A response - 'Predictors of health behaviours in college students'

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While I am always interested to read any health promotion- related paper, the one by Von Ah et al. raised a number of concerns for me. The study on which the paper was based was grounded in the psychosocio-cognitive, behaviourally-orientated, lifestyle-related framework that focuses on issues of individual self-efficacy, social learning, stress and threat/risk. Von Ah et al. then suggest that their study outcomes can be applied to current and future health promotion programmes. However, individualistic, behavioural and preventative-focused indicators do not fit with wide- reaching health promotion programmes. Health education has several functions that include imparting health-related informa- tion to influence values, beliefs, attitudes and motivations in order to achieve health or illness-related learning through knowledge acquisition, assimilation and dissemination, skills development and lifestyle/behaviour modification. These activities are generally targeted at the level of individuals and range from information-giving through to enabling processes. On the contrary, health promotion seeks to directly influence the broader aspects of ecological, cultural, economic and environ- mental health that determine the health of individuals in their communities, and have political underpinnings within an ‘envi- ronmental engineering’ process. Current health promotion strategies are drawn from policy-driven initiatives that work through the processes of social examination and modification, particularly at the level of collective social action. According to the above and my recent concept analysis, Von Ah et al.’s study has little to do with health promotion, but is firmly located instead in a health education context (Whitehead 2004a). Interchangeably categorizing behaviourally-focused health education outcomes with those of broader health promotion strategies sets a dangerous precedence for health-related researchers in today’s climate. All nurses need to define and delineate exactly what constitutes both health education and health promotion practice. Rawson (2002, p. 267) argues that ‘the asking will help better define the subject matter and create the discipline to discover the true potential of health promotion’. Similarly, Whitelaw et al. (1997) argue that health promotion is judged not only on its actions but also on its capacity to develop an appropriate theoretical agenda. Therefore, effective health promotion and health education practice need to be based on clear conceptual theory in order to validate current practice and serve as a springboard for innovation and advancement. Health researchers need to understand the context of their health education and health promotion research so that their findings can be compared with those of other studies in terms of location and conceptualization. Von Ah et al. (p. 465) state that their study was ‘designed to delineate factors, which significantly contribute to health behaviours in college students’, implying that their research is original and suggesting that similar studies are lacking. However, many studies have been reported in the generic (and sometimes nursing) health promotion and health education literature on the same and similar subjects (see, for example, Carter & Kahnweiler 2000, Kear 2002, Barth et al. 2002, Prokhorov et al. 2003, Britton 2004). Much of the literature used by Von Ah et al. has become dated in comparison with many of the studies I have cited. Also, the theoretical link between cognitive health behaviour, threat, social mechanisms and self-efficacy has long been established in social learning theory (Dijkstra & de Vries 2000, Keeling 2000, Leganger et al. 2000). Thus, this study only seems to ‘prove what is already well proven’. Socio-cognitive behavioural-change programmes are notoriously complex, problematical and, more often than not, unsuccessful without very careful consideration and attention to their context, aims, rationale and considered outcomes (Whitehead 2001a,b, Whitehead & Russell 2004). In this case, I would have to argue that the apparent lack of any health-related programme to pin the findings on, or to match them against, presents a precarious state of affairs for this research. Using terms, as the authors do, like ‘must use interventions to maximise self-efficacy’, ‘should incorporate methods for enhancing self-efficacy’, or ‘further research...may be needed’ come across as polemical, especially in the absence of programme-related findings or outcomes. Another issue is that of the validity of the findings. Von Ah et al. acknowledge the small sample size, need for further psychometric testing of the questionnaires, limited generalizability of the findings, and need to interpret the findings with caution. Finally, there is barely a mention of nursing or the