking action in the next 6 months
3. preparation, which the individual intends to make a change, has begun taking
behavioral steps, and expects full action within the next 30 days
4. action, which is the process of changing (within 6 months or less)
5. maintenance, which is maintaining the behavior change after the 6 month mark
Different information needs may be associated for each stage. Also, different types of
information are needed to advance the individual to the next stage (Weinstein, 1988).
In these ways, information helps people maintain or advance in their behavior change
stage.
20
3.2.3.3. Theory of Planned Behavior / Theory of Reasoned Action
The Theory of Planned Behavior (TPB) and the Theory of Reasoned Action (TRA) are
associated theories. They view behavioral intentions (i.e. the intention to act, or the
perceived likelihood to perform a behavior) as the central factors to determining health
behaviors (i.e. the actual performance). With the appropriate intention, we may change
our health behavior. In other words, people do what they want to do.
The theories assume people are rational beings and reasonably process information
when making behavioral decisions.
Figure 5 illustrates the TRA and TRB constructs. Note that TPB includes the construct
of perceived behavioral control, which the TRA excludes from its model.
Constructs
Attitude
toward
behavior
TRA
TPB
Subjective
norms
shapes
drives
Behavioral
intention
Health
behavior
Perceived
behavioral
control
Figure 5 Central constructs of the Theory of Planned Behavior (TPB) and Theory of Reasoned Action
(TRA)
According to the theories, there is a causal link amongst constructs. Beliefs and
attitudes shape behavioral intentions, which in turn drive health behavior.
The constructs are defined as follows (National Cancer Institute, 2005):
 Attitudes are the personal evaluation of the behavior and its outcomes (e.g. good,
bad, neutral).
 Subjective norms are the beliefs about whether engaging in particular behaviors
would gain the approval of key people. Peer pressure is an example.
 Perceived behavioral control is the belief that one has control over a behavior
and an ability to change it.
21
According to the TPB/TRA model, health interventions should address the underlying
beliefs, attitudes and social approval of the health behavior. Focusing on people’s
beliefs and attitudes is important for change, as they influence rational health behavior
choices (Skinner and Kreuter, 1997).
Therefore, information may change the beliefs and attitudes that drive our intention and
efforts at behavior change (Skinner and Kreuter, 1997).
3.2.4. Interpersonal level theory: Social cognitive theory
According to social cognitive theory, personal factors, environmental factors and human
behavior are part of an ongoing and dynamic process.
This theory was developed from social learning theory, which asserts that people learn
by personal experiences and by observing the actions and beneficial results of others
(Bandura (1977), with later work by Baranowski, Perry and Parcel (1996 cited in Skinner
and Kreuter, 1997)).
While social cognitive theory includes many constructs, there are three relevant to
health behavior change. They include:
 Self-efficacy, which is “the beliefs of an individual in his/her ability to take action,
perform a behavior and overcome any barriers” (Skinner and Kreuter, 1997). It is
the perceived ability that matters, not the actual ability.
 Goals
 Outcome expectations, which are the beliefs that a particular behavior will lead to
specific desired outcomes
In social cognitive theory, self-efficacy is the most important factor towards health
behavior change (National Cancer Institute, 2005). With self-efficacy, people believe
they can change their health behavior and persist despite barriers. High self-efficacy is
correlated with initiating new behaviors, maintaining them, exerting greater effort and
persisting longer (Bandura 1977, 1982; Strecher et al., 1986).
Other important factors include: (1) observational learning, which is the acquisition of
new behaviors by watching other people's experiences and outcomes; and (2) positive
reinforcements, such as rewards, or negative reinforcements, such as alarms and
warnings (National Cancer Institute, 2005).
Information may influence self-efficacy for health behavior change. Information may
provide the following (National Cancer Institute, 2005; Skinner and Kreuter, 1997):
 Arguments that a person can change behavior
 Explanation of the value of behavior change
 Reinforcement, such as progress and achievement reports
 Tips, suggestions and advice for making goals seem possible
22
The potential of information to influence self-efficacy has been confirmed in a number of
health behavior change studies. This research has examined behaviors ranging from
dietary control (Baranowski et al., 1993) through to pain control (Lorig et al., 1999).
3.2.5. Community level theory
Community level theories are not explored this literature review. These theories
address changes to the environment that shapes our health behavior. Useful theories
include communication theory, diffusion of innovations and community organization
(National Cancer Institute, 2005).
3.3. Health behavior constructs
There are many more health behavior theories than the select few described in the
previous section.
There are recent research attempts to identify the common theoretical constructs of
health behavior theories (i.e., the key concepts). The Institute of Medicine recommends
advances in the convergence of theoretical views and the identification of the key health
behavior constructs (Institute of Medicine, 2002).
Understanding key health behavior constructs may facilitate the application and
development of theory. To this end, the Division of Cancer Control and Population
Sciences (DCCPS) at the National Cancer Institute have developed a project to define
the major constructs and develop measures for them.
The key constructs are defined below:
Dispositional optimism
Regarding expectations of the future, pessimists expect disaster, while optimists believe
adversity is surmountable. This affects coping and risk behavior (Carver, 2007).
Illness representations
Illness representations comprise of the following notions: identity, timeline,
consequences, cause and control/cure for the condition, as well as the coherence of
thoughts regarding these areas (Diefenbach, 2007). It follows that information have the
potential to shape our illness representations. It has been postulated that our beliefs
and expectations of a health condition determine our appraisals of illness and health
behavior.
Normative beliefs
These are beliefs about the extent which other people who are important to us think we
should or should not perform particular behaviors (Trafimow, 2007).
Optimistic bias
A mistaken belief that one’s chances of a negative experience are lower than that of
their peers – or in the case of positive experiences, a higher chance (Klein, 2007).
23
Perceived benefits
These are beliefs of positive outcomes from health behavior change (Champion, 2007).
Perceived control
“Perceptions that one has the ability, resources or opportunities to get positive
outcomes or avoid negative effects through one’s own actions” (Thompson and
Schlehofer, 2007).
Perceived vulnerability
Beliefs about the likelihood of developing or experiencing a health problem or threat
(Gerrard and Houlihan, 2007).
Social influence
The health influences from the social context including family, peers and community
(e.g. peer pressure) (Willis, Ainette and Walker, 2007).
Social support
This includes perceived support from social networks, supportive actions by others, and
social relationships that obligate support (e.g., marriage) (Lakey, 2007).
Intention, expectation and willingness
Intentions are the “the amount of effort one is willing to exert to attain a goal” (Ajzen,
1991 cited in Gibbons, 2007). It is related to expectations, which addresses the
subjective value assigned to outcomes (Gibbons, 2007).
