Theory in health education practice.

Theory

in Health Education Practice

Godfrey M. Hochbaum, PhD, FAPHA James R. Sorenson, PhD Kate Lorig, RN, DrPh Although social and behavioral science theories are claimed to be able to contribute greatly to the effectiveness of health education programs, most practitioners in the profession seem to doubt this, and very few ever deliberately use theories in their work. Some reasons

for such diverse views reside in the

nature

of the theories, in the very different

they play in the worlds of theory-minded and practice-oriented health educators, respectively, in widespread unrealistic expectations of what theories can and cannot contribute to practice, and in lack of appropriate training in theories and their uses. Suggestions are offered to both practicing and academic health educators on ways to bridge the gap between the two camps, to render theories more useful to practitioners, and to train practitioners and health education students to appreciate the potentials of theories and to acquire skills needed to utilize such potentials. roles

INTRODUCTION Health education, as every profession, must deal with an infinite variety of problems, situations, challenges. There is no fixed body of knowledge and skills that fully prepares us for every contingency and tells us what to do. Each situation, each problem must be examined anew, and specific strategies to meet challenges must often be developed. To survive and prosper as a profession we must learn to understand and respond to new problems that a changing world mav impose on us and diligently expand our knowledge base and our armamentaria of strategies, methodologies, and skills. These challenges could become overwhelming if each problem and each problem situation were so unique that we would have to search for new solutions

Godfrey M. Hochbaum, PhD, is Professor Emeritus, Department of Health Behavior and Health Education, School of Public Health, University of North Carolina, Chapel Hill, North Carolina. James R. Sorenson, PhD, is Professor and Chairman, Department of Health Behavior and Health Education, School of Public Health, University of North Carolina, Chapel Hill, North Carolina. Kate Lorig, RN, DrPH, is with Stanford University Patient Education, Research Center, Stanford University School of Medicine, Palo Alto, California. Address reprint requests to Godfrey M. Hochbaum, PhD, Department of Health Behavior and Health Education, School of Public Health, University of North Carolina, Chapel Hill, NC 27599-7400. 295-

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every time. Luckily, there are always some common elements, factors, or variables that arise and exert themselves in many apparently dissimilar problem situations. Thus, for example, the same desire for lasting health can be the driving force for a great variety of behaviors from changing one’s nutritional habits, seeking periodic medical examination, using quack medical gadgets, or taking out health insurance, to praying in church, subscribing to various healthrelated magazines, contributing to various health organizations, or lobbying for anti-smoking legislation. Theories aim at identifying and helping us understand elements that affect seemingly diverse classes of behaviors and tell us how these elements function. They may also suggest or actually offer ideas of how we can influence such elements under a variety of circumstances and thereby furnish us with valuable tools for solving a wide variety of problems in our work. In the context of our professional piactice, our theories can be regarded as being essentially statements identilving factors that are likely to produce particular results under specified conditions. To put it in other words, good and proven theories, if well chosen and skillfully adapted, can help us predict what consequences various interventions arc likely to have even in situations we have never before encountered. Certain social and behavioral science theories and theories from a number of other fields represent our best understanding of human healthrclevant behavior and of other factors of concern to the profession. They can, therefore, be invaluable at times as guides for selecting or developing and applying the most promising strategies and methods in any given situation. Such is, at least, claimed by &dquo;academicians.&dquo; In contrast, many practitioners in health education tend to be very skeptical concerning the applicability and usefulness of theories in their work. The reason does not seem to be a lack of acquaintance with theories. since most health educators have been exposed as students at least to theories popular at a given time. It seems, however, that most health educators in the field do not see much relevance of the theories to the realities of the professional problems they face. Many health educators encounter difficulties with utilizing theories profitably even when they wish to. Thus. by and large, our academically oriented and our practicing colleagues tend to have quite contrasting views concerning the utility and importance of theory in our profession. There seem to be two &dquo;camps&dquo; in our profession to which we might refer as the &dquo;academicians&dquo; and the &dquo;practitioners,&dquo; respectively. although interest and actual involvement in practice as weil as in theory are to be found among individuals both in academia and in the field. This division does much harm to our profession. It robs practitioners of potentially useful tools for planning, conducting, and evaluating programs. It inhibits the emergence of novel approaches to problems. As Pasteur said, &dquo;Theory is the mother of practice. Without theorv, practice is just routine born of habit.&dquo; On the other side, those in our profession who are expected to help us understand and cope effectively with our professional problems are robbed of

*This term is meant here to refer to health educators and social and behavioral scientists whose interests are predominantly in theories and in theory-directed and theory-driven research. Both &dquo;academicians&dquo; and &dquo;practitioners&dquo; (hcalth educators concerned mainly with delivering services) are found, of course, both inside and outside of academic institutions. _


297

of improving existing ideas and developing and testing new of the damage that this gap is doing to our profession realization Growing has stimulated much discussion and examination of why practitioners fail to utilize theories more widely and more effectively, and why academicians fail to develop or present theories that are more useful to practitioners. In this article we will examine first the current situation and try to analyze the nature and sources of factors that limit the utilization of theories in health education practice. Following this, we will advance various ideas for bridging the gap and making theories more accessible and profitable for practitioners. We will also make a case for taking advantage of the experiences and insights of practitioners for testing and improving current theories and for generating invaluable

sources

ones.

new ones.

