P6050_HB1_Glanz2010

ANRV405-PU31-26 ARI 22 February 2010 17:2

The Role of BehavioralScience Theory inDevelopment andImplementation of PublicHealth InterventionsKaren Glanz1 and Donald B. Bishop2

1Schools of Medicine and Nursing, University of Pennsylvania, Philadelphia, Pennsylvania19104; email: [email protected] Department of Health, St. Paul, Minnesota 55164;email: [email protected]

Annu. Rev. Public Health 2010. 31:399–418

First published online as a Review in Advance onJanuary 4, 2010

The Annual Review of Public Health is online atpublhealth.annualreviews.org

This article’s doi:10.1146/annurev.publhealth.012809.103604

Copyright c© 2010 by Annual Reviews.All rights reserved

0163-7525/10/0421-0399$20.00

Key Words

theoretical frameworks, concepts, health behavior, strategies,ecological perspective

AbstractIncreasing evidence suggests that public health and health-promotioninterventions that are based on social and behavioral science theoriesare more effective than those lacking a theoretical base. This article pro-vides an overview of the state of the science of theory use for designingand conducting health-promotion interventions. Influential contempo-rary perspectives stress the multiple determinants and multiple levels ofdeterminants of health and health behavior. We describe key types oftheory and selected often-used theories and their key concepts, includ-ing the health belief model, the transtheoretical model, social cognitivetheory, and the ecological model. This summary is followed by a reviewof the evidence about patterns and effects of theory use in health behav-ior intervention research. Examples of applied theories in three largepublic health programs illustrate the feasibility, utility, and challenges ofusing theory-based interventions. This review concludes by identifyingcross-cutting themes and important future directions for bridging thedivides between theory, practice, and research.

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Interventions:programs andstrategies intended toinfluence healthand/or health-relatedbehavior positively

Theory: set ofinterrelated concepts,definitions, andpropositions thatexplain or predictevents or situations byspecifying relationsamong variables

Ecologicalperspective: view thatpublic health/health-promotioninterventions shouldtarget individual-,interpersonal-,organizational-, andenvironmental-levelfactors

INTRODUCTION

The most prominent contributors to death anddisease in the United States and globally arebehavioral factors, particularly tobacco use, dietand activity patterns, alcohol consumption, sex-ual behavior, and avoidable injuries (22, 75).Effective public health programs to help peo-ple maintain and improve health, reduce dis-ease risks, and manage illness usually requirebehavior change at many levels (e.g., individ-ual, organizational, and community). The mostsuccessful public health programs and initia-tives are based on an understanding of healthbehaviors and the contexts in which they occur(32, 33, 36, 38, 39). Strategic planning modelsprovide a structured framework for develop-ing and managing public health interventionsand improving them through evaluation (11,45). Health behavior theory can contribute toprogram planning and evaluation and to ad-vance research to test innovative interventionstrategies (24, 39).

Interventions to improve health behaviorcan be best designed with an understanding ofrelevant theories of behavior change and theability to use them skillfully (12, 39). A growingbody of evidence suggests that interventions de-veloped with an explicit theoretical foundationor foundations are more effective than thoselacking a theoretical base and that some strate-gies that combine multiple theories and con-cepts have larger effects (4, 63, 78). The scienceand art of using health behavior theories re-flect an amalgamation of approaches, methods,and strategies from social and health sciences.This broad range of perspectives from health,social, and behavioral sciences are referred toas “behavioral science theory” throughout thisarticle. Influential work draws on the theoreti-cal perspectives, research, and practice tools ofsuch diverse social and behavioral science disci-plines as psychology, sociology, social psychol-ogy, anthropology, communications, nursing,economics, and marketing. As the research lit-erature grows, it is increasingly important thatthe evidence base becomes accessible to bothresearchers and practitioners (112).

This article provides an overview of contem-porary behavioral science theory use for devel-opment and implementation of public healthand health promotion interventions. The firstsection gives broad context to influential con-temporary perspectives on the multiple deter-minants and multiple levels of determinants ofhealth and health behavior and defines theoryand key types of theory. We next describe se-lected often-used theories and their key con-cepts and summarize the evidence about theuse of theory in health behavior interventionresearch. Examples of the application of theo-ries in large public health programs illustratethe feasibility, utility, and challenges of usingtheory-based interventions. Finally, this reviewidentifies cross-cutting themes and importantfuture directions for bridging the divides be-tween theory, practice, and research.

Multiple Determinants and MultipleLevels of Health Behavior

Many social, cultural, and economic factorscontribute to the development, maintenance,and change of health behavior patterns (101).No single factor or set of factors adequately ac-counts for why people eat as they do, smokeor do not smoke, and are active or sedentary.Knowledge, attitudes, reactions to stress, andmotivation are important individual determi-nants of health behavior. Families, social re-lationships, socioeconomic status, culture, andgeography are other important influences. Abroad understanding of some of the key fac-tors and models for understanding behaviorsand behavior change can provide a foundationfor well-informed public health programs, helpidentify the most influential factors for a partic-ular person or population, and enable programdevelopers to focus on the most salient issues.

Public health and health-promotion inter-ventions are most likely to be effective if theyembrace an ecological perspective (71, 100).Interventions should not only be targeted atindividuals but should also affect interper-sonal, organizational, and environmental fac-tors influencing health behavior. This mindset

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is clearly illustrated when one thinks of the con-text of groups of employees purchasing foodand eating during the work day. Employeesmay bring their food with them from home orbuy food from workplace cafeterias and vend-ing machines. Their choices are influenced bypersonal preferences, habits, nutrition informa-tion, availability, cost, and placement, amongother things. The process is complex and de-termined not only by multiple factors but byfactors at multiple levels.

Before the 1970s, public health educationemphasized a broad view of social determinantsof health, and community organization skillswere central to training programs (33). Duringthe next two decades, health educators and clin-icians focused more on intraindividual factorssuch as a person’s beliefs, knowledge, and skills.Many behavior-change programs for reducingrisk factors continue to have these emphases(62, 78, 118). Current views reflect a returnto earlier public health roots and suggest thatthinking beyond the individual to the social mi-lieu and environment can enhance the chanceof successful health promotion (100). Programplanners can and should work toward under-standing the various levels of influence that af-fect individuals’ and populations’ behaviors andhealth status.

What is Theory, Explanatory Theory,and Change Theories?

A theory presents a systematic way of under-standing events, behaviors, and/or situations(36). A theory is a set of interrelated concepts,definitions, and propositions that explain orpredict events or situations by specifying rela-tions among variables. The notion of generality,or broad application, is important (32, 33, 38,39). Thus, theories are, by their nature, abstractand not content- or topic-specific. Even thoughvarious theoretical models of health behaviormay reflect the same general ideas, each the-ory employs a unique vocabulary to articulatethe specific factors considered to be important.Theories vary in the extent to which they havebeen conceptually developed and empirically

tested; however, testability is an important fea-ture of a theory (109).