Worry
This is “a chain of thoughts and images, which are negatively laden and relatively
uncontrollable” (Borkovec et al., 1983 cited in McCaul ad Goetz, 2007).
Self-efficacy
Self-efficacy is “an individual’s level of confidence in his or her own skills and
persistence to accomplish a desired goal” (Abrams et al., 1999). This construct is an
important predictor of future behavior. It has been acknowledged as the most
commonly cited construct in health behavior theory (Whitlock et al., 2002).
Self-efficacy is not concerned with actual abilities, but emphasizes the perception of the
ability. It is also context specific: an individual may experience different levels of selfefficacy from one task or behavior to another (Abrams et al., 1999).
The self-efficacy construct is central to Bandura’s Social Learning Theory (Bandura,
1977; Bandura, 1982). This theory predicts and explains behavior by examining
incentives, outcome expectations and self-efficacy expectations (as detailed in section
3.2.4. ).
Self-efficacy has a strong influence on behaviors by addressing the following (Bandura,
1977 and 1982):
24
1.
2.
3.
4.
acquisition of new behaviors
inhibition of existing behaviors
disinhibition of behaviors
obstacles: the effort, time and persistence expended are positively correlated
with self-efficacy
5. emotions and behavioral patterns such as thoughts and anxiety
Self-efficacy expectations are learned and developed from four major "sources of
efficacy information" (as defined by Strecher et al., 1986):
1. performance accomplishments due to learning and personal experience;
2. vicarious experiences due to observing others' experiences;
3. verbal persuasion, such as encouragement from health professionals for
perseverance; and
4. physiological state of the individual, such as level of anxiety or physical agitation,
which may deter self-efficacy.
Information may therefore influence self-efficacy for health behavior change. Sources
of information relevant to self-efficacy include: documented experiences of others,
suggestions, tips, guidance and instructions. These sources may help people recognize
that behavior change is accomplishable and that there are established methods and
supports available.
In a review of studies, Strecher et al. (1986) found that self-efficacy is important to
number of behavior change conditions, including smoking, weight control, contraceptive
behavior, alcohol abuse and experience.
Summary of health behavior constructs
The health behavior constructs fall into three categories. Each is influenced by
information to a varying degree.
The first category is related to social experiences and forces. These constructs include
intention, expectation and willingness; normative beliefs; social influence; and social
support. In these constructs, social cues and social interactions serve as information
and influence health behavior. This category is best studied by other disciplines such
as sociology or health psychology.
The second category is related to personality issues and affective dispositions. This
includes dispositional optimism, optimistic bias and worry. These constructs may be
irrational or involuntary in nature, and are not necessarily influenced by information.
The third category is related to beliefs and understanding that may be shaped by
learning and information use and processing. This includes illness representations,
perceived benefits, perceive control, perceived vulnerability and self-efficacy.
There is a need to explore how information influences these constructs and drives
health behavior.
25
4.
Tailored health communication
4.1. Definition
Tailored health communication is an individualized approach for responding to the
information and communication needs of patients. According to Kreuter and Skinner
(2000), tailoring imparts information to suit the individual’s needs and characteristics.
Rimer and Kreuter`s definition (2006) includes an “assessment-based approach in
which data from or about a specific individual and related to a given health outcome are
used to determine the most appropriate information or strategies to meet the person’s
unique needs”.
4.2. Example
Smoking cessation self-help guides are a prime example of tailored health
communication. These educational materials have addressed different population
segments according to demographic and behavioral variables. Rimer and Kreuter
(2006) identified seminal projects that tailored smoking cessation guides to audience
segments such as blue-collar smokers, African-Americans, older smokers, pregnant
women and women with young children.
4.3. Value of tailored health communication
Tailoring emerged from an increasing market demand for the customization of
information. Several trends have motivated this demand: the increasing demand for
customization (i.e. consumer-driven services ); the increasing use of the
Transtheoretical Model for health education, which asserts that individuals belong to
varying stages of “readiness” for adopting or modifying health behaviors; and the
technological capability of generating customized and personalized communications
(Rimer and Kretuer 2006).
Tailored health communications exhibit positive outcomes, benefits and preferences in
a number of ways:
 Patients prefer tailored health communications and find it effective for delivery of
consumer health information (Jimison, Fagan et al., 1992)
 It is proposed that salient health information facilitates attention and thorough
information processing, which enhances the impact (Cacioppo and Petty, 1984
cited in Latimer et al., 2005)
 From research on the media and content characteristics of breast cancer
education programs, informational content has the strongest effect on knowledge
acquisition and self-reported involvement, while differences in media types
exhibit little evidence of differentiation (Street and Manning, 1997).
 Messages tailored to health information processing styles were more persuasive
in promoting screening mammography and fruit and vegetable consumption
(Latimer et al., 2005)
 Tailored messages may enhance motivation for information processing in four
ways: (1) matching content to information needs and interests; (2) providing
meaningful context; (3) capturing attention with design and production elements;
26

and (4) matching individual preferences for the amount, type and channel of
information delivery (Rimer and Kreuter, 2006)
Using computers for tailored health communications may approximate the
advantages of face-to-face tailored communications in terms of encouragement
and message relevance enhancement (Skinner et al., 1993)
Other health behavior change determinants may be more important than information.
For example, structural barriers and limited access to health care, which information
delivery may not necessarily ameliorate (Rimer and Kretuer, 2006).
4.4. Variables for tailoring
Health information may be tailored along the following variables:
 Audience segments by socio-demographic characteristics, ethnic or racial
background, life cycle stage and disease or at-risk status (Glanz et al., 2002).
 Psychological and emotional constructs such as the need for cognition, coping
styles, health locus of control (the personal attribution of responsibility for one's
own health), and regulatory focus (the motivational system pertaining to health
promotion and disease prevention) (Latimer et al., 2005).
 Stage of readiness for behavior change along the stages of Transtheoretical
theory (see section 3.2.3.2. ) (Rimer and Kreuter, 2006).
 Skills and behaviors such as reading level, learning ability and styles, selfmonitoring capability and preventative skills (Rimer and Kreuter, 2006).
5. Interactive technology for health behavior change and
communication
5.1. Background
This section examines health behavior change communication via interactive
information and computer technology.
Interactive technology refers to “computer-based media that enable users to access
information and services of interest, control how the information is presented and
respond to information and messages in the mediated environment (e.g., answer
questions, send a message, take action in a game, receive feedback or a response to
previous actions)” (Street and Rimal, 1997).
Two important capabilities of interactive technology are: (1) responsiveness, which is
addressing the user's previous actions and (2) user control, which permits users to
modify the mediated environment (Street and Rimal, 1997). Interactive technology
typically consists of modular components linked into a unified service (e.g., combining
image, animation, voice, text, etc.).