COMMONSENSE AND SCIENTIFIC THEORIES As is true in most any

profession, the word &dquo;theory&dquo; (especially in reference theories) has a somewhat unsavory connotation Some health educators see theories as so abstract among many practitioners. and &dquo;unreal&dquo; that their relation to problems actually encountered by professionals is often obscure. Some do not put much stock in theories because they seem to be at odds with everyday experiences. To others, theories seem to &dquo;merely reflect, in incomprehensible jargon, what we in our wisdom already to social and behavioral science

know.&dquo;’ Even among those who strongly advocate the usefulness of theories in health education practice, questions are raised about the present state of theory. Thus, Green sees a paradox in the contrast between Kurt Lewin’s widely cited pronouncement that &dquo;there is nothing as practical as a good theory&dquo; and the fact that &dquo;so much practice in health education is atheoretical.&dquo; He seeks an answer to this

paradox in the &dquo;quality of teaching social and behavioral theory in the health professions&dquo; due to the &dquo;wide-ranging theories to be mastered and the race to stay abreast of new developments and applications of the theories in research and practice&dquo;’- (p. XIX). Green is surely right. The growing number of theories (and of subtheories, pseudotheories, and models often passing as theories) presents problems not only to teachers but also to health education practitioners. Both teachers and students tend to feel overwhelmed in their efforts to keep abreast of this fecundity and to find ways of ferreting out what might have sufficient potential practical value to justify devoting time and effort to teaching, learning, and perhaps using it. These problems, in turn, are very likely to have negative effects on beliefs. attitudes, and willingness and ability to use theory in everyday practice. But this explanation is far from complete. Moreover, just as theories are often accused of offering plausible explanations but no practical solutions, so does this explanation fail us: there is little chance that we can control the proliferation of theories. Moreover, there are just too many health educators who have mastered

dubious

array of theories relevant to their work but still consider them of practical value at best, totally useless at worst. The limited use of theory an


298

practice is sureiv not just the result of a stultifying supply or of inadequate training for budding professionals. The world of practice requires easily implemented simple solutions that are politically, fiscally, and administratively feasible. These requirements can severely limit a practitioner’s or agency’s interest in using theories, especially those that suggest complex. expensive, and administratively cumbersome programs. A theory may be of very great value as a contribution to science and may even, in time to come, become a source of technological or other substantive progress, yet it may be of no ready use to professionals who are looking for help with their immediate professional problems. To meet these needs, there must be a link between the abstract formulation of the theory and the concrete needs of the professionals, a link that is readily identifiable and can be translated into realistic action implications. When practitioners of the profession voice doubts concerning the usefulness of theories, they question basically the existence of this link. Our first question, then, concerns the existence and character of such a link. The logically following second question is whether such a link can furnish practitioners with means for performing more effectively. in

There are many definitions of &dquo;theory’ (sec pp. 20-22). Given this present article’s professional rather than scientific perspective. we view theories as tools to help health educators better understand what influences health-relevant individual, group, and institutional behaviors and to thereupon plan effective interventions directed at health-beneficial results. Theories, so defined, are not restricted to the scientific milieu. All of us go through life collecting observations of our own and others’ behaviors and draw inferences from such observations about how people (and ourselves) are likely to respond to some given events or conditions. It would be strange, to say the least, if, given our own accumulated experiences and those passed on to us by others, we had not gained considerable insights into why people (including ourselves) act in certain ways under certain circumstances. Indeed, if we did not have some undcrstanding (i.e.. &dquo;theories&dquo;) of what shapes our own and others’ behaviors, we could not function. Although we may not usually enunciate them in so many words, most of our daily behavior is shaped by such theories. In our professional lives as well, our decisions are mostly determined by &dquo;theories&dquo; we carry in our heads. They are the product of what we have learned from studies, by word of mouth, and from our own experiences. Even when we decide on some professional action that has become something of a standard procedure in our profession, we decide on the basis of what are really only theoretical assumptions. For example, when we produce an educational video about the role of cholesterol, we are guided by our own internalized &dquo;theories&dquo; as to what ways of presenting the material will probably make it meaningful and to the audience and will affect their behaviors. acceptable Whether we are actually aware of it or not, such &dquo;theories&dquo; are indeed important tools we use in the course of making professional decisions and plans. Indeed. many such theories have become elements of our profession’s &dquo;conventional wisdom.&dquo; We may not think of them in the same vein as we think of such &dquo;formal&dquo; theories as social comparison or social cognitive theory. But they are theories, nonetheless. They may or may not always be supported by scientific research, but they at least seem to be supported by accumulated professional Downloaded from heb.sagepub.com at Bobst Library, New York University on June 18, 2015

299

(and other) experiences. They are what Heifer’ called &dquo;common-sense theories&dquo; that &dquo;make sense&dquo; because they seem to fit well into our daily subjective experiences and into what is held to be true in our social or our professional circles. In fact, our profession has absorbed over the years many of the theoretical concepts from the social and behavioral sciences and made them the very marrow of its thinking and of its field strategies, so much so that we are often totally unaware of how much we depend on and use these in our daily work. Indeed, many of the theories, which have metamorphosized with time into these commonsense wisdoms, encountered considerable initial resistance and were actually rejected as impractical or even senseless by many health educators, even by some in academic positions. Yet, now they are taken for unquestionable truths. To givc but one example, most health educators take it for granted today that without some emotional and/or social involvement, factual health knowledgc alone will not have much effect on behavior. Yet but a little over 50 years ago this was but a &dquo;theory&dquo; that met considerablc skepticism in our field. There is much overlap between &dquo;commonsense&dquo; and &dquo;scientific&dquo; theories. This is not surprising. Scientists who study behavior can hardly help being intluenced by what they believc about their own and others’ behaviors (i.e., their own commonsense theories). Thus we find that many behavioral theories, when shorn of their scientific terminology, sound suspiciously like &dquo;what we havc known all along.&dquo; For example, social cognitivc theory says (among other things) that &dquo;value expectancy&dquo; is a vital factor in shaping behavior. Said another way. &dquo;people are likely to take some action if they believe that it will bring them something then want.&dquo; At first glance, common sense tells us much the samc thing and, indeed, it has been one of the most basic guiding principles in health education: we promise long, hcalthful life and protection against disease and injury as incentives to get people to act as we think they should. This commonsense theory, as many othcrs, has indeed proven its value in innumerable programs. But as much as we do and must rely often on hunches based on commonsense theories in our social and our professional lives, we must be aware of the risk involved. Scientific theories are cunstantly tested and challenged to prove themselves. Evidence of successes as well as of failures to live up to their claims are rigorously investigated over years under a variety of conditions. Data thusly collected are meticutousty examined and lead to either adoption, revision, or rejection of the theories. Commonsense theories tend to escape such critical scrutiny. In fact. exactly because they make sense, we tend to remember how often they have proven themse)ves right, and we overlook or forget how often they have failed us. Additionally. there is a tendency to regard interventions as effective because they have achieved some reasonable measure of success, disregarding the pussihility that an intervention based on refined or different assumptions might have been far more effective. Satisfaction with moderate success may prevent a health educator from searching for some other, more effective

