Advancing Theory in Health Promotion and Community Health

Science is always seeking to generate new information and to update the old. Modern science seeks to bring fresh ideas to use and to find new ways to improve the translation of knowledge into action. Theory is instrumental in this regard. Theory has always been the underpinning of traditional scientific disciplines such as mathematics, physics, and biology; however, public health has been slow to embrace theory as a foundational element in building programs and improving practices.1,2

The development and application of sound health promotion theory are critical to public health practice and research.3 By applying theory, we can begin to understand the many influential factors that prevent or allow health promotion interventions to take hold and to help select strategies most likely to build the supportive environments needed to both foster and sustain change.4 Within a research context, theory unifies and codifies knowledge and guides the search for why people adopt, do not adopt, or abandon healthy lifestyles. From a practitioner perspective, theory organizes information into patterns that promote health and prevent diseases. For these reasons, public health efforts based on theory are more likely to succeed than those developed without it.1

Given this backdrop, we developed a request for manuscripts that have the potential to advance theory in the field. We were pleasantly surprised that this call led to a number of excellent articles that described innovative studies, cutting across a wide spectrum of health behaviors. Four studies applied theory to physical activity-related behaviors. In the first study, Hamilton and colleagues describe the theoretical framework of Project SHAPE (Shaping Health using Activity Photovoice and E-Video), a physical activity program for rural, medically underserved children. The article does an excellent job at demonstrating how theory can be translated into practice, and lessons learned when doing so. In the next study, Nazaruk and colleagues utilized the Self-Determination Theory (SDT) for physical activity among rural young and middle-aged women. The use of SDT is growing in health behavior research and is useful in the way the theory is operationalizing motivation into intrinsic and different types of extrinsic motivation. This suggests that motivation, which is a cornerstone theory in many models, may not be a 1-dimensional construct as many may think. In the third study, the community health development framework was utilized to develop physical activity interventions in 3 rural communities. Each of the 3 communities used this theoretical model in slightly different ways to achieve the same goal. This study was particularly innovative in the way it demonstrates how theory can be used as a framework to establish local priorities and goals. Finally, Heinrich and colleagues applied the Integrated Theory of Health Behavior Change to understand key factors that both facilitate and restrict participation in group-based training.

Next, Abbass-Dick and Dennis discussed a breast-feeding coparenting framework. This model was developed on the basis of a number of coparenting models and research related to fathers' involvement with breast-feeding. An innovation to this model is the inclusion of fathers for playing a key role for this health behavior. Next, Branscum and Lora utilized the Integrative Behavioral Model (IBM) of Prediction to predict maternal monitoring of fruit and vegetable consumption among Hispanic mothers. The IBM represents advancement in the Theory of Planned Behavior (TPB), and research using this model has been limited, especially compared with research still being done using the TPB. This study targeted low-income, Hispanic mothers and describes how a proper needs assessment can be done, using a new and emerging theory. In an interrelated article, Maness and Branscum present a new, unified framework for social determinants of health (SDoH), which are traditionally utilized to address health disparities at the community level. Maness and Branscum then described how this SDoH framework can be incorporated into the perceived behavioral control construct of the TPB and IBM. In the next study, Cheskin and colleagues used an innovative study design to evaluate a text message-based intervention targeting weight loss among African Americans. The innovation in this study lies in the way the theory was utilized: participants were assigned to receive message framing that was matched or mismatched to their motivational orientation. Studies that go beyond the cross-sectional design are greatly needed to advance theory-driven research.

The final studies in this issue mostly center around substance abuse, such as tobacco, alcohol, and illicit drugs. Two studies used the multitheory model (MTM) of health behavior change. The MTM was recently developed by Dr Manoj Sharma. In the first study, Sharma and colleagues described the development of an instrument based on the MTM for predicting binge drinking among college students. The innovation of this approach lies in their attention toward establishing validity and reliability of the newly developed instrument. In the second study based on the MTM, Knowlden et al used the MTM to predict intentions to initiate and sustain healthy sleep behaviors for college students. Their findings suggest the MTM is a useful model for this behavior. In the next study, Smith and colleagues evaluated the Biopsychosocial Model (BPSM) as a framework for understanding alcohol, tobacco, and marijuana (ATM) use among adolescents. Results showed that constructs of the BPSM were significant factors related to ATM use; however, not all of the theorized pathways were significant. This article demonstrates an important point about theories and how there is a need to test theories before using them in practice. Not all theories are going to work in the same way for all populations and all behaviors. While in this study, parts of the BPSM were found to be significant for ATM use among adolescents, it is likely that if the authors used the BPSM as a framework for fall prevention behaviors among the elderly, other parts of the BPSM may be useful. In the next study, researchers were interested in the Truth antismoking campaign.

In the field of public health, only a few theories are based on discrete emotions, and one of the most popular (and oldest) is the Health Belief Model, which has as its dominant theme, "Perceived Threat." Ilakkuvan and colleagues used Turner's Anger Activism Model to evaluate 2 Truth antismoking advertisements. Finally, only a few studies in this issue utilized qualitative methods. Walsh-Buhi also points out that many of our current theoretical paradigms are based on Western ideologies, which may not translate to other countries or cultures. Therefore, she conducted in-depth interviews with Native and non-Native American researchers to understand components of Indigenous theoretical perspectives, including cultural elements such as balance, social cohesion, and belongingness, which are currently absent from many traditional health behavior theories used today.

Given the enormous role behavior plays in premature morbidity and mortality, and the importance of applying behavior change theories and ecological perspectives to prevent chronic disease and injury, we hope this issue helps bring light to the importance theory holds in addressing public health problems. We were encouraged to learn that various attempts are being made to develop new theories, to modify existing ones, and to tailor applications to new and emerging health problems.5 The emphasis on intervention planning that is theory-based and occurs at multiple levels is a welcomed affirmation of modern health promotion and education.6 However, as Crosby and Noar7 point out, we still have a long way to go in theory development to keep pace with the evolution of health promotion practice. They believe that the evolution of theory "...should be practice-based, largely ecological in nature, and the resulting theories should be easily accessible to practitioners."7^(p259) We believe you will find the articles in this special issue reflect this approach and that the scholarship represented here will move the field even closer to embracing theory as a foundation for improving community health practice.

-David Sleet, PhD

-Paul Branscum, PhD, RD

-Adam P. Knowlden, PhD, MS, CHES, MBA

REFERENCES