implications of this study for nurses. Four of the five authors are attached to schools of nursing, yet the first mention of nursing comes in the final line of the conclusion. Also, the study is heavily biased in favour of the US context and the discussion is not balanced to reflect the wider international context. This means that related important international texts are not acknowledged (e.g. Petkeviciene et al. 2002, Xiangyang et al. 2003). There is also no mention of the World Health Organisation’s (WHO) Health Promoting University (HPU) movement which has been in place since 1997 (Dooris 2001). Nor do Von Ah et al. mention the 72-member college and university institutions of the American Network of Health Promoting Universities (ANHPU) movement – through its association with the Association of Academic Health Centres (AHC) (Whitehead 2004b). I do not want to seem overly negative about this paper but, on the contrary, criticism of any published research may help to ensure that future studies are more robust. Nursing has long had a poor reputation in the field of health education and health promotion research. This is slowly changing, with more examples emerging of sound evaluation studies of health-related programmes. However, studies such as that reported by Von Ah et al., are merely replicating what is well-established and not adding to the development of health-related research. This needs to change so that appropriately located, constructed and valid recommendations can emerge from future nursing-related health research. References Barth K.R., Cook R.L., Downs J.S., Switzer G.E. & Fischoff B. (2002) Social stigma and negative consequences: factors that influence college students’ decisions to seek testing for sexually transmitted infections. Journal of American College Health 50(4), 153–159. Britton P.C. (2004) The relation of coping strategies to alcohol consumption and alcohol-related consequences in a college sample. Addiction Research and Theory 12, 103–114. Carter C.A. & Kahnweiler W.M. (2000) The efficacy of the social norms approach to substance abuse prevention applied to fraternity men. Journal of American College Health 49(2), 66–71. Dijkstra A. & de Vries H. (2000) Self-efficacy expectations with regard to different tasks in smoking cessation. Psychology and Health 15, 501–511. Dooris M. (2001) The ‘Health Promoting University’: a critical exploration of theory and practice. Health Education 201, 51–60. Kear M.E. (2002) Psychosocial determinants of cigarette smoking among college students. Journal of Community Health Nursing 19, 245–257 Keeling R.P. (2000) Social norms research in college health. Journal of American College Health 49(2), 53–56. Leganger A., Kraft P. & Roysamb E. (2000) Perceived self-efficacy in health behaviour research:conceptualisation, measurement and correlates. Psychology and Health 15, 51–69. Petkeviciene J., Miseviciene I. & Petrauskas D. (2002) Health behaviour and interest in health promotion in relation to subject of study among students of Kaunas Universities. European Journal of Public Health 12(Suppl.), 27. Prokhorov A., Warneke C., de Moor C., Emmons K., Mullin-Jones M., Rosenblum C., Suchanek-Hudmon K. & Gritz E. (2003) Self-reported health status, health vulnerability, and smoking behaviour in college students: implications for intervention. Nicotine and Tobacco Research 5, 545–552. Rawson D. (2002) Health promotion theory and its rationale construction: lessons from the philosophy of science. In Health Promotion: Disciplines, Diversity and Developments, 2nd edn (Bunton R. & Macdonald G., eds), Routledge, London, pp. 249– 270. Von Ah D., Ebert S., Ngamvitroj A., Park N. & Kang D.-H. (2004) Predictors of health behaviours in college students. Journal of Advanced Nursing 48, 463–474. Whitehead D. (2001a) A social-cognitive model for health promotion/health education practice. Journal of Advanced Nursing 36(3), 417–425. Whitehead D. (2001b) Health education, behavioural change and social psychology: nursing’s contribution to health promotion? Journal of Advanced Nursing 34(6), 822–832. Whitehead D. (2004a) Health promotion and health education: advancing the concepts. Journal of Advanced Nursing 47(4), 311– 320. Whitehead D. (2004b) Health Promoting Universities (HPU): the role and function of nursing. Nurse Education Today 24, 466–472. Whitehead D. & Russell G. (2004) How effective are health education programmes: resistance, reactance, rationality and risk? Recommendations for effective practice. International Journal of Nursing Studies 41(2), 163–172. Whitelaw S., McKeown K. & Williams J. (1997) Global health promotion models: enlightenment or entrapment? Health Education Research 12(4), 479–490. Xiangyang T., Lan Z., Xueping M., Tao Z, Yuzhen S. & Jagusztyn M. (2003) Bejing health promoting universities: practice and evaluation. Health Promotion International 18, 107–113.

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