approaches. Scientific theories of human behavior are not sacrosanct either. Several, once accepted widely by behavioral scientists, have fallen into disuse and even the best theories available now do not fully explain and predict complex human behaviors. Yet they help us understand much that common sense leaves unex-


300

plained, and they offer help professional wisdom fail us.

in

our

professional

work where

common sense

and

The primary goal of the social and behavioral sciences is to learn to understand the determinants of human behavior. Working towards this goal, researchers in these sciences have spent years developing and testing theories. It seems foolish for applied fields, such as health education, not to draw on that works

Consider the following hypothetical, though quite realistic illustration of how scientific theories could add to professional wisdom and thereby increase a program’s effectiveness. THE CASE OF THE WEIGHT REDUCTION PROGRAM

planning a weight-reduction program for a corporation’s overweight employees, decides to focus on two incentives for getting overweight employees to participate. One, based on her commonsense belief that everyone wishes to protect their health, is to conduct an educational campaign stressing the serious health risks involved with excessive weight. She also has persuaded the chief executive officer (CEO) to promise participating employees extra paid leave, the amount to depend on meeting individually determined goals of pounds shed, making this another incentive to participate. Thus, relying on common sense and professional wisdom, her program echoes typical patterns of such programs in that it combines educational input, opportunity to take desirable health action, and promise of rewards. When the program ended the results compared reasonably well with those of most such programs. But satisfaction with the outcome was somewhat mitigated by a few facts: many identified overweight employees did not participate or dropped out before the program’s completion, not all participants reached the weight loss targets, and some who did regained weight later. Shortly thereafter this health educator became impressed with some behavioral science theories during a continuing education course. When asked to stage a weight-reduction program for another corporation, she A health educator,

decided to use ideas from some of these theories (or, as we would say, to let these theories &dquo;inform&dquo; her program). She recognized that the concept of &dquo;value expectancy&dquo; in social cognitive theory is similar to the commonsense notion of offering rewards that she had used the first time. Both say, in effect, that people are likely to take some action if they believe the action will bring them something they want and value. But value expectancy is more precise in defining its terms in that it stresses that it is the person himself or herself who must value the actions’s results. This leads our health educator to question whether the vague prospect of better health in the future really means as much to all employees as it means to her with her professional orientation. A series of informal interviews reveal that prospects of better health are less tempting to many than such &dquo;expectancies&dquo; as being more attractive, being able to wear last year’s clothes, or improving performance in games. Consequently, the health educator widens the scope of expected benefits to include these. Social cognitive theory also ascribes much importance to people’s confidence in their ability to perform the task leading to the rewarding outcome (called


301

&dquo;self-efficacy&dquo;). It alerts the health educator to the need to be concerned with overweight employees feel about their ability to lose weight. For example, employees who have tried in the past and have failed may lack enough selfefficacy to try again. To enlist their participation the health educator now thinks of ways to make them feel more optimistic about their ability to succeed. This may, indeed, prove more important than just appealing to the promise of better health. Self-efficacy is related to &dquo;barriers,&dquo; a concept to be found in several behavioral theories. Here it refers to specific problems that employees may anticipate encountering, and which might well inhibit their participation in the program. Again, being alerted to this factor, the health educator will try to learn what typical problems employees who ought to lose weight may anticipate, such as inability to resist temptation when it comes to food or drink, lack of cooperation by whoever prepares meals in the home, inability to cope with social demands, excessive appetite, or simply the feeling of helplessness engendered by past failures to lose weight. Now, strategies are incorporated into the program to help participants overcome their lack of self-efficacy. Still other theories (e.g., &dquo;stage theory&dquo; and the &dquo;transtheoretical model&dquo;) suggest certain specific stages people experience in the process of reaching an action decision, from learning about an issue to finally taking or not taking the action Some of the overweight employees may be &dquo;ready&dquo; to participate as soon as they learn of the program and need only the word; others may have thought about losing weight but need some particular informational or other input by the program before they are ready to sign up: still others may not even be interested as yet and may need further stimulation before they become interested enough to even listen. Thinking in terms of such theories, our health educator may decide to plan her program in stages covering several weeks prior to the start of the actual weight-reduction activities. During these weeks she may attempt to get as many of the overweight employees as possible &dquo;ready&dquo; to consider and later to sign up when the actual weight-reduction program starts. The commonsense idea of offering extra paid leave is a very appealing one at first sight. But research-supported theories differentiate factors that account for behavior change and factors that account for maintenance of newly acquired behaviors versus relapse to the old ways. Thinking in terms of &dquo;relapse theory&dquo; makes the health educator more keenly aware how important it is in this, as in all behavior change programs, to think as much in terms of preventing relapse as it is to think in terms of behavior change itself.’ In our case, for example, she comes to think about the fact that the earlier program’s promised extra leave rewards only for weight loss but offers no rewards for maintaining the target weight. In turn, she now builds appropriate additional rewards into the program to be offered at certain time intervals following the end of the weight-reduction phase. Moreover, her program will now also focus intensely on potential causes of relapse in the several participants and on ways to prevent them. This brief and superficial example shows how even just considering ideas and variables from properly selected behavioral science theories can expand and enrich a practitioner’s grasp of factors that may substantially reduce or increase a project’s ultimate effectiveness. It can lead the practitioner to collect otherwise neglected but immensely useful information. It also shows that practitioners who are knowledgeable about theories can benefit occasionally even from merely how


