Education as a method of dietary behavioral change

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As mentioned above, nutritional education should always be considered as part of an intersectoral health promotion policy. An approach that is solely based on educational activities will hardly ever be effective. As part of an intersectoral program, however, in combination with the other types of intervention, planned health education can indeed be effective in changing people's behavior.

The development of theories concerning behavioral change by communication has resulted in a matrix with the stages of the change process vs. the communication variables (see Figure 22.4).

message receiver channel source attention comprehension attitude change change in social influence change in self-efficacy maintenance of behavioral change

Figure 22.4 Matrix of behavioral change by education (Adapted from McGuire, 1985.)

On the left of the matrix the stages that lead to a continuous change in behavior are listed:

- attention for and comprehension of the message;

- alteration of the determinants of behavior, such as attitudes, social influence and self-efficacy (see Part 1B), in combination leading to a change in behavior;

- maintenance of the behavioral change.

Above the matrix the communication variables can be found: message (form and content), receiver (target group), channel (medium), and source (an expert, organization, authority, etc.). The questions that need to be answered in the development of communication interventions can be formulated as: what is communicated (message), to whom (receiver), how (channel), and by whom (source)? The boxes of the matrix represent large numbers of decisions which have to be made in order to develop an effective educational intervention. The first decision concerns the desired behavioral change (message) in a particular target group (receiver). The second decision is directed at the determinants of behavior, i.e., what message is needed to affect attitude, social influence, and self-efficacy (see Part 1B). Subsequent decisions concern the communication of the various messages to target groups, choosing appropriate channels. A decision is necessary on how to attract attention, as well as on how to get people to understand the message.

A good deal of knowledge is available concerning the various boxes in the matrix. In order to make optimal decisions, the existing empirical data and theoretical insights should be carefully weighed. It should be noted, however, that decisions in one box may conflict with decisions in another. A source that attracts the most attention may not necessarily be a credible source for attitude change. A mass medium that reaches many people may not be the best medium to improve skills (e.g., the ability to prepare low-fat meals). These dilemmas have also been studied. In the next paragraphs, a number of conclusions from research in the various boxes are summarized. The reader who wants to try and develop a new intervention should always bear in mind that there is no such thing as "one intervention method is always more effective than the other." The "rules" that are presented here should always be weighed carefully against the specific characteristics of a new problem. The following remarks are relevant here as regards the effects of the four communication variables.

Message effects. In health education, messages' explicit conclusions are often more effective than implicit conclusions. The more a message is repeated, the more effectively it is received. After three times, however, repetition may no longer be effective, or may even lead to opposite effects. New and valid arguments may change someone's attitude, but information about the opinions and behaviors of others may also contribute to changes in attitude and perceptions of social standards. The discrepancy between the position of the source regarding the issue at hand, and the position of the receiver should not be too large, especially in the case of high involvement of the receiver in the issue under consideration. Improvement of self-efficacy by giving specific instructions is important, particularly in the case of fear-arousing messages (e.g., about the relationship between diet and cancer). An individual's efforts and perseverance in attaining a behavioral change are stimulated if a challenging but realistic goal is stated in the message and care is taken to give feedback information about the effects of the change, as has been shown in weight-loss programs.

Receiver effects. Characteristics of the receiver may affect the results of health education. Changes in attitudes and behavior are curvilinearly related to age. Up to nine, the higher the age the more change. For older people the reverse has been found. Public commitment of the receivers to a certain behavior may cause them to resist change. However, public commitment to the new (changed) behavior can lead to greater maintenance of the behavioral change. Low self-efficacy can be the cause of lapses or relapses (people falling back into their former unhealthy behaviors). It may even keep a person from trying to change. Improving self-efficacy by relapse prevention techniques can result in behavioral change and maintenance of that change. In relapse prevention, four steps are distinguished:

1. convince the person that the reasons for former failure are not stable, but changeable;

2. identify high-risk situations and find adequate responses to high-risk situations;

3. put those responses into practice until they become automatic;

4. in case of (re)lapse, use the lapse as a learning experience and start again with 3, 2, or 1.

Relapse prevention techniques have proved to be effective in changing compulsive and habitual behavior, such as (non)compliance with diet advice.