27
5.2. Example applications
5.2.1. Settings
Interactive technology for health behavior change may exist in a variety of settings. Its
versatility may complement or enhance traditional health behavior change interventions.
To name a few, online environments may deliver support group meetings,
communication with health care providers, and journaling.
For health behavior change, there are two important domains for interactive technology:
ubiquitous computing and just-in-time technology.
With ubiquitous computing, information processing extends beyond the desktop
computer to everyday objects and activities (e.g., checking email on your cell phone). It
extends the human-computer interface and automatically “determine[s] where and when
to [best] present messages to motivate healthy behaviors” (Intille, 2004). For example,
preventive health action messages may be presented upon detection of a crisis or a
decline in health. This has been deployed for seat belt use and increasing physical
activity (Intille, 2004).
Just-in-time technology facilitates information processing when print and traditional
resources are not conveniently accessible. For example, Intille et al. (2003) describe
the use of handheld computers to review and compare the nutritional value of foods and
alternatives. This device includes a scanner for reading food barcodes and provides
additional convenience.
5.2.2. Uses and purposes
Interactive technology may be used in all behavior change counseling steps of the 5A
framework (assess, advise, agree, assist, arrange follow-up) (Glasgow et al., 2004).
For example, Internet forms for patient assessment, follow-up information electronically
delivered in a tailored manner, automatic patient reminders, and online forums and
support groups for social support. More research projects are detailed by Glasgow et al.
(2004).
Interactive technology could be used for health behavior change in three ways (Street
and Rimal, 1997):
 Provide an information environment for health learning. An information
environment is the presence of media to permit active exploration of information.
Interactive technology may promote active learning, information seeking, and
individualized knowledge when users may select information to their interest and
retrieve different information media (e.g. videos, text, statistics) along personal
directed paths (Dede and Fontana, 1995; Kahn, 1993 cited in Street and Rimal,
1997).
 Provide simulation environments for problem-solving and health skills
development. For example, virtual reality video games may mimic everyday
health choices and dilemmas, such as building a virtual breakfast where
nutritional value and health outcomes may be taught (Street and Rimal, 1997).
28

Simulation environments may also increase self-efficacy by cultivating personal
experiences, emphasizing individual responsibility and promoting knowledge and
skills development (Dede and Fontana, 1995).
Provide access to a network of people and resources. This includes social and
informational support for decision making and behavior change (Street and Rimal,
1997).
Other uses and purposes of interactive technology are highlighted below:
 Provide “expert” behavioral advice that is responsive to user input and needs
(Velicer and Prochaska, 1999; Ramelson et al., 1999; Paperny and Hedberg,
1999). This function may address screening, education and counseling needs.
 Gather patient data and provide personalized feedback through automated or
online communications (Dirkin, 1994).
 Virtual environments may reduce the inhibitions or perceived risks in discussing
sensitive health issues (relative to face-to-face encounters) (Owen et al., 2002).
 Computer-based telephone programs are used for real-time patient data
collection and feedback. Patients respond via touch tone or voice recognition.
Communication is at the convenience of the user and is verbal, which is
important for low literacy. An important factor is timeliness, receiving interactive
health information whenever the individual experiences a health situation. Such
technology has been found to promote health behavior change (McBride and
Rimer, 1999; Soet and Basch, 1997).
 The Internet may integrate health education, self-monitoring and social support
through systems that collect data, provide guidance and offer avenues for online
social support (Owen et al., 2002).
 Additional functions of interactive technology for health communication include:
relay information, enable informed decision-making, promote healthy behaviors,
promote peer information exchange and emotional support, promote self-care
and help manage demand for health services (e.g., serving as an automated
triage system for health professionals) (these functions were identified in a
review by the Science Panel on Interactive Communication and Health (1999)).
Currently, interactive technologies are deployed across different media types and health
applications. From a ten year retrospective review of new technologies for health
communication, various programs have been identified for stand-alone computer-based
communication (e.g. CD-Roms), web-based communication, telephone-based
communication, and computer-based tailoring technology (e.g. programs that provide
information according to a patient needs assessment) (Suggs, 2006).
5.3. Value of interactive technology for health behavior change
Interactive technology is well regarded by health professionals. According to
publications in medical journals and the popular press, professionals are enthusiastic
about interactive technology for health promotion (Booker, 1996; Jelovsek and
Adebonjo, 1993; Kahn, 1993 – all cited in Street and Manning, 1997; Gysels and
Higginson, 2007; Sidorov, 2006).
29
Such technologies are regarded as “fun, engaging, novel and used in accordance with
individual needs and interests” (Street and Manning, 1997). However, there is little
research on the technology's promise from a user's perspective. Perhaps, the health
providers' enthusiasm is influenced by perceived potentials in cost efficiency and time
savings (Street and Manning, 1997).
For health promotion, the positive impacts of interactive technology include (Science
Panel on Interactive Communication and Health, 1999):
 patient satisfaction
 good patient-provider relationships (e.g., tailored information systems may
engage users for shared decision-making and health behavior change),
 improved communication
 encouragement of honest self-reports. For instance, individuals may provide
more honest personal histories when solicited by computers (Erdman et al.,
1985). Blood donors were more likely to report HIV-related risks to a computer
than to a health care worker (Locke et al., 1992).
 Reduction of unnecessary services, since health education and self-care may
decrease the number of unnecessary health care visits (Fries and McShane,
1998)
Interactive technology, such as the Internet, is a valuable source of social support. For
example, email, web pages for societies, online forums, social groups, chat, video
phone and more. Social support may lead to better health outcomes (Mookadam and
Arthur, 2004; Fratiglioni et al., 2004).
The Internet is a unique social outlet. Active users may learn new information in
addition to creating and disseminating new information (e.g. providing anecdotal
experiences, instructions). In this way, online users support and encourage others to
become their own health communicators (Science Panel on Interactive Communication
and Health, 1999).
Interactive technology for health behavior change may lead to positive health outcomes.
For example:
 A tailored interactive multimedia program to encourage diet improvements
exhibited a statistically significant improvement in positive eating habits (Irvine et
al., 2004).
 In a systematic review of randomized controlled trials for interactive computerassisted technology in diabetes self-care, patients exhibited improved health care
utilization, behaviors, attitudes, knowledge, and skills (Jackson et al., 2006).
5.4. Caveats of interactive technology
There are many calls for further research on interactive technology for health behavior
change. Priorities include effectiveness, user experiences and the influence of
information processing on health beliefs, attitudes and behaviors (Street and Manning,
1997).