302

considering them and drawing inferences from them (as reflected in the term, &dquo;theory-informed&dquo; projects) without actually applying one or another theory more formally. of fact, because many health educators have studied social and behavioral science theories at one time or another, far more programs are even now at least partly informed by such theories (and benefit from them) than is generally realized even by the practitioners themselves. Of But when thc complaint is voiced that our profession does not utilize what scientific theories might offer, the reference is to more deliberate, systematic, and sophisticated application of theories in practice. Academicians in our profession claim, surely with some justification, that failure to utilize such theories systematically, appears tantamount to neglecting some of the most pc~wcrful tools available to our profession. In contrast, a sizahle majority of practitioners find furmal theories useless for dealing with the realities encountered in their work, even when, as is not often the case. they may find them interesting. Assuming, as we must, that both sides havc legitimate causes for their views in this matter, we shall in the next section examine such causes and draw from thcm inferences as to how the gap might hc bridged to the benefit of both academicians and practitioners. As

a

matter

THEORY OR!ENTED VERSUS PRACTICE-ORIEN‘I’ED PROJECTS interests of those to whom we have referred as &dquo;academicians&dquo; understand better what determines people’s health-relevant decisions (a) and behaviors as well as managerial and policy decisions in institutions and organizations. and (b) to derive improved strategies and methods from such understanding that would hclp the profession fulfill its mission. Since scientific theories are the huilding blocks for understanding both behavior itself and how behavior may be influenced, development and testing of theories rank high among the profcssional interests in this group and are often even the primary goal,. In contrast, practitioners in the profession are and must he concerned (usually exclusively) with producing tangible results in terms of health-related hehaviors, policy decisions. and thc like. Their building blocks are not theories but strategies, methods, and techniques designed to produce such results. Although both &dquo;camp;&dquo; are ultimately dedicated to improving peoples health, these differences are a primary source of the problems that impede better cooperation between them. Academicians’ strong theoretical leanings make them seek opportunities to use, test, and improve upon theories in which they happen to be interested. Grant-supported research offers, of course, a chance to do so. But there are also many health education projects that offer opportunities for academicians to pursue their theory-directed interests as well as to contribute to the outcome of the projects. If an academician is asked or wishes to introduce a given theory into the project design, research principles demand that the project meet certain conditions. Among these are that the project entails at lcast one component to The

are

primary to

+l’hc article in this issue

by.

Howze and Redman otters

an

apt example.


303

which the chosen theory is applicahle: that the situation, the population, and other aspects meet certain requirements; that there be enough leeway in the design of the project to assure that the theory is properly applied and that its effects on the project outcome can be assessed. Thus, given a choice, an academician’s involvement in a health education project is influenced strongly by the extent to which it meets certain theory- and research-related conditions. Figure 1 depicts this situation, alhcit in an ovcrsimplified way. Practitioners start out with a different scenario. They cannot often choose a problem, a situation, or a population that happen to fit their interests and allow them to use and test some of their preferred strategies or methods. They are usually expected to assail assigned problems in a given situation and population under conditions over which they may have very little control. Although academics may wish to test whether (or demonstrate that) some given theories contribute to a project’s success and look for opportunities to do so, practitioners search for ways to assure success. While academicians generally have a relatively wide range of freedom in designing and conducting their work once it is approved and funded. practitioners do not enjoy such independence. They work constantly with administrators. colleagues and superiors, community leaders, and others whose support or resistance they cannot disregard without paying a dear price. They must pay attention to such matters as agency policies and community politics, public relations, and a host of other matters that will influence and often dictate design and operation of the project. Given such a situation, with such a bewitdering array of factors that practitioners must consider, they must search for and utilize anything and everything that will help them plan and conduct programs to assure success. Figure 2 reflects their situation. They will have to draw on their own training, experience and ingenuity, on their own commonsense theories and professional wisdom, on council by colleagues and consultants, and on a lot of guesswork. Thus. the actual design, the strategies chosen, the methods applied, even the final project objectives are likely to be the result of a muttifaceted. complet, disurderly, and often confusing process-very different from the logical, carefully planned, orderly process to which academicians are accustomed in their scientific research. Moreover, academicians in joint projects seek ways to assure that the implica-

Figure

1.

Characteristic rote of

theory in academical-oriented projects.


304

Figure

2.

Characteristics of

theory

in

practice-oriented projects.

tions of their theories are built into a project and their effects, whatever they may be, are given a good chance to be identified and measured. Practitioners in such a joint project, are, however, more concerned with maximizing the project’s ultimate effects in ways that may conflict with the academicians’ needs. Table I summarizes some of the more salient differences in the perspectives, values, and objectives of academicians and practitioners. While some of the differences may be overdrawn, awareness of these two orientations by each group could serve as a springboard for discussion and perhaps the development of more effective collaboration and exchange.