Channel effects. As far as the effects of communication channels are concerned, it is important to pay attention to mass media on the one hand and interindividual communication on the other. Mass media can be very effective in reaching many people, and in attracting attention to the message. However, interpersonal communication is essential in improving self-efficacy, resistance to social pressure, skills, and maintenance of behavioral change. The simplest conclusion is of course to combine the strengths of both channels in a multi-media intervention. Recently, a number of technological innovations have made it possible to use mass media in combination with interindividual communication, e.g., interactive computer programs and computerized individualized feedback.

Source effects. The source of an educational message is not always the educator himself or herself. It can also be the organization represented by the educator, e.g., a national cancer foundation. Important sources are opinion leaders from people's own environment: medical doctors and paraprofessionals such as dieticians, but also colleagues and friends. The effectiveness of sources is positively related to their competence, their integrity, their attractiveness (including similarity), and power. Powerful and attractive sources may lead to compliance, i.e., do what the source wants you to do. However, this change will only continue while the source is present. On the other hand, competent and trustworthy sources will lead to acceptance, i.e., an internalized change of attitudes and behavior that will be maintained by itself.

The requirements for the source to motivate people to a certain change are:

- explicit conclusions,

- some repetition, but not too much,

- new and valid arguments,

- information on the opinion and behaviors of others,

- information that is not too discrepant from the receiver's position, and

- specific instructions.

And his/her own characteristics are preferably: attractiveness (similarity), competence, integrity, and power.

The various stages of the change process need completely different interventions. Educational programs should have the possibility of differentiated interventions for people at different stages. In the case of people not aware of a possible problem with their diet, the accent is on attention, comprehension, and attitude change. For people who are aware of problems but do not know how to change their behavior, interventions should be directed at attitude change, social influence, and in particular, at self-efficacy and skills (including resistance to social pressures). For people who try to change their behavior, the intervention is focused on maintenance of that behavioral change, and methods such as feedback and relapse prevention are used.

Approaching people who are not aware of a problem with interventions directed at training skills is as useless as approaching relapsers with information about the nutritional problem: it may even be counterproductive.

Community-based programs (see Section 22.1.3) are a specific application of the matrix approach. The six characteristics of these programs, particularly the use of the social network and the participation of para-professionals from the target group, improve the chances of achieving attention and comprehension. Messages will be better adapted to the psychological, social, and structural situation of the receivers, resulting in more changes in determinants and behavior, and in maintenance of behavioral changes.

Even professional educators tend to underestimate the differences between the target group and themselves regarding receiver characteristics. This explains also the effectiveness of paraprofessionals from within the target group itself. The source-receiver dissimilarity can be approached by careful pretesting of all materials that are used in the intervention. Pretesting consists of a critical review of the educational materials by the following groups:

- experts in the field of the subject concerned;

- experts in communication and health education;

- a subpopulation of the target group itself, preferably a random sample.

Pretesting by the latter group is extremely important in order to prevent costly mistakes.

The effectiveness of nutrition education programs has not been studied much. In addition, the range of behaviors involved is rather wide. This, combined with the low quality of the research designs, makes it difficult to draw well-considered conclusions.

Programs aimed at students were found to impart knowledge, but not to lead to behavioral change. As far as high-risk groups such as patients with diabetes, cancer, kidney problems, high blood pressure, high cholesterol level, and obesity are concerned, maintenance of behavioral change (diet compliance) is the major problem. Mass media nutrition education programs do not yield positive results. Successful nutrition education programs are characterized by interpersonal contact, social support, self-control, and feedback. Adaptation of the intervention to the individual's attitudes and skills is effective. Interventions aimed at groups (e.g., patient groups) and those based on relapse prevention techniques are promising. For example, in the Netherlands, a large number of programs are available, but subsequent evaluation is often lacking. The "Way of Life" television campaign, intended to combine health education with entertainment, appeared to attract people's attention, and to heighten their awareness of the importance of a healthy lifestyle (including nutrition) for the prevention of cardiovascular diseases and cancer. Group interventions as well as individual counselling have been proven to be effective in weight-loss programs.

In conclusion:

1. effective nutritional education interventions are possible if they are carefully planned and evaluated. They should be based on the results of an analysis of the determinants of the behavior involved;

2. education interventions alone are not sufficient to change an individual's behavior. They should be integrated in an intersectoral approach, not only at national level but also at local level (community).

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