Theories can guide the search to un-derstand why people do or do not practicehealth-promoting behaviors, help identify whatinformation is needed to design an effectiveintervention strategy, and provide insight intohow to design a program so that it is successful(39, 51). Theories and models help explain be-havior, as well as suggest how to develop moreeffective ways to influence and change behav-ior. These two types of theory—explanatorytheory and change theory—may have differ-ent emphases but are quite complementary.For example, understanding why an employeesmokes is one step toward a successful cessationeffort, but even the best explanations will notbe enough by themselves to fully guide changeto improve health. Some type of change modelwill also be needed. All the theories and modelsdescribed here have some potential as bothexplanatory and change models, although theymight be better for one or the other purpose.For example, the health belief model (20) wasoriginally developed as an explanatory model,whereas the stages of change construct of thetranstheoretical model (87) was conceived tohelp guide planned change efforts.

IMPORTANT THEORIES ANDTHEIR KEY CONSTRUCTS

Theories that gain recognition in a disciplineshape the field, help define the scope of prac-tice, and influence the training and socializa-tion of its professionals. Today, no single theoryor conceptual framework dominates researchor practice in health promotion and education.However, reviews of journal articles publishedin the past two decades across a broad range ofhealth behavior topics have revealed the mostoften used theories and trends in theory use. Ina review of 116 theory-based articles publishedbetween 1986 and 1988 in two major healtheducation journals, 51 distinct theoretical for-mulations were identified. At that time, thethree most frequently mentioned theories weresocial learning theory, the theory of reasoned

www.annualreviews.org • Behavioral Theory in Public Health 401

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HBM: health beliefmodel

SCT: social cognitivetheory

TRA: theory ofreasoned action

TPB: theory ofplanned behavior

TTM: thetranstheoretical model

action (TRA), and the health belief model(HBM) (32).

In another review of 526 articles from 24different journals published from mid-1992to mid-1994, the majority of all instances oftheory use were accounted for by five theories:HBM; social cognitive theory (SCT) (theupdated version of social learning theory) (6)and self-efficacy construct (7); the TRA and itsnew version, the theory of planned behavior(TPB) (2); the transtheoretical model/stagesof change (TTM); and social support/socialnetworks (33).

In our review of journal articles published in1999 and 2000, ten theories or models clearlyemerged as the most often used. The firsttwo, and the most dominant, were SCT andTTM/stages of change. Other often-used the-ories and models were the HBM, social sup-port and social networks, the TRA/TPB, stressand coping, community organization, ecolog-ical models/social ecology, and diffusion ofinnovations (38).

In another recent, updated review of the-ory use in published research between 2000 and2005, the most often used theories were TTM,SCT, and the HBM (84). Overall, the same the-ories dominate late in the current decade as didin 1999 and 2000 (39). Dozens of theories andmodels have been used, although only a few ofthem were used in multiple publications and byseveral authors. To provide context for the restof this review, we briefly describe the centralelements of four of the most widely used theo-retical models of health behavior.

Health Belief Model

The HBM was one of the first theories of healthbehavior and remains one of the most widelyrecognized in the field. It was developed tohelp understand why people did or did not usepreventive services offered by public health de-partments in the 1950s (50) and has evolvedto address newer concerns in prevention anddetection (e.g., mammography screening, in-fluenza vaccines) as well as lifestyle behav-iors such as sexual risk behaviors and injuryprevention (20).

The HBM theorizes that people’s beliefsabout whether they are at risk for a disease orhealth problem, and their perceptions of thebenefits of taking action to avoid it, influencetheir readiness to take action (20, 36, 93). Thekey constructs of perceived susceptibility andperceived severity, perceived benefits and per-ceived barriers, cues to action, and the morerecent addition of self-efficacy (95) are the coreconstructs of the HBM. The HBM has beenapplied most often for health concerns that areprevention-related and asymptomatic, such asearly cancer detection and hypertension screen-ing, where beliefs are as important or more im-portant than overt symptoms. The HBM is alsoclearly relevant to interventions to reduce riskfactors for cardiovascular disease (118).

Transtheoretical Model/Stagesof Change

Long-term changes in health behavior involvemultiple actions and adaptations over time.Some people may not be ready to attemptchanges, whereas others may have already be-gun implementing changes in their smoking,diet, activity levels, etc. The construct of stageof change is a key element of the TTM of be-havior change and proposes that people are atdifferent stages of readiness to adopt health-ful behaviors (87). The notion of readiness tochange, or stage of change, has been examinedin health behavior research and was found use-ful in explaining and predicting changes for avariety of behaviors including smoking, phys-ical activity, and eating habits (e.g., 25, 35,67). The TTM has also been applied in manysettings (87).

Stages of change is a heuristic model that de-scribes a sequence of steps in successful behav-ior change: precontemplation (no recognitionof need for or interest in change), contempla-tion (thinking about changing), preparation(planning for change), action (adopting newhabits), and maintenance (ongoing practice ofnew, healthier behavior) (87). People do notalways move through the stages of change ina linear manner; they often recycle and repeat

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certain stages (e.g., individuals may relapse andgo back to an earlier stage depending on theirlevels of motivation and self-efficacy).

The stages of change model can be used bothto help understand why people who are at highrisk for diabetes might not be ready to attemptbehavioral change and to improve the successof health counseling. Another application of thestages of change model in organizations andcommunities involves conceptualizing organi-zations along the stages-of-change continuumaccording to their leaders’ and members’ (e.g.,employees’) readiness for change (13, 86).

Social Cognitive Theory

SCT, the cognitive formulation of social learn-ing theory that has been best articulated byBandura (6), explains human behavior in termsof a three-way, dynamic, reciprocal model inwhich personal factors, environmental influ-ences, and behavior continually interact (70).SCT synthesizes concepts and processes fromcognitive, behavioristic, and emotional modelsof behavior change, so it can be readily appliedto counseling interventions for disease preven-tion and management. A basic premise of SCTis that people learn not only through their ownexperiences, but also by observing the actionsof others and the results of those actions (6,70). Key constructs of SCT that are relevant tohealth behavior change interventions includeobservational learning, reinforcement, self-control, and self-efficacy (118). Some elementsof behavior modification based on SCT con-structs of self-control, reinforcement, and self-efficacy include goal-setting, self-monitoring,and behavioral contracting. As is discussed be-low, goal-setting and self-monitoring seem tobe particularly useful components of effectiveinterventions.

Self-efficacy, or a person’s confidence in hisor her ability to take action and to persist inthat action despite obstacles or challenges, isespecially important for influencing health be-havior change efforts (7). Health providers canmake deliberate efforts to increase patients’self-efficacy using three types of strategies:

(a) setting small, incremental and achievablegoals; (b) using formalized behavioral contract-ing to establish goals and specify rewards; and(c) monitoring and reinforcement, includingpatient self-monitoring by keeping records (6).