SOME SUGGESTIONS FOR USING THEORIES In the various papers that follow in this issue, a number of specific suggestions made for utilizing theory in practice. Here we would like to highlight several general considerations a practitioner might find useful in trying to apply theories to real-life programs. In making these suggestions, however, we are cautioned by recalling the following observation: are

...

applying general principles to specific problems in the real world can get are talking about physics or economics, the real world complex than anything you can possibly imagine in x

very messy. Whether you is always infinitely more your theories.

Identifying Helpful

Data and Other Information

Among the first project planning considerations is usually the question of what data and other information will be needed for planning and executing the project. The question deserves careful deliberation because of the risks of wasting time and funds collecting data that turn out to be superfluous, and of disDownloaded from heb.sagepub.com at Bobst Library, New York University on June 18, 2015

305 Table 1. Some Characteristic Differences between ented Projects

Theory-Oriented

and Practice-Ori-

’

.

I

later that other, potentially valuable information had been omitted. Theories and models can often minimize such risks.$ Take, for example, a project to get residents in a community’s retirement homes to comply more responsibly with their medicine regimens. The health educator could set out to collect a great variety of data about residents’ sex and ages, diagnostic categories, marital status, income, how long they had lived in the retirement home, and so on, without thinking strictly in terms of why and how such data would be helpful for planning an effective strategy. But thinking, for example, in terms of the Health Belief Model, the health educator would automatically consider collecting information about such variables as &dquo;perceived susceptibility and severity,&dquo; &dquo;cues,&dquo; &dquo;cost-benefits,&dquo; &dquo;social influences,&dquo; and other of the Model’s varia-

covering

as

$Although, strictly speaking, theories and models differ in certain ways, synonymous for the purposes of this article.

we are


treating

them

306 on how these variables arc distributed in the target population could have immediate and significant bearing on planning promising specific interventions. The health educator would probably not waste any resources on collecting such other data as mentioned earlier because it would be doubtful at best whether and how they might be used. It will also be recalled how the health educator in the weight control program was led by the several theories to collect very valuahle information but which would probably not have been considered had it not been for the theories.

bles.9-&dquo;’-’’ Information

Selecting

Theories

In attempting to apply theory, a first and most basic point is that the choice of theories should not proceed just from which theories the practitioner (or any academic consultant or coworker) happens to know best, like most, or feels most comfortable with. The choice should proceed from a planned identification of specific questions and problems that may arise in the course of the project and with which theories might help. Although this article is not the place to deal with the matching of theory to problems, we would urge practitioners to consider among other things, (1) whether they are dealing with individuals, small groups, or larger populations; (2) whether the issue is a specific and one-time or a sporadic behavior (e.g., seeking prenatal medical care or getting one’s annual mammogram) or more invasive behavior change that could bring prolonged or repeated problems (e.g., smoking cessation, a lasting schedule of daily exercise, use of condoms); (3) whether the behaviors of concern are a personal nature or are embedded in &dquo;official&dquo; contexts as would be the case, for example, in policy decisions made at a board meeting; and (4) the closeness of fit between a theory’s assumptions and the values of the group where the theory will be used to inform an intervention. The reasons for such considerations are quite self-evident. Theories that are appropriate when we work with individuals are usually inappropriate for larger populations and vice versa; and theories that point to ways by which to get people to take a particular action at a particular time, would fail us if we wished to bring about lasting changes in people’s lifestyle. Corporate and institutional actions are not very well explained by purely psychological theories. The number of projects is legion that have not lived up to expectations, mainly because theories were used that would have served well elsewhere but proved inappropriate for the purposes for which they had been chosen this time. Anticipating the resources that various theories would require in application will also limit the number of theories to be considered. Clearly, utilization of theories that involve long-term or profound changes in attitudes or habits must be expected to require far more resources in time, staff, and funds than utilization of theories aiming at short-range effects. Some theories demand specialized knowledge and command of techniques that may not be available. The application of other theories may require the development of special psychometric instruments (such as not-yet-available scales to assess individuals’ locus of control or perceived susceptibility relating to the prevention of some particular disease). Clearly, the selection of theories for a particular application should not be made


307

solely on the basis of the quality or even of the appropriateness of one or another theory alone. The practitioner must try to anticipate contingencies that may arise. Such a selective process will often much reduce the number of theories to be further considered.

Fitting

Theories to

Projects

and

Anticipating

Problems

Academicians are more or less accustomed to design research around a single theory. When working with a real-life project many researchers are consequently tempted to select what seems to be the most appropriate theory (or the one they happen to be most interested in at the time) to guide the entire project. But real-life projects are invariably far too complex and involve far too many facets to be encompassed by a single theory. Different theories may shed light on a project’s different aspects as seen in our weight-control program. The situation is much like building a bridge. There is no theory of bridge building per se. There are only theories, such as metal fatigue and stress, that are used within the construction of a bridge to guide the engineer in a multitude of decisions that must be made. And even then, there are numerous decisions to be made where there are no guiding theories to counsel the engineer. For these reasons, practitioners, engaging in a fairly large and complex project, may be well advised not to hunt for a single theory that might solve all their prohlems with the project. Rather, the practitioner should try to anticipate early in the project planning phase any major problem clusters and decision points where various theories might offer help. Although experts on theories would probably be very helpful in this task, the onus is mainly on the practitioner because few academicians have the training and experience needed to think realistically in terms of complex problems that involve factors outside the academician’s realm of competence. Thus, even excellent behavioral scientists may not be equipped to deal effectively with political, organizational, or management problems that health educators face routinely. In essence, selecting and applying theories to a fairly complex program and reaping full benefits from them demand a wedding of the academician’s and the practitioner’s respective knowledge, experience, and judgment. As said before, however, the final responsibility still is and should be the practitioner’s. Although already mentioned in passing, it is worth reiterating how important it is to try to anticipate possible findings and their practical implications from theory-informed projects. Findings that may have considerable importance to understanding a problem may not offer keys to solving it. In medicine the causes of some diseases are known but cures are still elusive. Conversely, there are effective treatments for some diseases whose causes remain a mystery. Similarly, a well-established behavioral theory may identify certain factors as leading to some self-destructive health behavior with remedial action still beyond our grasp.§ Even when we do have some notions about some remedial action, such may not be practical. Although we know many ways for intluencing people’s