30
There is a lack of convincing effectiveness data (Science Panel on Interactive
Communication and Health, 1999). Methodologically, few clinical outcomes
measurements have been defined to quantify the technology's efficacy (Jackson et al.,
2006). Furthermore, the underlying mechanism for the success of this technology is
poorly understood (National Cancer Institute, 2005). Practitioners are advised to
carefully identify the costs and limitations of interactive technology while the evidence
base is limited (Glanz, 2002).
Only a few studies demonstrate that interactive technology is more effective than
traditional methods for health promotion (Street and Rimal, 1997). In some cases, the
two methods show little difference. For instance, Internet weight loss programs. In a
randomized controlled trial, individuals attending in-person weight control meetings
were no more effective in the long term than those who supplemented their meetings
with an Internet weight loss treatment (Micco et al., 2007).
Other studies found a negative impact on health behavior change. New interactive
technologies may be detrimental when they promote inappropriate self-care or interfere
with the patient-provider relationship (Science Panel on Interactive Communication and
Health, 1999). Inappropriate information may mislead patients to poor medical
treatment or delay their pursuit of appropriate health care (Weisbord et al., 1997). The
provider-patient relationship may be jeopardized when poor quality consumer
information is used to guide health decision-making (e.g. questionable information found
on the Internet). This may lead to unnecessary conflicts and confrontations with the
doctor (Bero and Jadad, 1997) or “second guessing” (Keoun, 1996).
5.5. Theoretical perspectives on interactive technologies
5.5.1. Traditional health behavior theories
Researchers encourage established health behavior theories in the development of
interactive health technologies (Skinner and Kreuter, 1997).
These theories are helpful in a number of ways: (1) they cultivate an understanding of
the target behavior and its determinants; (2) they suggest methods for behavior change;
and (3) they help identify technical features useful for behavior change.
For example, interactive technologies may be used to:
 change perceptions, in accordance to the Health Belief Model
 provide opportunities for skills development, in accordance to the Social
Cognitive Theory,
 determine individual readiness for behavior change and deliver relevant
information, in accordance to the Transtheoretical model (Skinner and Kreuter,
1997).
31
5.5.2. A conceptual framework for interactive technology for health
promotion
Street and Rimal (1997) have proposed an “organizing and heuristic framework” for
interactive media environments in health promotion. This framework identifies the
variables and processes helpful for understanding use and effectiveness. Figure 6
outlines three overlapping stages in a cyclical model of interactive technology use.
Figure 6
A three stage model of health promotion using interactive technology
(excerpt from Street and Rimal, 1997)
Stage 1 examines the implementation and utilization of interactive technology, focusing
on the interactions among health care institutions, users and technology. The factors
involved include: (1) service deployment issues; (2) technical features that encourage
user adoption; and (3) attitudes and experiences that encourage utilization.
Stage 2 examines technology effectiveness through the concept of a user-mediamessage interaction (Street and Rimal, 1997). It conceptualizes users receiving and
processing health messages (e.g. engagement, attention, integration of information with
existing knowledge), which then brings about desired experiences and results (e.g.
learning, motivation, enjoyment, problem-solving, reassurance). The user-mediamessage interaction also examines user characteristics (e.g. demographics, health
condition, personality, etc.) and message characteristics (e.g., content, credibility, level
of evidence, etc.).
32
Intermediate outcomes are an important component of the use-media-message
interaction. Interactive technology may lead to different intermediary outcomes, which
in turn bring about the desired health outcomes. Many of the intermediate outcomes
are not physical and objective health measures: many are constructs from health
behavior theories that are relevant to the behavior change process.
Stage 3 explores health outcomes. Interactive technology use may lead to the health
outcomes by providing patients with support in a number of ways: informational,
emotional, procedural, cognitive, etc. The model acknowledges that technology is only
one contributing factor towards health outcomes. There are also psychosocial factors
that are exclusive of technology, such as financial constraints or cultural barriers.
From a methodological standpoint, there are three domains for research analysis:
 Stage 1: the reasons an interactive technology is provided and adopted
 Stage 2: what occurs when an individual uses a technology, from receiving the
health message through to intermediate and final outcomes
 Stage 3: the eventual health outcomes attributable to the technology
The first two domains are relevant to information science research, while the remaining
question may be best addressed by health professionals.
5.5.3. Information environments for health promotion
Information environments are a metaphorical environment. It is the computer
atmosphere where the user explores and experiences information (Street and Manning,
1997). Information environments typically involve multiple media formats (e.g., text,
music, graphics, video) and include an interactive element, which provides a sense of
activity or “following a path”.
Figure 7 models health promotion with information environments. User involvement in
message processing leads to educational outcomes, which bring about desired health
outcomes. The level of involvement depends on the characteristics of the message, its
mediated delivery, and the user characteristics.
The model acknowledges barriers to desired health behavior changes, including:
personal, social, cultural and economic factors.
33
Figure 7
A model of health promotion using information environments
(excerpt from Street and Manning, 1997)
According to the information environments model, interactive technologies create
information environments where users may explore, learn and develop skills for health
behavior change.
6.
Conclusion
6.1. An analytical framework for information, interactive technology
and health behavior change
To conclude this literature review, an analytical framework is developed. The purpose
of this framework is to guide future examination of the question: how do information and
interactive technology influence health behavior change at the intra- and interpersonal
levels? This framework summarizes the main research concepts identified in this
review, and is not meant to be comprehensive.
34
Information
(1)
Other
factors (8)
Actions
(4)
Information
environment
(3)
Intermediate
outcomes (6)
Health
behavior
change /
outcomes
(7)
Actions
(5)
Interactive
technology
(2)
Perspectives for
examination (9)
Figure 8
Analytical framework for how information and interactive technology influences health behavior change at
the intrapersonal and interpersonal level
6.2. Explanation of the framework






Information (item #1) and interactive technology (2) cultivate an information
environment (3).
Information drives particular actions (4) that lead to intermediate health outcomes
(6).
Similarly, interactive technology drives particular actions (5) that lead to
intermediate health outcomes (6).
Intermediate outcomes lead to health behavior change and eventual health
outcomes (7).
Other factors unrelated to information (8) also influence health behavior change
and health outcomes.
When examining these constructs, different research perspectives and foci (9)
may be utilized.
35
6.3. Framework details
Details and issues for each construct of the framework are detailed below.
Information (item # 1)
 The definition of information is varied and encompasses the following: advice,
suggestions, feedback, instructions, knowledge, documented experiences of
others, social cues and comparison, external experiences, messages,
observations, test results, knowledge, mental models and representations
 Descriptive characteristics of information: how the information is framed, context,
intended audience, purpose, timing, tailoring to individual needs and experiences
 User response to information: attention, processing, acquisition, relevance,
salience, personal preferences, motivation
 User characteristics influence response to information: personalities, disposition,
psychological needs, stage of readiness, learning and behavioral skill levels,
personal information styles
 Information behavior: establishing information needs, information seeking, and
information use
Interactive technology for health promotion (2)
 Media type and applications
 Modular components
 Capabilities: responsiveness and user control
 Relationship to face-to-face interactions: complementary?