The key SCT construct of reciprocal deter-minism means that a person can be both anagent for change and a responder to change.Thus, changes in the environment, the exam-ples of role models, and reinforcements canbe used to promote healthier behavior. Thiscore construct is also central to social ecologicalmodels and is more important today than everbefore.

Social Ecological Model

The social ecological model helps users to un-derstand factors affecting behavior and alsoprovides guidance for developing successfulprograms through social environments. Socialecological models emphasize multiple levelsof influence (such as individual, interpersonal,organizational, community, and public policy)and the idea that behaviors both shape and areshaped by the social environment (71, 100). Theprinciples of social ecological models (of whichseveral have been proposed) are consistent withSCT concepts, which suggest that creating anenvironment conducive to change is importantto facilitate adoption of healthy behaviors (6).For example, given the growing epidemic ofobesity in the United States and other devel-oped countries, more attention is being focusedtoward examining and improving the health-promoting features of communities and neigh-borhoods and reducing the ubiquity of high-calorie, high-fat food choices (104, 114).

REVIEWS OF THEORY USEIN INTERVENTIONS

Which Theories Have Been Used,and With What Findings?

The analyses described in the preceding sec-tion reveal the dominant theories across thebroad arena of health behavior research andtrends over the past two decades. In addition


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to these reviews, several reviews have also ex-amined which theories were used and whethertheory-based strategies are positively associatedwith desirable effects. One important indicatorof increased attention to theory in evidence re-views is inclusion of description and coding ofthe theoretical bases of interventions in author-itative systematic reviews such as those con-ducted by the Task Force on Community Pre-ventive Services (121).

Table 1 summarizes 11 systematic reviewspublished since 2000—most within the pasttwo years—that reported on theory use and,in several cases, the effects of using theoriesfor intervention design. They cover a rangeof behavioral topics: dietary fat and fruit andvegetable intake (4), cancer screening (3, 63),injury prevention (108), HIV-related sexual riskbehaviors (77, 79, 81), and contraception (65).These reviews also examined tailored print andcomputer-based interventions (3, 66, 78, 79).

As shown in Table 1, the most-oftenused theories in the areas reviewed are SCT,the TTM/stages of change, the HBM, theTPB, and the PRECEDE/PROCEED plan-ning model. These findings are similar to thosein general reviews of the literature (above) andshow that a small number of theories are beingused to develop and test interventions.

Few of these reviews compared the relativeeffects of using different theories as the basisfor interventions, but several explored whetherhaving a theoretical foundation led to larger ef-fects. Several reviews concluded that interven-tions based on theory or explicitly describedtheoretical constructs were more effective thanthose not using theory (3, 4, 63, 65, 77–79).The mechanisms that explain these larger ef-fects have not been studied. The use of theo-ries that fit well with the problems and con-text in the studies might explain the success oftheory-based interventions. It is equally plausi-ble that theory-based strategies are developedwith greater care, fidelity, and structure. Theremay be other explanations as well.

Most of these reviews examined individ-ual and small-group interventions, and fewaddressed organizational change or provider

behavior (111) or community-level interven-tions (97). The absence of these broader-levelreviews mirrors the smaller literature base ofempirical research that uses theories at the or-ganizational and community levels (39).

How Has Theory Been Used?

Along with published observations about whichtheories are being used, concerns have beenraised about how the theories are used (or notused) in research and practice (84, 108, 115).A common refrain is that researchers may notunderstand how to measure and analyze con-structs of health behavior theories (69, 89) orthat they may pick and choose variables fromdifferent theories in a way that makes it diffi-cult to ascertain the role of theory in interven-tion development and evaluation.

Building on our earlier distinctions amongthe type and degree of theory use (31), Painterand colleagues’ recent review of theory usefrom 2000 to 2005 (84) classified articles thatemployed health behavior theory along a con-tinuum: (a) informed by theory (a theoreticalframework was identified, but no or limitedapplication of the theory was used in specificstudy components and measures), (b) appliedtheory (a theoretical framework was specified,and several of the constructs were applied incomponents of the study), (c) tested theory(a theoretical framework was specified, andmore than half the theoretical constructs weremeasured and explicitly tested, or two or moretheories were compared with each other in astudy), or (d ) building/creating theory (new orrevised/expanded theory was developed usingconstructs specified, measured, and analyzed ina study). Of all the theories used in the sampleof articles (n = 69 articles using 139 theories),69.1% used theory to inform a study, 17.9% oftheories were applied, 3.6% were tested, andonly 9.4% involved building/creating theory(84). These findings are consistent with the callsby Noar & Zimmerman (82) and Weinstein &Rothman (116) for more thorough applicationand testing of health behavior theories toadvance science and move the field forward.

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Tab

le1

Rev

iew

sof

theo

ryus

ein

heal

thbe

havi

orin

terv

enti

onre

sear

cha

Art

icle

Top

ical

focu

sT

heor

ies

used

Com

men

tsA

mm

erm

anet

al.

2002

(4)

Die

tary

fat,

frui

tand

vege

tabl

e(F

&V

)con

sum

ptio

nT

heor

yus

eye

s/no

;SC

Tco

nstr

ucts

(goa

lse

ttin

g);s

ocia

lsup

port

Usi

nga

theo

retic

alba

sis

was

asso

ciat

edw

ithgr

eate

rfa

tre

duct

ion

and

high

erF&

Vin

take

Goa

lset

ting,

fam

ily,a

ndso

cial

supp

orts

trat

egie

sw

ere

mor

eef

fect

ive.

Leg

ler

etal

.200

2(6

3)M

amm

ogra

phy

prom

otio

nin

hist

oric

ally

unde

rser

ved

grou

psT

heor

yus

edin

68.4

%of

incl

uded

stud

ies.

Mos

tuse

d:H

BM

,TT

M,S

CT

,P

RE

CE

DE

/PR

OC

EE

D

Stro

nges

tint

erve

ntio

nsw

ere

acce

ss-e

nhan

cing

,con

sist

ent

with

SCT

,HB

M,a

ndec

olog

ical

mod

el.

Tri

filet

tiet

al.2

005

(108

)U

nint

entio

nali

njur

ypr

even

tion

rese

arch

Mos

tuse

d:T

RA

/TP

B,H

BM

,P

RE

CE

DE

/PR

OC

EE

Dm

odel

The

orie

sw

ere

notw

ellr

epre

sent

edin

inju

rypr

even

tion

rese

arch

from

1980

to20

01.

Noa

ret

al.2

007

(78)

Tailo

red

prin

thea

lthbe

havi

orch

ange

inte

rven

tions

TT

M/s

tage

sofc

hang

e,H

BM

,TR

A/T

PB

,m

ostu

sed.