§Leglslation. enforcement. and other societal respond to more subtle interventions.

pressures

are

designed

to

deal with behaviors that

do not


308

and action, we may lack the resources for applying them in certain situations. For instance, a project may be designed to get more chronically ill patients to return to a clinic for periodic check-ups. The academician on the project staff utilizes attribution theory and finds that, as the theory might predict, patients who attribute their disease to divine will are less likely to come for check-ups than patients who believe in biologic causation. One implication is that we need to change the beliefs of those who ascribe their disease to divine will, to beliefs in their own capacity to prevent recurrence of the disease. But changing such deep-seated beliefs would require considerable resources that may be in short supply. In addition, the results are quite uncertain and, at best, could take an excessively long time to become manifest. Thus, something of considerable scientific interest might be learned, but it would be of little use to either the health educator or the clinic. Unfortunately, academicians do not always think in terms of whether the results of their involvement in a project will point towards feasible interventions of immediate and practical value. It would be prudent of practitioners always to think (and to pressure academicians involved in any of their projects to think) in terms of immediate, feasible, and effective implications that might be drawn from the results of the theory component.

thoughts, feelings,

Midproject Changes Most scientific research projects must adhere to the basic project design and follow the predetermined course unalterably to the very end, regardless of what happens One can’t change variables, procedures, samples, or anything else midway. In practice, however, adjustments and even radical changes throughout a project are the rule rather than the exception. Always there are unanticipated events that require revamping of initial plans. Experienced health educators will even try to anticipate possible hitches that might develop and draw up contingency plans for introducing appropriate changes in the project if and when such hitches should become manifest. Because midstream changes in research projects are generally anathema to academicians, a suddenly arising situation that requires abrupt changes in the project delivery could cause problems for either the academician, the practitioner, or both. Because such an event is not rare, all participants need to reach an early understanding about how to handle it, should it arise. In most instances, we would say, the concerns of the practitioner ought to prevail unless it is clearly and explicitly understood at the very beginning that research considerations should be granted priority. All this leads us back to the already stated fact: theories do not tell practitioners what to do, how to plan a project, what interventions to use, any more than theories in physiology tell the physician how to treat a particular disease, or any more than theories in physics tell engineers how to build bridges or manufacture electricity. That is why we use terms like, &dquo;suggested by such and such theory&dquo; or &dquo;theory-informed&dquo; rather than &dquo;theory-determined&dquo; or &dquo;theoryIlThere

are

exceptions

such

as

is found in

qualitative and

process research.


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driven&dquo; when we speak of health education programs. &dquo;Theories ... become instruments (to search for answers), not answers to enigmas&dquo;’‘ (p. 163). And to paraphrase this: our theories are merely instruments to help us find (not tell us) the most promising designs, strategies, methods, and techniques in the process of planning our programs, and powerful instruments they can be when selected and used properly. But even the best and most proven theories are no substitute for practitioners’ training, experience, mastery of skills, knowledge, and inventiveness. Those possessing these qualities will find theories potentially powerful tools; those lacking these qualities will find them useless at best, misleading at worst. We cannot stress this too much because disillusionment with theories is very often due to expecting from them what they simply cannot deliver.

Using

Parts of Theories

Another common mistake in practice is to claim to have used a particular theory and to credit this theory for a project’s success or blame it for the project’s failure, even though actually only one or, at best, a few of the theory’s several variables have been used. As indicated above, theories are not simple lists of variables each of which by itself somehow determines an outcome. Theories deal with the interaction of variables, and it is this interaction of all the theory’s variables that are supposed to bring predicted results. We have seen earlier that, for instance, according to the theory, neither self-efficacy nor value expectancy by itself can be expected to result in some desired outcome: both conditions need to be satisfied. The most effective utilization of a theory, therefore, would entail its application in toto. Nonetheless, utilizing only a single theoretical variable can still at times contribute to a project’s effectiveness. Although efforts to assure only self-efficacy among overweight employees would probably have little effects on those with low value expectancy, it may furnish just the needed ingredient for those with high value expectancy but low self-efficacy. Similarly, health educators who wish to use the Health Belief Model could select perceived susceptibility and severity and perceived costs-and-benefits from among the Model’s variables and, assuming these are translated into effective methodology, thereby probably add to the success of the program. But they have not used the Model itself because they have not involved other of its critical variables such as &dquo;cues.&dquo; Had they also provided for proper cues in the course of the project, they would very probably have much increased its impact. And had they tried (and been able) to utilize the Model as a whole, success might well have been even more impressive. In short, a theory is more than its parts, and using only parts of a theory does not justify a claim to have used the theory itself, nor do either success or failure when using parts justify a judgment of the theory itself. Thus, although selecting single theoretical variables may at times contribute positively to a project’s impact, the full potentil of the theory may not be utilized, and there is even a risk that the use of only one or even a few of its variables may be counterproductive.