 Institutional factors for deployment
 Technological factors
 User factors
 Utilization
 User-media-message interaction
Information environment (3)
 A metaphorical environment where the user explores information via experiences
in a computer atmosphere
 Interactivity
 Possibilities for learning through exploration
 Developing skills for health behavior change
 Message characteristics
 Media characteristics
 User characteristics
Information-driven actions (4)
 Cultivate an understanding of health
 Shape information behavior
 Shape cognitive processes
 Shape experiences
 Elucidate options and choices
36


























Facilitate decision making
Facilitate learning and knowledge development
Shape emotional issues
Provide social support
Promote health awareness and self-care
Activate good health behavioral skills
Activate behavioral skills that lead to eventual preventive behavior
Motivate good health behavior
Empower the individual
Facilitate the behavior change pathway
Delay or impede the seeking of medical care (possible negative impact of health
information)
Encourage more thoughtful and deliberative processes when making decisions
about health behavior
Advise patients on the benefits of behavior change
Motivate and help the patient to decide on the appropriate goals and methods for
behavior change
Help develop the knowledge, attitudes and beliefs that shape perceptions of
health, which in turn motivates health actions
Misinform the individual and shape perceived barriers
Serve as a cue to action
Help people maintain or advance along their "stage" of behavior change
Persuade an individual towards behavior change
Inform the individual of the value behavior change
Provide reinforcement of changed behavior
Shape our illness representations
Guide user attention to health topics
Encourage thorough information processing
Approximate face-to-face communication (especially with tailored health
communication)
Serve as a source of social support
Actions driven by interactive technology for health promotion (5)
 Facilitate behavior change counseling activities (the 5A’s: assess, advise, agree,
assist, arrange follow-up)
 Provide an information environment for health learning
 Provide simulation environments for problem-solving and practicing health
behavior skills
 Provide access to a network of people and resources
 Provide “expert” behavioral advice that is responsive to user needs and
characteristics
 Gather data from patients
 Provide personalized feedback and follow-up
37








Integrate education, self-monitoring and social support through systems that
collect data, provide guidance and offer avenues for social support in online
environments
Relay information
Enable informed decision making
Promote healthy behaviors
Promote peer information exchange
Provide emotional support
Promote self-care
Help manage demand for health services
Intermediate outcomes (6)
 Decision making skills development
 Problem solving skills development
 Informed decision making
 Shared decision making as the result of an informed patient
 Patient satisfaction
 Scope and nature of information acquisition
 Repertoire of alternative courses of action known to the searcher
 Health action taken
 Cognitive outcomes: perceptions, opinions, knowledge, attitudes or beliefs that
may be conducive to healthy behavior
 Behavioral outcomes: changes as the result of a conscious and informed choice
 Perceived susceptibility, severity and benefits
 Intention for behavior change
 Self-efficacy
 Involvement
 Disclosure of personal or embarrassing details relevant to health
 Timeliness
 Relationship with providers
 Communication with health professionals
 Reduction in unnecessary services
 Health behavior change setbacks
Health behavior change / outcomes (7)
 End results
 Targeted behaviors
 Sustained behavior change
Other factors affecting health behavior (8)
 Demographic variables, such as: age, gender, race, ethnicity and socioeconomic
status
 Structural barriers and limited access to health care, which information
acquisition may not necessarily ameliorate
38




Economic factors
Medical factors
Sociocultural factors
Psychosocial factors
Perspectives for examination (9)
 Context and environments for health behavior change
 Ecological perspective of health: intrapersonal, interpersonal, and community
levels of influence
 Behavioral diagnosis for identifying appropriate theories and constructs for
examination
 Use of established health behavior theories
 Why an interactive technology/information is provided and adopted?
 What occurs when an individual uses a technology? Understanding the
mechanism from the receiving of health information through to outcomes.
 What are the eventual health outcomes that may be attributed to technology and
information?
6.4. Further research
There is a need for research in the following areas:
 There is a lack of research on users seeking information themselves. The
research on health information has focused on the push model, whereby health
professionals deliver information to health consumers.
 Effectiveness of information and technology for intermediate health outcomes
 User experiences with information and technology
 The mechanisms by which information influences health beliefs, attitudes and
behaviors
 Define health outcomes for measuring and evaluating the role of health
information
 Further examination of the notion of health information in health behavior theory
and studies
39
7.
References
Abrams, D.B., Emmons, K.M. & Linnan, L.A. 1999, "Health behavior and health
education: the past, present and future" in Health behavior and health education, eds.
K. Glanz, B.K. Rimer & F.M. Lewis, 2nd edition edn, Jossey-Bass, San Francisco, pp.
453-478.
Alonzo, A.A. 1993, "Health behavior: issues, contradictions and dilemmas", Social
science & medicine (1982), vol. 37, no. 8, pp. 1019-1034.
Amico, K.R., Toro-Alfonso, J. & Fisher, J.D. 2005, "An empirical test of the Information,
Motivation and Behavioral Skills model of antiretroviral therapy adherence", AIDS
Care - Psychological and Socio-Medical Aspects of AIDS/HIV, vol. 17, no. 6, pp.
661-673.
Azocar, F., McCabe, J.F., Wetzel, J.C. & Schumacher, S.J. 2003, "Use of a behavioral
health web site and service utilization", Psychiatric services (Washington, D.C.), vol.
54, no. 1, pp. 18.
Baker, L., Wagner, T.H., Singer, S. & Bundorf, M.K. 2003, "Use of the Internet and email for health care information: results from a national survey", JAMA : the journal
of the American Medical Association, vol. 289, no. 18, pp. 2400-2406.
Bandura, A. 1982, "The self and mechanisms of agency" in Psychological perspectives
on the self, ed. J. Suls, Erlbaum, Hillsdale, NJ.
Bandura, A. 1982, "Self-efficacy mechanism in human agency", Am Psychol, vol. 37,
pp. 122-147.
Bandura, A. 1977, "Self-efficacy: Toward a unifying theory of behavioral change",
Psychol Rev, vol. 84, pp. 191-215.
Bandura, A. 1977, Social Learning Theory, Prentice Hall, New Jersey.
Baranowski, T., Domel, S., Gould, R., Baranowski, J., Leonard, S., Treiber, F. & Mullis,
R. 1993, "Increasing Fruit and Vegetable Consumption among 4th and 5th Grade
Students - Results from Focus Groups using Reciprocal Determinism", Journal of
Nutrition Education, vol. 25, no. 3, pp. 114-120.