Nea

rly

ever

yst

udy

tailo

red

onat

leas

tone

theo

retic

alco

ncep

t

Tailo

ring

with

4–5

conc

epts

yiel

ded

larg

eref

fect

size

stha

ndi

dta

ilori

ngon

0–3

conc

epts

.Nea

rly

alls

tudi

esth

atta

ilore

don

theo

retic

alco

nstr

ucts

had

larg

eref

fect

size

s.Jo

rone

net

al.2

008

(59)

Scho

ol-b

ased

dram

ain

terv

entio

nsSC

T,T

TM

Use

ofSC

Tw

asm

ostc

omm

on(r

ole

mod

els,

inte

ract

ion,

etc)

.Mos

tlypo

sitiv

eef

fect

sw

ere

foun

d.N

oar

2008

(77)

Red

ucin

gH

IV-r

elat

edse

xual

risk

beha

vior

;rev

iew

of18

met

a-an

alys

es

Mos

toft

enm

entio

ned:

self-

man

agem

ent,

prob

lem

-sol

ving

trai

ning

,ski

llstr

aini

ngw

ithSC

Tco

ncep

ts

3m

eta-

anal

yses

foun

dth

eory

-bas

edst

rate

gies

tobe

supe

rior

,2sh

owed

poss

ible

evid

ence

,and

2w

ere

null

orag

ains

tthe

ory-

base

dco

mpo

nent

s.A

lbad

aet

al.2

009

(3)

Tailo

red

info

rmat

ion

abou

tcan

cer

risk

and

scre

enin

gM

ostu

sed

wer

eT

TM

,HB

M,S

CT

,and

PAP

MR

evie

wsu

gges

ted

that

theo

ry-b

ased

inte

rven

tions

are

mos

teff

ectiv

e.L

opez

etal

.200

9(6

5)In

terv

entio

nsfo

rco

ntra

cept

ion

(non

-hig

h-ri

skgr

oups

)SC

Tw

asth

em

ain

theo

retic

alba

sis

inm

ostt

rial

sT

heor

y-ba

sed

inte

rven

tion

grou

psha

dm

ore

posi

tive

resu

ltsin

mos

ttri

als

Lus

tria

etal

.200

9(6

6)C

ompu

ter-

tailo

red

inte

rven

tions

deliv

ered

over

the

Web

;var

ious

beha

vior

s(d

iet,

activ

ity,a

lcoh

ol,

smok

ing)

Mos

tuse

dth

eori

esar

eSC

T,T

TM

,and

TR

A/T

PB

.Mos

tstu

dies

indi

cate

da

theo

retic

alfr

amew

ork.

Use

ofm

ultip

leth

eori

esan

dco

ncep

tsw

asco

mm

onbe

caus

eon

line

com

pute

r-ta

ilore

dst

rate

gies

are

mor

eco

mpl

exth

anpr

intt

ailo

ring

.

Noa

ret

al.2

009

(79)

Com

pute

rte

chno

logy

–bas

edH

IVpr

even

tion

inte

rven

tions

The

orie

sus

ed:S

CT

,TP

B,I

MB

,and

TT

MIn

terv

entio

nsus

ing

TT

M/s

tage

sof

chan

gean

din

divi

dual

tailo

ring

wer

em

oste

ffec

tive.

Noa

ret

al.2

009

(81)

HIV

/AID

Sm

ass

com

mun

icat

ion

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NBCCEDP:National Breast andCervical Cancer EarlyDetection Program

Well-IntegratedScreening andEvaluation forWomen Across theNation(WISEWOMAN)program: publichealth program tooffer risk factor–screening and lifestyleinterventions to low-income women atNBCCEDP cancer-screening locations

A further concern relates to the external va-lidity of studies that test theory-based interven-tions (42). The difficulty of reliably translatingtheory into interventions to improve clinicaleffectiveness has led to calls for more “prag-matic trials” (116) and increasing attention tothe generalizability and translation of interven-tions into real-world clinical practice (80, 96)and community settings (42, 83, 91). These im-portant issues should encourage us to questionhow we use theory, how we test theory, howwe turn theories into interventions, and whatconclusions we draw from research.

APPLICATIONS OF THEORYIN PUBLIC HEALTHINTERVENTIONS

Current examples of large-scale women’shealth interventions and a statewide health-improvement program illustrate the ap-plication, opportunities, and challenges ofdeveloping, delivering, disseminating, andevaluating theory-based and theory-informedpublic health programs. This section describesthese programs to highlight applications ofsocial and behavioral science theory for healthimprovement.

Women’s Health Programs

Large, widely disseminated women’s healthprograms have largely used behavioral sciencetheories to help develop core interventionsand to train managers and interventionists toconduct programs for diverse groups of womenin a wide range of locales. The NationalBreast and Cervical Cancer Early DetectionProgram (NBCCEDP) was established in1991 as a nationwide, comprehensive publichealth program to increase access to breastand cervical cancer–screening services formedically underserved women (48). TheWISEWOMAN project (Well-IntegratedScreening and Evaluation for Women Acrossthe Nation) provides cardiovascular disease riskfactor–screening and lifestyle interventions tounder- and uninsured women in conjunctionwith the NBCCEDP in many states (107, 119).

Analysis of theory use in recruitmentand professional development in theNBCCEDP. The NBCCEDP has expandedand operated continuously for nearly twodecades and currently operates in all 50states, five U.S. territories, and 12 AmericanIndian/Alaska Native tribal organizationsto provide screening services for breast andcervical cancer. The program screens hundredsof thousands of women each year (19). Theprogram has narrowed the gap in early detec-tion for breast and cervical cancers betweenwhite women and African Americans but notfor Hispanics (1).

Two of the major components of theNBCCEDP are interventions to improve howhealth care professionals perform their jobs—professional development—and interventionsto enroll, or recruit, eligible women intobreast and cervical cancer–screening services(18). These program components parallel thetypes of interventions to promote screen-ing that were systematically reviewed by theTask Force on Community Preventive Ser-vices (106): “provider-directed” and “client-directed” interventions (9, 10, 98). These typesof interventions often have foundations in be-havioral science theory (55, 63), and expertshave concluded that the application of theorycan contribute to their effectiveness (23, 55,63).

Escoffery (29) recently completed inter-views with 59 program-development coordi-nators and 61 recruitment coordinators inNBCCEDP programs. The main aims of thestudy were to inventory NBCCEDP grantees’recruitment and professional development ac-tivities, to assess the extent to which evidence-based cancer-prevention strategies were used,and to understand the bases for and evaluationof these strategies.

The interviewers asked respondents if oneor more theories were used as a basis forintervention strategies. Responses to open-ended questions were coded by two inde-pendent coders. Just under 50% of respon-dents stated that a theory or theories wereused to design the professional development

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(provider-directed) strategies. The most com-monly mentioned theories were adult learn-ing theory, social influence theory, diffusionof innovations, and stages of change. For re-cruitment, or client-directed strategies, 27% ofresponding coordinators named one or moretheories, including social marketing, stages ofchange/TTM, HBM, social influence theory,social networks, and peer-to-peer theory. A fewpeople responded by merely listing a conceptor term, not a theory; and others said theythought that a theory was used to design thestrategy or system, but they did not know whatit was called (29). When asked why particularprofessional-development or recruitment activ-ities were chosen, some of the most commonreasons for each were the organization’s sup-port, the low cost, and the ease of implementa-tion of the activity (29).