310

PRACTICE AS THE MOTHER OF THEORY The subject of the utilization of theories by practitioners has received far attention in health education literature than its obverse, utilization of practice in the realm of theory, possibly because the discussion has emanated almost exclusively from the academic side of the profession. This is a pity because almost every great scientific theory has had its root in everyday experiences. Pasteur’s revolutionary theory of fermentation, which marked the birth of microbiology. began with his observations in a beet distillery and his later observation of two herds of sheep, one healthy and one sick and dying. psychoanalytic theory emerged from Freud’s clinical experiences with neurotic patients, and, perhaps the most famous case, Darwin’s painstaking collection of data which gave birth to the theories of evolution and natural selection. Dr. Watson’s irrefutable diary has Sherlock Holmes say, &dquo;One cannot theorize, dear Watson, without facts.&dquo;~ And one could make the point that no one has more facts on which to base theories than those whose entire professional lives deal with such facts. Practitioners can offer the openminded academic many remarkable insights that can stimulate the latter to construct a new theory or revise an existing one. It is the next best thing to having academics actively and intimately involved in field work. Even serendipitous observations can be the seeds of new theories. The role of serendipity has been much misunderstood. Originally, it referred to Horace Walpole’s coinage of the term in reference to the fairytale of three princes of Serendip who. on their travel, repeatedly found things they had not expected (in Walpole’s The Three Princes of Serendip). But in science serendipity refers not just to a gratuitous, sheer-luck stumbling on something new. It refers to a mind that is prepared to see something of significance in simple phenomena that normally go unnoticed. The American physicist, Joseph Henry, spoke of &dquo;the seeds of great discoveries are constantly tloating around us, but ... only take root in minds well prepared to receive them,&dquo;13 and Robert K. Merton spoke of &dquo;serendipity&dquo; as referring to &dquo;what the observer brings to the datum rather than the datum itself. 1114 Experienced health educators have amassed a rich supply of observations and insights in people’s health-related behaviors, in the functioning of organizations, and in the interplay of local politics. Such embryonic theories emerge not from controlled experiments or repeated surveys but from getting involved in projects with people and agencies. Scientists can proceed to organize such ideas into more formal theories that allow further investigation and rigorous testing. The psychologist Paul Meehl distinguishes between &dquo;research in the context of discovery&dquo; and &dquo;research in the context of verification.&dquo; The former relies much on serendipity and qualitative research via planned and unplanned personal observations. This phase is often referred to as &dquo;hypothesis generation.&dquo; It is here where practitioners have unequalled opportunities to make their contributions to theory development-if academicians actively seek out what their practicing colleagues may have to offer. more

lfOne

can

also argue the opposite, however: and wasteful.

collecting

data without

some

usually nonproductive


guiding theory

is

311

TEACHING/LEARNING THEORIES As is true in every field of endeavor, knowing something, knowing how it is to be applied, and being able to apply it skillfully are interrelated but very different. Many a layperson who has tried to build a brick terrace and many a tourist who has studied foreign language and then tried to communicate with natives in their country can attest to this. It is also true in the realms of teaching, learning, and applying theories. Mastering a number of such theories well enough to be able to recall them on examinations and to earn good grades is not a very difficult task for most students. Nor is it a very demanding task for most teachers of theory-centered courses to teach our theories. The most demanding part may well be, as Green points out, selecting a manageable number from the burgeoning supply of theories. More difficult then learning (and teaching) theories themselves is to learn (and teach) how to apply given theories to &dquo;real-life&dquo; projects where theories usually have to be bent and twisted and adapted to uncontrollable conditions. D’Onofrio’s article in this issue offers an insightful and helpful examination of this subject. We believe that the underutilization of theories in health education practice is due less to an oversupply of theories and more to inadequate training in using them. Admittedly, we have no supportive data for this. We base this claim on strong impressions from having known, and discussed this issue with, a wide range of current students, practicing health educators, and academics. In many health education departments theory courses are taught not very differently from the way they are taught in departments of the social and behavioral sciences. In the latter, theories are considered, quite rightly, as the essential stuff of which these sciences are made. To generate, test, revise, drop, and replace theories is a sine qua non for progress in these sciences. In the professional fields in which such theories must be adopted and used, their value lies only in their applicability and utility. These properties should therefore be the foci in the theory training of future practitioners. Theories seem to be commonly taught to be memorized by students, followed only later by discussion and exercises in how they might be applied to hypothetical projects. Such may impress at least some students as indicating that knowledge of theories is itself the main course objective with their application a sort of second thought. It also may tend to create or reinforce the view, pictured earlier in Figure 1 and the subsequent discussion, that one starts with a given theory and applies it to whatever the problem may be. This view is not often effectively counteracted by subsequent efforts in the course to demonstrate and teach the uses of theory. A second problem is that program planning and evaluation as well as other practice-related subjects are usually taught, not only separate from theory but often as atheoretical. Indeed, it is not uncommon that practice-related courses are taught by faculty who are openly skeptical of the practical uses of theory, and theory courses by faculty who have relatively little, if any, field experience. An alternative might be to start with some typical problems as faced by practitioners, guide students in analyzing these, draw conclusions as to what accounts for the problems and what could be done about them, and then get

supposed


312

students to &dquo;discover&dquo; relevant theories. Exploring and teaching theories more formally only afterwards might impress students with their value and, at the same time, train them to adapt theories to situations rather than the other way around. The hypothesis underlying this proposition is that the nature of students’ first exposure to health education theories will often determine how they feel about the utility of theories regardless of what they are taught later. In addition we suggest that the &dquo;discovery of theory&dquo; be integrated into all practice-based courses. Unless students see theory and practice as mutually supportive dimensions of the profession, many will consider theory as intellectual baggage to be shed as soon as the degree has been earned rather than as devices that may, if used properly, result in greater professional competence. A better understanding of the linkage between real-life professional problems and theory could also have implications for the problem identified by Green?2 It is clearly impractical, if not impossible, to imbue all students with sufficient mastery of all present and yet-to-come theories. Teachers must bear the onus of deciding which theories to teach and which to neglect. Such decisions should, however, be based not so much on how well theories meet scientific criteria as on how readily they may serve the needs of practitioners. And this would almost surely greatly reduce the range of theories to be considered.#