Bero, L.A. & Jadad, A.R. 1997, "How consumers and policymakers can use systematic
reviews for decision making", Annals of Internal Medicine, vol. 127, no. 1, pp. 37-42.
40
Carpenter, M.J., Strange, C., Jones, Y., Dickson, M.M., Carter, C., Moseley, M.A. &
Gilbert, G.E. 2007, "Does genetic testing result in behavioral health change?
Changes in smoking behavior following testing for alpha-1 antitrypsin deficiency",
Annals of Behavioral Medicine, vol. 33, no. 1, pp. 22-28.
Carver, C.S. 2007, "Dispositional optimism" in Health behavior constructs: theory,
measurement & research, eds. M. Gerrard, K. McCaul, P.E. Etcheverry & S. Kobrin,
National Cancer Institute, Bethesda, MD.
Castells, M. 1993, "The informational economy and the new international division of
labor" in The New Global Economy in the Information Age: Reflections on Our
Changing World, eds. M. Carnoy, M. Castells, S.S. Cohen & F.H. Cardoso,
Pennsylvania State University Press, University Park,PA.
Champion, V. 2007, "Perceived benefits" in Health behavior constructs: theory,
measurement & research, eds. M. Gerrard, K. McCaul, P.E. Etcheverry & S. Kobrin,
National Cancer Institute, Bethesda, MD.
Cline, R.J. & Haynes, K.M. 2001, "Consumer health information seeking on the Internet:
the state of the art", Health education research, vol. 16, no. 6, pp. 671-692.
DiClemente, C.C., Marinilli, A.S., Singh, M. & Bellino, L.E. 2001, "The role of feedback
in the process of health behavior change", American Journal of Health Behavior, vol.
25, no. 3, pp. 217-227.
Diefenbach, M.A. 2007, "Illness representations" in Health behavior constructs: theory,
measurement & research, eds. M. Gerrard, K. McCaul, P.E. Etcheverry & S. Kobrin,
National Cancer Institute, Bethesda, MD.
Dirkin, G. 1994, "Technological supports for sustaining Exercise" in Advances in
Exercise Adherence, ed. R. Dishman, Human Kinetics, Champaign, IL.
Erdman, H.P., Klein, M.H. & Greist, J.H. 1985, "Direct patient computer interviewing",
Journal of consulting and clinical psychology, vol. 53, no. 6, pp. 760-773.
Fazio, R.H. & Towles-Schwen, T. 1999, "The MODE model of attitude-behavior
processes" in Dual-process models in social psychology, eds. S. Chaiken & Y.
Trope, Guildford, New York, pp. 97-116.
Fisher, J.D., Fisher, W.A., Williams, S.S. & Malloy, T.E. 1994, "Empirical tests of an
information-motivation-behavioral skills model of AIDS-preventive behavior with gay
men and heterosexual university students", Health psychology : official journal of the
Division of Health Psychology, American Psychological Association, vol. 13, no. 3,
pp. 238-250.
41
Fisher, J.D., Fisher, W.A., Williams, S.S. & Malloy, T.E. 1994, "Empirical tests of an
information-motivation-behavioral skills model of AIDS-preventive behavior with gay
men and heterosexual university students.", Health Psychology, vol. 13, no. 3, pp.
238-250.
Fleming, M.F., Barry, K.L., Manwell, L.B., Johnson, K. & London, R. 1997, "Brief
physician advice for problem alcohol drinkers. A randomized controlled trial in
community-based primary care practices", JAMA : the journal of the American
Medical Association, vol. 277, no. 13, pp. 1039-1045.
Fratiglioni, L., Paillard-Borg, S. & Winblad, B. 2004, "An active and socially integrated
lifestyle in late life might protect against dementia", Lancet neurology, vol. 3, no. 6,
pp. 343-353.
Fries, J.F. & McShane, D. 1998, "Reducing need and demand for medical services in
high-risk persons. A health education approach", The Western journal of medicine,
vol. 169, no. 4, pp. 201-207.
Frosch, D.L. & Kaplan, R.M. 1999, "Shared decision making in clinical medicine: past
research and future directions", American Journal of Preventive Medicine, vol. 17,
no. 4, pp. 285-294.
Gerrard, M. & Houlihan, A.E. 2007, "Perceived vulnerability" in Health behavior
constructs: theory, measurement & research, eds. M. Gerrard, K. McCaul, P.E.
Etcheverry & S. Kobrin, National Cancer Institute, Bethesda, MD.
Gibbons, F.X. 2007, "Intention, expectation, and willingness" in Health behavior
constructs: theory, measurement & research, eds. M. Gerrard, K. McCaul, P.E.
Etcheverry & S. Kobrin, National Cancer Institute, Bethesda, MD.
Ginman, M. & Eriksson-Backa, K. 2001, "Information empowered health
consciousness", Health Informatics Journal, vol. 7, no. 3, pp. 171-182.
Glanz, K. 2002, "Perspectives on using theory: Past, present, and future" in Health
behavior and health education, eds. K. Glanz, B.K. Rimer & F.M. Lewis, 3rd edition
edn, Jossey-Bass, San Francisco, pp. 545-558.
Glanz, K., Rimer, B.K. & Lewis, F.M. 2002, "The scope of health behavior and health
education" in Health behavior and health education, eds. K. Glanz, B.K. Rimer &
F.M. Lewis, 3rd edition edn, Jossey-Bass, San Francisco, pp. 3-21.
Glanz, K. & Yang, H. 1996, "Communicating about risk of infectious diseases", JAMA :
the journal of the American Medical Association, vol. 275, no. 3, pp. 253-256.
42
Glasgow, R.E., Bull, S.S., Piette, J.D. & Steiner, J.F. 2004, "Interactive behavior change
technology a partial solution to the competing demands of primary care", American
Journal of Preventive Medicine, vol. 27, no. 2, pp. 80-87.
Green, L.W. & Kreuter, M.W. 1999, Health promotion planning : an educational and
ecological approach, 3rd edn, Mayfield Pub. Co., Mountain View, CA.
Gysels, M. & Higginson, I.J. 2007, "Interactive technologies and videotapes for patient
education in cancer care: systematic review and meta-analysis of randomised trials",
Supportive care in cancer : official journal of the Multinational Association of
Supportive Care in Cancer, vol. 15, no. 1, pp. 7-20.
Institute of Medicine 2002, Speaking of health: Assessing health communication
strategies for diverse populations, National Academies Press, Washington, DC.
Intille, S.S. 2004, "Ubiquitous computing technology for just-in-time motivation of
behavior change", Medinfo.MEDINFO, vol. 11, no. Pt 2, pp. 1434-1437.