These findings provide a window to theworld of public health practice and indi-cate that practitioners—in this case, programcoordinators—have a moderate level of aware-ness of theory and theoretical constructs thatare used in their interventions. The roleof theory in ongoing program planning andevaluation for the NBCCEDP appears to besecondary to practical concerns. This is not sur-prising and raises the question of how, and atwhich level, practitioners can best integrate the-ory into large-scale public health programs.

The role of theory in the WISEWOMANprogram: lifestyle interventions, commu-nity linkages, and environment and organi-zational change. The WISEWOMAN pro-gram began in 1995 in three states (phaseI, 1995–1998), was expanded to 16 state andtribal health agencies (phase II, 1999–2007),and currently funds 21 programs in phase III(since June 2008) (107, 118, 119; http://www.cdc.gov/WISEWOMAN/). The program of-fers assessments of cardiovascular disease(CVD) risk factors (blood pressure, choles-terol, smoking, weight, diet, and physical ac-tivity) to low-income and uninsured women atNBCCEDP cancer-screening locations. Datafrom these screening assessments have consis-

CVD: cardiovasculardisease

tently revealed high rates of risk factors amongthose attending the program: More than 80%of women have at least one risk factor, and morethan three-fourths are overweight or obese (92,102, 107, 118).

From the beginning, WISEWOMANprogram sites have conducted and evaluatedlifestyle change interventions to reduce CVDrisk through improved nutrition and increasedphysical activity (107). Although interventionsvary across project sites, the “enhanced inter-ventions” are required to be evidence-based,culturally relevant to local populations, andgrounded in behavioral science theory (107,118). The first project sites used strategies basedon the socioecologic model, SCT, stages ofchange/TTM, social support and lay health ad-visors, and the HBM (107). Two core constructsare included in the standard intermediate mea-sures: readiness to change and barriers tobehavior change. Readiness to change is a keyconstruct of the TTM, and barriers to changecan be conceptualized as related to the HBM,the TTM, social cognitive theory, and othertheories.

The lifestyle change interventions arelocally tailored and vary in intensity and havebeen evaluated in several studies, including ran-domized controlled trials, quasi-experiments,case studies, and mixed-method evaluations(14, 15, 30, 54, 61, 64, 92, 102, 110). Thedata clearly show that lifestyle interventionsdelivered in WISEWOMAN are feasible andacceptable for reaching socially and medicallyvulnerable women (46, 118). Comparisons ofminimal interventions and enhanced inter-ventions of various types have revealed thatenhanced interventions achieved incrementallygreater, but modest, changes in nutrition,physical activity, and some risk factors(118).

A close look at the theoretical bases ofthe interventions and published programevaluations is useful in analyzing the strengthsand limitations of WISEWOMAN, whichby all accounts is an exemplary public healthintervention that has grown to be widelydisseminated for more than a decade. The


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RE-AIM model:Reach, Efficacy, andAdoption,Implementation,Maintenance Model

SHIP: StatewideHealth ImprovementProgram (Minnesota)

focal theoretical constructs used in counselingsessions usually focus on self-monitoring, readi-ness to change, self-efficacy, social support,goal-setting with monitoring and reinforce-ment, and overcoming barriers (118). Cross-cutting themes—often lumped with “theory”but not actually theories at all—includeindividual tailoring and multiculturalism(107, 118).

Case studies with program leaders and man-agers from the first three WISEWOMANstates yielded important lessons about these in-terventions. First, respondents identified theneed to change organizational culture andprovider practices at the clinical sites. Second,they noted that reaching beyond a focus on in-dividuals is a key challenge (110). A survey ofcounselors in the program by Jilcott and oth-ers (58) showed that those who had conductedenhanced intervention sessions had higher self-efficacy for their effectiveness and spent moretime with participants. They commonly citedthe lack of time as a barrier and reportedchallenges to the program’s sustainability. Thefindings suggest that organizational and envi-ronmental challenges may interact with the ef-fectiveness of individual counseling and mayeven impede its effectiveness.

WISEWOMAN program managers andfunders increasingly began to recognize that thefocus on individual behavior change might limitthe program’s potential to influence CVD dis-parities successfully. They spoke of the needto incorporate environmental and organiza-tional strategies (74, 120), potentially bring-ing the program closer to the central tenetsof the socioecological framework (5, 71, 100).A North Carolina Enhanced WISEWOMANprogram was developed to better link clini-cal care to community resources, integratingchronic care model elements into the existingWISEWOMAN model (57). An analysis (bythese authors) of the recommended interven-tions suggests that several of the enhanced in-terventions in the program focus on encourag-ing patients to try to change their environmentsrather than having the program or its staff mo-bilize social or built environment change (e.g.,

increasing available healthy food, reducing thecost of physical activity programs).

Two unique, recent studies of WISE-WOMAN used the RE-AIM framework(Reach, Efficacy, and Adoption, Implementa-tion, Maintenance), an evaluation model thatfits well with theory-driven programs (42). Thefirst study used a mixed-method approach thatcompared high- and low-performing sites toidentify best practices for WISEWOMAN pro-grams (14). High performers were more likelyto ensure that appropriate behavior change the-ory was understood and applied by staff inlifestyle interventions and to train local staffon how to use behavior change theories fortheir clients and to reinforce their own behavior(15). The second study used WISEWOMANand NBCCEDP data to compare two high-performance sites with two low-performancesites on all five RE-AIM dimensions. They con-cluded that RE-AIM provides a richer measureof how contextual factors operate in successfulprograms than do evaluation approaches thatare merely effectiveness-focused (30).

The WISEWOMAN program providessubstantial food for thought and is an impor-tant application using theory, research, andpractice in a large public health intervention.The lifestyle counseling components are wellaligned with behavioral theories. Many futurechallenges for the future of the program pointto the need for increased use of a social ecolog-ical model (119).

Minnesota Statewide Health ImprovementProgram. The Statewide Health Improve-ment Program (SHIP) was developed inresponse to the 2007 Minnesota Legislature’srequest to develop a plan for statewide healthpromotion to address the rising cost of healthand health care. The goal of SHIP (http://www.health.state.mn.us/healthreform/ship)is to reduce the burden of chronic disease byreducing the percentage of Minnesotans whouse or are exposed to tobacco and who are obeseor overweight. SHIP is modeled after Steps toa Healthier US (http://www.cdc.gov/steps),a federal initiative tested in four Minnesota

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communities. Building on the successes ofSteps, SHIP was designed to use effective,evidence-based strategies to create changes inpolicies, environments, and systems to supporthealthy behaviors in communities throughoutMinnesota.