CONCLUSION The last few years have seen an upsurge of concern, mainly among acadeover the limited utilization of theories and models by health educators. The concern is justified for good reasons, some of which are spelled out in this article. Any profession that is not based on sound and continuously evolving theories that yield new understanding of its problems and yield new methods, is bound to stagnate and fall behind in the face of every changing challenges. Health education has faced and met its challenges in the relatively short span of being a professional entity to a considerable degree thanks to being infused by a rich body of theories from the social and behavioral sciences. As we bemoan the apparent neglect of theories by practitioners, we might consider what health education practice would be like if it had indeed remained totally immune to the theories from these sciences and had relied totally on what could be learned from random accumulation of experiences in the field. If our profession today differs from what it was, say, 50 years ago, and surely it does differ impressively, it is due much to the infusion of more sophisticated theories which, in turn, have provided us with more effective strategies and methods. We need to remind ourselves and our students constantly of the extent to which our profession needs and depends on theories and theory-directed research to increase its effectiveness in individual programs and as a profession. In closing, we would like to direct attention to the fact that nothing said in this article places the onus on one camp or the other. Each, by performing its own role in the service of the profession, must pursue its own destined course and thereby make the contribution it is best qualified to make. However, the

micians,

#These ideas

are

of

course

appropriate only

for students who

plan

for

a


practice

career.

313

complement one another and need one another. Each can and must enrich the other’s capacity to contribute to shared goals. This fact, while widely recognized on both sides in principle, is not being utilized as widely or as effectively as it might. This article attempted (as do also the following articles) to throw light on differences and common features, on factors that have hindered more fruitful intermingling of ideas and operations, and, especially, on ways that might enable academicians and practitioners to work more profitably and comfortably with one another. two camps

References ’New Man’ in Washington for the Social Sciences. Saturday Review 1961. January 7, 2. Green LW: Foreword. In Glanz K, Lewis FM, Rimer BK (eds.), Health Behavior and Health Education: Theory, Research and Practice. San Francisco, CA, JosseyBass Publishers, 1990. 3. Glanz K, Lewis FM, Rimer BK (eds.): Health Behavior and Health EducationTheory, Research and Practice. San Francisco, CA, Jossey-Bass Publishers, 1990. 4. Heider F: The Psychology of Interpersonal Relations. New York, NY, John Wiley & 1.

Darley JG:

Sons, 1958. 5. Devellis BM: Why Theory and Attribution Theory. Unpublished presentation at the symposium, Health Education Theory: Which One and Why Bother? (Chair: Lorig K). Annual meeting of the American Public Health Association, New Orleans, LA, 1987. 6. Prochaska JO, DiClemente CC: Toward a comprehensive model of change. In Miller WR, Heather N (eds.); Treating Addictive Behavior. New York, NY, Plenum Press 1986, pp. 3-27. 7. Brownell K, Marlatt GA, Lichtenstein E, William CT: Understanding and preventing relapse. Am Psychol 41:765-782. 8. Trefil JS: Phenomena, comments, and notes. Smithsonian 16(5):24, 1985 (August). 9. Hochbaum GM: Public Participation in Medical Screening Programs: A Socio-Psychological Study. Public Health Service Publication No. 572. Washington, D.C., U.S. Government Printing Office, 1956 (2nd Ed., 1970). 10. Rosenstock IM: Why people use health services. Milbank Memorial Fund Q 44:94127, 1966 (July). 11. Becker MH: The Health Belief Model and personal health behavior. Health Educ Monog 2(4), 1874. 12. White M: The Age of Analysis. New York, NY, New American Library, 1955. 13. Cannon WB: The Way of an Investigator: A Scientist’s Experience in Medical Research. New York, NY, W.W. Norton & Co., 1945, p. 75f. 14. Merton RK: Social Theory and Social Structure. Glencoe, IL, The Free Press, 1957, p. 10.


The potential of grounded theory for health education research: linking theory and practice.

The Flipped Classroom - From Theory to Practice in Health Professional Education.

[Training -- competency-based education -- learning theory and practice].

Evaluation of nursing education programmes--theory and practice.

Surgical education and adult learning: Integrating theory into practice.

Domains for global health education and practice.

Developing a theory of nursing: the relation of theory to practice, education and research.

Integrating mental health and social development in theory and practice.

Theory and the empowerment of health education practitioners.

Health education: using a video in general practice.

The Importance of Public Health in Pharmacy Education and Practice.

The application of humanization theory to health-promoting practice.

Evaluation of competence-based teaching in higher education: From theory to practice.

Integrating theory and practice in modular schemes for basic nurse education.

Bioethics education in clinical settings: theory and practice of the dilemma method of moral case deliberation.

patient education database for family practice.

Integrative health care: implications for nursing practice and education.

Frustration: Theory and practice.

Celiprolol: theory and practice.

Theory and practice.

Deconstructing dementia and delirium hospital practice: using cultural historical activity theory to inform education approaches.

"In theory there is no difference between theory and practice - in practice there is" (Yogi Berra).

Putting theory into practice.

From theory to action: applying social determinants of health to public health practice.