Intille, S.S., Kukla, C., Farzanfar, R. & Bakr, W. 2003, "Just-in-time technology to
encourage incremental, dietary behavior change", AMIA ...Annual Symposium
proceedings / AMIA Symposium.AMIA Symposium, , pp. 874.
Irvine, A.B., Ary, D.V., Grove, D.A. & Gilfillan-Morton, L. 2004, "The effectiveness of an
interactive multimedia program to influence eating habits", Health education
research, vol. 19, no. 3, pp. 290-305.
Jackson, C.L., Bolen, S., Brancati, F.L., Batts-Turner, M.L. & Gary, T.L. 2006, "A
systematic review of interactive computer-assisted technology in diabetes care.
Interactive information technology in diabetes care", Journal of general internal
medicine : official journal of the Society for Research and Education in Primary Care
Internal Medicine, vol. 21, no. 2, pp. 105-110.
Jimison, H.B., Fagan, L.M., Shachter, R.D. & Shortliffe, E.H. 1992, "Patient-specific
explanation in models of chronic disease", Artif Intell Med, vol. 4, pp. 191-205.
Johnson, J.D. 1997, Cancer-related information seeking, Hampton Press, Cresskill, N.J.
Keoun, B. 1996, "At last, doctors begin to jump online", Journal of the National Cancer
Institute, vol. 88, no. 22, pp. 1610-1612.
Kivits, J. 2004, "Researching the 'Informed Patient': The Case of Online Health
Information Seekers", Information, Communication & Society, vol. 7, no. 4, pp. 510530.
43
Klein, W.M.P. 2007, "Optimistic bias" in Health behavior constructs: theory,
measurement & research, eds. M. Gerrard, K. McCaul, P.E. Etcheverry & S. Kobrin,
National Cancer Institute, Bethesda, MD.
Kreuter, M.W. & Skinner, C.S. 2000, "Tailoring: what's in a name?", Health education
research, vol. 15, no. 1, pp. 1-4.
Kreuter, M.W., Strecher, V.J. & Glassman, B. 1999, "One size does not fit all: the case
for tailoring print materials", Annals of Behavioral Medicine : A Publication of the
Society of Behavioral Medicine, vol. 21, no. 4, pp. 276-283.
Lakey, B. 2007, "Social support" in Health behavior constructs: theory, measurement &
research, eds. M. Gerrard, K. McCaul, P.E. Etcheverry & S. Kobrin, National Cancer
Institute, Bethesda, MD.
Latimer, A.E., Katulak, N.A., Mowad, L. & Salovey, P. 2005, "Motivating cancer
prevention and early detection behaviors using psychologically tailored messages",
Journal of health communication, vol. 10, no. SUPPL. 1, pp. 137-155.
Lenz, E.R. 1984, "Information seeking: a component of client decisions and health
behavior", ANS.Advances in nursing science, vol. 6, no. 3, pp. 59-72.
Lewis, M.A., DeVellis, B.M. & Sleath, B. 2002, "Social influence and interpersonal
communication in health behavior" in Health behavior and health education, eds. K.
Glanz, B.K. Rimer & F.M. Lewis, 3rd edition edn, Jossey-Bass, San Francisco, pp.
240-264.
Locke, S.E., Kowaloff, H.B., Hoff, R.G., Safran, C., Popovsky, M.A., Cotton, D.J.,
Finkelstein, D.M., Page, P.L. & Slack, W.V. 1992, "Computer-based interview for
screening blood donors for risk of HIV transmission", JAMA : the journal of the
American Medical Association, vol. 268, no. 10, pp. 1301-1305.
Lorig, K.R., Sobel, D.S., Stewart, A.L., Brown, B.W.,Jr, Bandura, A., Ritter, P.,
Gonzalez, V.M., Laurent, D.D. & Holman, H.R. 1999, "Evidence suggesting that a
chronic disease self-management program can improve health status while reducing
hospitalization: a randomized trial", Medical care, vol. 37, no. 1, pp. 5-14.
McBride, C.M. & Rimer, B.K. 1999, "Using the telephone to improve health behavior and
health service delivery", Patient education and counseling, vol. 37, no. 1, pp. 3-18.
McCaul, K.D. & Goetz, P.W. 2007, "Worry" in Health behavior constructs: theory,
measurement & research, eds. M. Gerrard, K. McCaul, P.E. Etcheverry & S. Kobrin,
National Cancer Institute, Bethesda, MD.
44
McGinnis, J.M. & Foege, W.H. 1993, "Actual causes of death in the United States",
JAMA : the journal of the American Medical Association, vol. 270, no. 18, pp. 22072212.
Micco, N., Gold, B., Buzzell, P., Leonard, H., Pintauro, S. & Harvey-Berino, J. 2007,
"Minimal in-person support as an adjunct to internet obesity treatment", Annals of
Behavioral Medicine : A Publication of the Society of Behavioral Medicine, vol. 33,
no. 1, pp. 49-56.
Mookadam, F. & Arthur, H.M. 2004, "Social support and its relationship to morbidity and
mortality after acute myocardial infarction: systematic overview", Archives of Internal
Medicine, vol. 164, no. 14, pp. 1514-1518.
National Cancer Institute 2005, Theory at a glance: A guide for health promotion
practice, National Cancer Institute, NIH, Bethesda, MD.
Noell, J. & Glasgow, R.E. 1999, "Interactive technology applications for behavioral
counseling: issues and opportunities for health care settings", American Journal of
Preventive Medicine, vol. 17, no. 4, pp. 269-274.
Ockene, J.K. & Camic, P.M. 1985, "Public health approaches to cigarette smoking
cessation", Ann Behav Med, vol. 7, pp. 14-18.
Ockene, J.K., Ockene, I.S., Quirk, M.E., Hebert, J.R., Saperia, G.M., Luippold, R.S.,
Merriam, P.A. & Ellis, S. 1995, "Physician training for patient-centered nutrition
counseling in a lipid intervention trial", Preventive medicine, vol. 24, no. 6, pp. 563570.
Owen, N., Fotheringham, M.J. & Marcus, B.H. 2002, "Communication technology and
health behavior change" in Health behavior and health education, eds. K. Glanz,
B.K. Rimer & F.M. Lewis, 3rd edition edn, Jossey-Bass, San Francisco, pp. 510-529.
Paperny, D.M. & Hedberg, V.A. 1999, "Computer-assisted health counselor visits: a
low-cost model for comprehensive adolescent preventive services", Archives of
Pediatrics & Adolescent Medicine, vol. 153, no. 1, pp. 63-67.
Ramelson, H.Z., Friedman, R.H. & Ockene, J.K. 1999, "An automated telephone-based
smoking cessation education and counseling system", Patient education and
counseling, vol. 36, no. 2, pp. 131-144.