The approach taken by SHIP communitiesfollows an ecological model, supporting multi-ple levels of influence on behavior, i.e., intra-personal, interpersonal, organizational, com-munity, and public policy (100). An ecologicalmodel provides a framework to guide healthycommunity initiatives to include not only indi-viduals and families, but also institutions, sys-tems, and the social and physical environmentsof a community. SHIP applies the New Spec-trum of Prevention (21), which was first devel-oped in 1982 by a county public health agency(and modified in 1996). This framework re-flects the core tenets of the ecological model(100) through seven levels: (a) strengtheningindividual knowledge and skills, (b) promotingcommunity education, (c) educating providers,(d ) fostering coalitions and networks, (e) chang-ing organizational practices, ( f ) mobilizingneighborhoods and communities, and ( g) in-fluencing policy and legislation.

For years, local public health in Minnesotahas practiced primarily at the first three lev-els. Recently, and especially around tobacco,the focus has broadened to include the latterfour levels. To further support this trend andachieve fundamental changes in environmentslikely to support and sustain healthy behaviors,the SHIP community grantees will focus prin-cipally on these broader levels in the spectrum.To help accomplish this change in focus, theSHIP communities will select their interven-tions from a Menu of Interventions included inthe recent request for proposals.

Each intervention in the Menu(s) meets sev-eral criteria. Interventions should address atleast one SHIP risk factor (tobacco, physi-cal activity, nutrition); occur in at least oneSHIP setting (school, community, work site,or health care); be population-based versusindividual-based; emphasize prevention versusindividual treatment; address policy, systems, or

CDC: Centers forDisease Control andPrevention

environmental change; be evidence-based oruse practice-based evidence; and have associ-ated evaluation outcomes.

All interventions selected to be included inthe Menu underwent a rigorous review pro-cess conducted by the Minnesota Departmentof Health (MDH) and by multiple stakeholdersincluding representatives from the Centers forDisease Control and Prevention (CDC), healthcare providers, nonprofit organizations, legalorganizations, cultural groups, University ofMinnesota and Extension Services, local publichealth agencies, tribal governments, and otherstate government agencies (26).

The majority of the physical activity andtobacco interventions on the Menu of In-terventions are based on either the CDC’sGuide to Community Preventive Services (121)or CDC’s “Best Practices for ComprehensiveTobacco Control Programs.” These publica-tions and their supporting documents are con-sidered gold standards for selecting evidence-based strategies. Programmatic interventionswere either excluded or built into broader pol-icy, system, and environmental interventions asaction steps.

Some of the action steps for imple-menting interventions in the SHIP “Guideto Implementing and Evaluating Interven-tions” (103) are based on the CDC’s andthe Partnership for Prevention’s publication“The Community Health Promotion Hand-book: Action Guides to Improve Commu-nity Health.” These action guides providehow-to guidance for implementing effectivecommunity-level health-promotion strategiesthat, in keeping with an ecological model,promote interventions that go beyond the in-dividual level to target broad social and en-vironmental factors (Community Health Pro-motion Handbook: http://www.prevent.org/actionguides/HandbookIntroduction.pdf ).

Despite the growing emphasis oncommunity-based health promotion, mostsuch programs have demonstrated only modestimpact (73), which is due in part to weaknessesin application of available theoretical models.Ecological models provide an important


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framework but generally do not provideenough detail to conceptualize adequately therelationship between multiple interventionsand multiple levels of influence that include thelarger community (8, 85). Ecological modelsthat are behavior-specific need to be articulatedbetter (100).

Merzel & D’Afflitti (73) make the point thatthe most developed theories are based on be-havioral psychology and tend to result in in-terventions that focus on individual change anddo not adequately consider contextual factorsthat influence behavior. For example, althoughSCT acknowledges social influence, it says lit-tle about the effect of the physical environmentor neighborhood issues, such as high rates ofunemployment, on behavior.

Because mediating influences within thecontext of communities are often not ade-quately recognized, measured, or reported, it isoften not possible to assess program processesand outcomes adequately (16). Although manycommunity-based programs emphasize com-munity participation and collaboration, fewhave demonstrated strong impacts on behav-ioral or health status outcomes (73). This lackof strong impact points to the need for inter-ventions that are based on an integrated the-ory of ecological change that targets social andpolicy influences through an “intensive pro-cess of community mobilization” that goes wellbeyond having quarterly community advisoryboard meetings (72).

Key decision makers within a community of-ten function within limited time frames, espe-cially when planning is tied to funding. Becausesocial norms and the physical environment of acommunity can take years to show meaning-ful change, ecological models that account fora long, often slow chain of events are neces-sary both to program design and to help deci-sion makers understand the need for patienceand continued support. This approach needs tobe combined with ongoing, concerted effortsto achieve policy, systems, and environmentalchange.

Ecological models can be better used bylarge programs, such as SHIP, to develop and

implement improved measurement methods,advances in multilevel analyses, models specificto each target behavior, and dedicated, multi-year funding for environmental and policy re-search (62, 100, 113). The new SHIP programis an opportunity to grow and improve theseapplications.

CONSTRUCTS AND ISSUESACROSS THEORIES

Several key constructs cut across the most oftencited models for understanding behavior andbehavior change: environmental influences, be-havior change as a multistage process, intentionversus action, and changing of behavior versusmaintenance of behavior change (34, 76).

Environmental Influences

An increasingly widely held view demonstratesthat social, organizational, and physical envi-ronments are important determinants of be-havior (71, 101). Environments, and people’sperceptions of their environments, may con-strain individuals’ behavior even when they arehighly motivated. Environment and policy con-cerns are often central to health disparities:Having access to walkable communities, safeparks, and recreational facilities is associatedwith more physical activity and lower risk ofobesity, but communities of color often haveless access to such resources in their neighbor-hoods (88). Well-designed interventions basedon an ecological model have great potential tohelp reduce or eliminate such environmentalhealth inequities (88, 99, 120). Equally impor-tant, the concept of environment is central toseveral leading theoretical frameworks (6, 70,71, 100) and is also important to keep in mindwhen applying individually oriented theories,as noted above.

Behavior Change as a Process

Research conducted over the past 30 yearsshows that the relationships among knowledge,awareness of the need to change, intention

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to change, and an actual change in behaviorare very complex. Sustained health behaviorchange involves multiple actions and adapta-tions over time. One central issue that hasgained wide acceptance in recent years is thesimple notion that behavior change is a process,not an event. It is not a question of someone de-ciding one day to quit smoking and the next daybecoming a nonsmoker for life. This idea is notnew, but it has gained wider recognition in thepast few years. Although the stages of changeconstruct is most recognized for cutting acrossvarious circumstances of individuals who needto change or want to change, other theories alsoaddress these processes. The TPB (2) and thePrecaution Adoption Process Model (117) alsoexplicitly identify cognitive stages of readinessand decisions to take action.

Intentions versus Action

The TTM makes a clear distinction betweenthe stages of contemplation and preparationand overt action (87). A further applicationof this distinction comes from the TPB (2).The TPB proposes that intentions are the bestpredictors of behavior. “Implementation inten-tions” are even more proximal and may be bet-ter predictors of behavior and behavior change(44).

