Health promotion, human behaviour and adherence to therapies
By Dr Aro Arja, Director, Education and Training Committee, International Society of Behavioural Medicine (ISBM)
Most long-term therapies combine medication with simultaneous instructions on health habits and lifestyle changes such as diet, physical activity and smoking cessation. Adherence to such lifestyle changes is often as important to optimal treatment outcome as adherence to medication. Furthermore, through lifestyle change, health promotion and disease prevention interventions can have a far-reaching impact in enhancing health beyond the specific condition being treated1.
1 Tuomilehto J et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine, 2001, 344: 1343 - 1350.
In comparison to the way in which adherence to medication has historically been addressed (in which the target behaviour is somewhat less multidimensional, but perhaps equally broadly determined), adherence to health-promoting or disease-preventing lifestyle changes now requires a different perspective. This perspective is quite broad in terms of the contexts or circumstances that directly influence these target behaviours; it requires a longer time horizon in which to evaluate benefits, consideration of a wider range of multi-level interventions, and a more varied theory-base.
The context extends beyond the person to the wider society, arrangement of working conditions and social processes. In practical terms it means that many factors outside the person, and perhaps beyond their volitional control must be considered. The time horizon means that the availability of data having a bearing on the effectiveness of programmes or procedures, in terms of recognizable health benefits, is often delayed by years or decades (as in the benefits of smoking cessation).This provides a challenge for motivation to adopt and maintain changes, especially in the absence of imminent threats to health.
The interventions needed are not only those that target the individual, but also those that act at the level of a society, community or group, and which are conveyed through a host of different channels of influence. For example using mass media, creating environmental changes, and regulations and laws such as smoking bans. Thus, multi-level approaches apply here too, but their range is wider than in compliance to medication.
The theoretical basis for surveillance, monitoring and intervention also requires the adoption of a wider social and cultural framework (e.g. social marketing and communication theory) outside the individual, family and patient - clinician relationship2. Models explaining the inter-relations between different health-relevant behaviours, the factors that influence them, and the causal pathways of change in different contexts and over the life-course are needed.
2 Nutbeam D, Harris E. Theory in a nutshell. A guide to health promotion theory. Sydney, McGraw-Hill, 1999.
Studying and enhancing adherence to preventive therapy and change towards a healthy lifestyle require building a bridge from the person-centred approaches to adherence to medical regimens with their traditional emphasis on individual volition and behavioural control, to the tools and concepts of health promotion which attempt to understand and intervene in a more systemic manner. This involves targeting causes at many levels of the processes that determine human behaviour, not just the behaviour of the individual.