Rimer, B.K. & Kreuter, M.W. 2006, "Advancing tailored health communication: A
persuasion and message effects perspective", Journal of Communication, vol. 56,
no. SUPPL., pp. S184-S201.
Rudd, J. & Glanz, K. 1990, "How individuals use information for health action: consumer
information processing" in Health behavior and health education: theory,
45
research, and practice, eds. K. Glanz, F.M. Lewis & B.K. Rimer, Jossey-Bass, San
Francisco, pp. 115-139.
Schwarzer, R. & Luszczynska, A. 2007, "Self-efficacy" in Health behavior constructs:
theory, measurement & research, eds. M. Gerrard, K. McCaul, P.E. Etcheverry & S.
Kobrin, National Cancer Institute, Bethesda, MD.
Science Panel on Interactive Communication and Health 1999, Wired for Health and
Well-Being: the emergence of interactive health communication, US Department of
Health and Human Services, Washington, DC.
Severtson, D.J., Baumann, L.C. & Brown, R.L. 2006, "Applying a health behavior theory
to explore the influence of information and experience on arsenic risk
representations, policy beliefs, and protective behavior", Risk Analysis, vol. 26, no.
2, pp. 353-368.
Sidorov, J. 2006, "Computer-assisted technology: not if, not when, but how. A
systematic review of interactive computer-assisted technology in diabetes care",
Journal of general internal medicine : official journal of the Society for Research and
Education in Primary Care Internal Medicine, vol. 21, no. 2, pp. 201-202.
Skinner, C.S. & Kreuter, M.W. 1997, "Using theories in planning interactive computer
programs" in Health promotion and interactive technology: theoretical applications
and future directions, eds. R.L. Street, W.R. Gold & T. Manning, Lawrence Erlbaum
Associates, Mahwah, NJ, pp. 39-65.
Skinner, C.S., Siegfried, J.C., Kegler, M.C. & Strecher, V.J. 1993, "The potential of
computers in patient education", Patient education and counseling, vol. 22, no. 1, pp.
27-34.
Smedley, B.D., Syme, S.L. & Institute of Medicine . Committee on Capitalizing on Social
Science and Behavioral Research to Improve the Public's Health 2000, Promoting
health : intervention strategies from social and behavioral research, National
Academy Pr., Washington, D.C.
Soet, J.E. & Basch, C.E. 1997, "The telephone as a communication medium for health
education", Health education & behavior : the official publication of the Society for
Public Health Education, vol. 24, no. 6, pp. 759-772.
Stevens, V.J., Glasgow, R.E., Toobert, D.J., Karanja, N. & Smith, K.S. 2002,
"Randomized trial of a brief dietary intervention to decrease consumption of fat and
increase consumption of fruits and vegetables", American Journal of Health
promotion : AJHP, vol. 16, no. 3, pp. 129-134.
46
Strecher, V.J., DeVellis, B.M., Becker, M.H. & Rosenstock, I.M. 1986, "The role of selfefficacy in achieving health behavior change", Health Education Quarterly, vol. 13,
no. 1, pp. 73-91.
Street, R.L. & Manning, T. 1997, "Information environments for breast cancer
education" in Health promotion and interactive technology: theoretical applications
and future directions, eds. R.L. Street, W.R. Gold & T. Manning, Lawrence Erlbaum
Associates, Mahwah, NJ, pp. 121-139.
Street, R.L. & Rimal, R.N. 1997, "Health promotion and interactive technology: a
conceptual foundation" in Health promotion and interactive technology: theoretical
applications and future directions, eds. R.L. Street, W.R. Gold & T. Manning,
Lawrence Erlbaum Associates, Mahwah, NJ, pp. 1-18.
Suggs, L.S. 2006, "A 10-year retrospective of research in new technologies for health
communication", Journal of health communication, vol. 11, no. 1, pp. 61-74.
Thompson, S.C. & Schlehofer, M.M. 2007, "Perceived control" in Health behavior
constructs: theory, measurement & research, eds. M. Gerrard, K. McCaul, P.E.
Etcheverry & S. Kobrin, National Cancer Institute, Bethesda, MD.
Trafimow, D. 2007, "Normative beliefs" in Health behavior constructs: theory,
measurement & research, eds. M. Gerrard, K. McCaul, P.E. Etcheverry & S. Kobrin,
National Cancer Institute, Bethesda, MD.
Veazie, P.J. & Cai, S. 2007, "A connection between medication adherence, patient
sense of uniqueness, and the personalization of information", Medical hypotheses,
vol. 68, no. 2, pp. 335-342.
Velicer, W.F. & Prochaska, J.O. 1999, "An expert system intervention for smoking
cessation", Patient education and counseling, vol. 36, no. 2, pp. 119-129.
Vogt, T.M., Hollis, J.F., Lichtenstein, E., Stevens, V.J., Glasgow, R. & Whitlock, E. 1998,
"The medical care system and prevention: the need for a new paradigm", HMO
practice / HMO Group, vol. 12, no. 1, pp. 5-13.
Weinstein, N.D. 1988, "The precaution adoption process", Health psychology : official
journal of the Division of Health Psychology, American Psychological Association,
vol. 7, no. 4, pp. 355-386.
Weisbord, S.D., Soule, J.B. & Kimmel, P.L. 1997, "Poison on line--acute renal failure
caused by oil of wormwood purchased through the Internet", The New England
journal of medicine, vol. 337, no. 12, pp. 825-827.
47
Wenzel, L., Glanz, K. & Lerman, C. 2002, "Stress, coping, and health behavior" in
Health behavior and health education, eds. K. Glanz, B.K. Rimer & F.M. Lewis, 3rd
edition edn, Jossey-Bass, San Francisco, pp. 210-239.
Whitlock, E.P., Orleans, C.T., Pender, N. & Allan, J. 2002, "Evaluating primary care
behavioral counseling interventions - An evidence-based approach", American
Journal of Preventive Medicine, vol. 22, no. 4, pp. 267-284.
WHO 2006, Constitution of the World Health Organization.
Wikipedia 2007, 7/13/2007-last update, Behavior change. Available:
http://en.wikipedia.org/wiki/Behavior_change [2007, 10/29] .
Wills, T.A., Ainette, M.G. & Walker, C. 2007, "Social influence" in Health behavior
constructs: theory, measurement & research, eds. M. Gerrard, K. McCaul, P.E.
Etcheverry & S. Kobrin, National Cancer Institute, Bethesda, MD.
Ybarra, M.L. & Suman, M. 2006, "Help seeking behavior and the Internet: a national
survey", International journal of medical informatics, vol. 75, no. 1, pp. 29-41.