Changing Behaviors versusMaintaining Behavior Change

Even when there is good initial complianceto a lifestyle change program, such as quittingsmoking or adopting an exercise routine, re-lapse is common. For example, many smokersquit, only to begin smoking again within a year.Undertaking initial behavior changes and main-taining behavior change require different typesof strategies. The TTM distinction betweenthe action and maintenance stages implicitlyaddresses this phenomenon (87). Relapseprevention specifically focuses on strategiesfor addressing maintenance of a recentlychanged behavior (68). It involves developing

self-management and coping strategies andestablishing new behavior patterns that empha-size perceived control, environmental manage-ment, and improved self-efficacy. These strate-gies are an eclectic mix drawn from SCT (70),the TPB (2), applied behavioral analysis, andthe forerunners of the stages of change model.

CHALLENGES ANDUNRESOLVED ISSUES

Selecting the Right Theoryor Theories

Effective health promotion and public healthdepend on marshaling the most appropriatetheory and practice strategies for a given sit-uation (39, 53, 78). The choice of a suitabletheory should begin with identifying the prob-lem, goal, and units of practice (105, 109), notwith selecting a theoretical framework becauseit is intriguing, familiar, or in vogue. As Green& Kreuter (45) have argued, ideally one shouldstart with a logic model of the problem and workbackward to identify potential solutions.

Theories may be judged in different ways inthe context of activities of practitioners and re-searchers. However, theory, research, and prac-tice are closely entwined phenomena, not sep-arate issues (27, 39, 51, 56). Practitioners mayapply the pragmatic criterion of usefulness to atheory and be concerned mainly with its con-sistency with everyday observations (17). Re-searchers may be more concerned with whethertheory or a theoretically based intervention isfound to be supported when empirically tested.We should test our theories iteratively in thefield (49, 94), as well as in more controlled set-tings. When we do so, theory, research, andpractice are more likely to converge.

When Is a New Theory Needed?

As noted above in the description of theoryuse in published articles, there are many the-ories available, but few are being widely used.Developers often state that existing theories


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do not meet their needs, so a new theory ormodel is necessary. However, careful thoughtabout the generalizability, testability, and sup-port for a “new” theory might instead lead tothe choice of a suitable theory, to minor adapta-tions for unique cultural groups, and to modi-fied measures and evaluation procedures. Workwith culturally diverse groups provides a casein point. Fundamental views of matters such ascauses of health and disease among some eth-nic groups may seem to point to a need fornew theories (28). However, familiarity with arange of theories and thoughtful selection ofthe best-suited theories might solve this prob-lem (82). An Institute of Medicine commit-tee concluded that “the evidence is quite thinabout differential effects” of theory-based in-terventions according to diversity subgroups(53).

Population-Focused Programs andIndividual-Focused Strategies

In population-focused programs, it is of limitedvalue to adopt a program oriented solely towardmodifying individuals’ behaviors (e.g., teach-ing a patient low-fat food cooking methods).A more productive strategy would also includeenvironmental change, for example expandingthe availability and affordability of more nu-tritious food choices (40, 41). When this stepis done along with individual skill training,longer-lasting and meaningful changes can beachieved. Many theories of policy and organi-zational change complement individually ori-ented theories, but they are underutilized (47,52). They should be further operationalized,tested, and disseminated.

FUTURE DIRECTIONS

The audience for health behavior change pro-grams is truly global, and the professional com-munity represents many different settings andcountries. Theory developers and theory usersmust more than ever consider how culture,

context, and health problems can and shouldaffect their choices and applications of theoryand interventions (37). Professionals designinginterventions have more options than ever be-fore, yet our theories have improved only incre-mentally; our technologies have changed expo-nentially, however. This situation should be awake-up call to public health practitioners tothink more concretely, expansively, and deeplyabout how they and their coworkers use theory.

We offer to readers some key cross-cuttingpropositions to put the use of health behaviortheory in perspective (37).

1. The strongest interventions may be builtfrom multiple theories. When combiningtheories, it is important to clearly thinkthrough the unique contribution of dif-ferent theories to the combined model.

2. Rigorous tests of theory-based interven-tions, including measurement and analy-ses of mediator and moderators, are thebuilding blocks of the evidence base inhealth behavior change. These evalua-tions should not be limited to random-ized trials of efficacy, but instead shouldalso be tied to planning and evaluationframeworks such as RE-AIM (30, 43) andPRECEDE/PROCEED (45).

3. Theory, research, and practice are part ofa continuum for understanding the de-terminants of behaviors, testing strategiesfor change, and disseminating effectiveinterventions (60, 90).

4. There is no substitute for knowing theaudience. Participatory program design,evaluation, and research improve theodds of success.

5. When planning interventions, strive tobe creative. Health-promotion interven-tions should be as entertaining and en-gaging as the other activities with whichthey compete. No matter how importanthealth communication and education ac-tivities are, they are secondary to attract-ing and retaining the interest and enthu-siasm of the audience.

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SUMMARY POINTS

1. Reviews of research on changing a variety of health behaviors have shown that interven-tions based on theory or theoretical constructs are more effective than are those not usingtheory. However, the mechanisms that explain the larger effects have not been studied.

2. The most often used theories of health behavior are social cognitive theory (SCT), thetranstheoretical model (TTM)/stages of change, the health belief model (HBM), and thetheory of planned behavior (TPB).

3. The most often mentioned theoretical model that has not been fully applied in researchand practice is the social ecological model. There are many needs to better articulate,apply, and evaluate this important and promising model.

4. Health-promotion and public health researchers and practitioners should both questionand improve how thoroughly we use theory, how we turn theories into interventions,how we test theories, and what conclusions we draw from research.

5. Health-promotion programs that address significant public health problems includinghealth disparities should complement individually oriented intervention models withstrategies and models to develop healthier policies, systems, and environments.

FUTURE ISSUES

1. Theory, research, and practice are part of a continuum for understanding the determi-nants of behaviors, testing strategies for change, and disseminating effective interventions(60, 90).

2. The strongest interventions may be built from multiple theories. When combining theo-ries, it is important to think through clearly the unique contribution of different theoriesto the combined model.

3. Rigorous tests of theory-based interventions, including measurement and analyses ofmediator and moderators, are the building blocks of the evidence base in health behaviorchange. These evaluations should not be limited to randomized trials of efficacy butshould also be tied to planning and evaluation frameworks such as RE-AIM (30, 43) andPRECEDE/PROCEED (45).

4. There is no substitute for knowing the audience. Participatory program design, evalua-tion, and research improve the odds of success.

5. The question of when a new theory is needed requires careful thought and more attention.There are many theories, although few are widely used.

6. When planning interventions, we should strive to be creative. Health-promotion in-terventions should be as entertaining and engaging as the other activities with whichthey compete. Communication technologies are opening up many different channels forengaging people’s interest in better health. No matter how important they are, healthcommunication and education are secondary to attracting and retaining the interest andenthusiasm of the audience.


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DISCLOSURE STATEMENT

The authors are not aware of any affiliations, memberships, funding, or financial holdings thatmight be perceived as affecting the objectivity of this review.

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AR405-FM ARI 23 February 2010 23:10

Annual Review ofPublic Health

Volume 31, 2010Contents

Symposium: Public Health Significance of Genomics and Eco-Genetics

Overview of the Symposium on Public Health Significanceof Genomics and Eco-GeneticsGilbert S. Omenn � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1

Genome-Wide Association Studies and BeyondJohn S. Witte � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 9

Methods for Investigating Gene-Environment Interactions inCandidate Pathway and Genome-Wide Association StudiesDuncan Thomas � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �21

Ecogenomics of Respiratory Diseases of Public Health SignificanceStavros Garantziotis and David A. Schwartz � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �37

Nutrigenetics/NutrigenomicsArtemis P. Simopoulos � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �53

Family History in Public Health Practice: A Genomic Tool for DiseasePrevention and Health PromotionRodolfo Valdez, Paula W. Yoon, Nadeem Qureshi, Ridgely Fisk Green,and Muin J. Khoury � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �69

The Behavioral Response to Personalized Genetic Information: WillGenetic Risk Profiles Motivate Individuals and Families to ChooseMore Healthful Behaviors?Colleen M. McBride, Laura M. Koehly, Saskia C. Sanderson,and Kimberly A. Kaphingst � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �89

Epidemiology and Biostatistics

Overview of the Symposium on Public Health Significanceof Genomics and Eco-GeneticsGilbert S. Omenn � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1

Genome-Wide Association Studies and BeyondJohn S. Witte � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 9

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Methods for Investigating Gene-Environment Interactions inCandidate Pathway and Genome-Wide Association StudiesDuncan Thomas � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �21

Ecogenomics of Respiratory Diseases of Public Health SignificanceStavros Garantziotis and David A. Schwartz � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �37

Nutrigenetics/NutrigenomicsArtemis P. Simopoulos � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �53


Prevention Trials: Their Place in How We Understand the Value ofPrevention StrategiesGraham A. Colditz and Philip R. Taylor � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 105

Two Decades of Declining Cancer Mortality: Progress with DisparityTim Byers � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 121

Teen Fertility in Transition: Recent and Historic Trends in theUnited StatesJohn S. Santelli and Andrea J. Melnikas � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 371

The Methamphetamine Problem in the United StatesRachel Gonzales, Larissa Mooney, and Richard A. Rawson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 385

Environmental and Occupational Health

Advances in Understanding Benzene Health Effects and SusceptibilityMartyn T. Smith � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 133

Approaches to Uncertainty in Exposure Assessmentin Environmental EpidemiologyDonna Spiegelman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 149

Mold Exposure and Health Effects Following Hurricanes Katrinaand RitaDeborah N. Barbeau, L. Faye Grimsley, LuAnn E. White, Jane M. El-Dahr,and Maureen Lichtveld � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 165

Plastics and Health RisksRolf U. Halden � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 179

Public Health Practice

A Review of Unintentional Injuries in AdolescentsDavid A. Sleet, Michael F. Ballesteros, and Nagesh N. Borse � � � � � � � � � � � � � � � � � � � � � � � � � � � � 195

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Evaluability Assessment to Improve Public Health Policies, Programs,and PracticesLaura C. Leviton, Laura Kettel Khan, Debra Rog, Nicola Dawkins,and David Cotton � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 213

Integrating Clinical, Community, and Policy Perspectives on HumanPapillomavirus VaccinationMarıa E. Fernandez, Jennifer D. Allen, Ritesh Mistry, and Jessica A. Kahn � � � � � � � � � � 235

Outcome-Based Workforce Development and Educationin Public HealthDenise Koo and Kathleen Miner � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 253

Progress Toward the Healthy People 2010 Goals and ObjectivesEdward J. Sondik, David T. Huang, Richard J. Klein, and David Satcher � � � � � � � � � � � � 271

Recent Advances in Public Health Systems Research in theUnited StatesTimothy W. Van Wave, F. Douglas Scutchfield, and Peggy A. Honore � � � � � � � � � � � � � � � � � � 283


Health in All Policies—The Finnish Initiative: Background, Principles,and Current IssuesPekka Puska and Timo Stahl � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 315

Social Environment and Behavior

Confronting a Neglected Epidemic: Tobacco Cessation for Personswith Mental Illnesses and Substance Abuse ProblemsSteven A. Schroeder and Chad D. Morris � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 297

Health in All Policies—The Finnish Initiative: Background, Principles,and Current IssuesPekka Puska and Timo Stahl � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 315

How Experience Gets Under the Skin to Create Gradients inDevelopmental HealthClyde Hertzman and Tom Boyce � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 329

Targeted Marketing and Public HealthSonya A. Grier and Shiriki Kumanyika � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 349

Teen Fertility in Transition: Recent and Historic Trends in theUnited StatesJohn S. Santelli and Andrea J. Melnikas � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 371

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The Behavioral Response to Personalized Genetic Information: WillGenetic Risk Profiles Motivate Individuals and Families to ChooseMore Healthful Behaviors?Colleen M. McBride, Laura M. Koehly, Saskia C. Sanderson,and Kimberly A. Kaphingst � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �89

The Methamphetamine Problem in the United StatesRachel Gonzales, Larissa Mooney, and Richard A. Rawson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 385

The Role of Behavioral Science Theory in Developmentand Implementation of Public Health InterventionsKaren Glanz and Donald B. Bishop � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 399

Health Services

Post-Approval Drug Safety SurveillanceRobert D. Gibbons, Anup K. Amatya, C. Hendricks Brown, Kwan Hur,Sue M. Marcus, Dulal K. Bhaumik, and J. John Mann � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 419

Simulation Modeling of Health Care PolicySherry Glied and Nicholas Tilipman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 439

The Health and Health Care of Lesbian, Gay, and Bisexual AdolescentsTumaini R. Coker, S. Bryn Austin, and Mark A. Schuster � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 457

What Have We Learned About Interventions to ReduceMedical Errors?Helen I. Woodward, Oliver T. Mytton, Claire Lemer, Iain E. Yardley,Benjamin M. Ellis, Paul D. Rutter, Felix E.C. Greaves, Douglas J. Noble,Edward Kelley, and Albert W. Wu � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 479

Integrating Clinical, Community, and Policy Perspectives on HumanPapillomavirus VaccinationMarıa E. Fernandez, Jennifer D. Allen, Ritesh Mistry, and Jessica A. Kahn � � � � � � � � � � 235

Indexes

Cumulative Index of Contributing Authors, Volumes 22–31 � � � � � � � � � � � � � � � � � � � � � � � � � � � 499

Cumulative Index of Chapter Titles, Volumes 22–31 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 504

Errata

An online log of corrections to Annual Review of Public Health articles may be foundat http://publhealth.annualreviews.org/

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