Tuesday, June 15, 2010

The Primacy of Self-Regulation in Health Promotion

Albert Bandura*
Stanford University, USA

We are witnessing a divergent trend in the field of health. On the one hand,
we are pouring massive resources into medicalising the ravages of detri-
mental health habits. On the other hand, the conception of health is shifting
from a disease model to a health model. It emphasises health promotion
rather than mainly disease management. It is just as meaningful to speak of
levels of vitality and healthfulness as of degrees of impairment and debility.
Health promotion should begin with goals not means (Nordin, 1999). If
health is the goal, biomedical interventions are not the only means to it. A
broadened perspective expands the range of health promoting practices and
enlists the collective efforts of researchers and practioners who have much
to contribute from a variety of disciplines to the health of a nation.

The quality of health is heavily in uenced by lifestyle habits. This enables
people to exercise some measure of control over the state of their health. To
stay healthy, people should exercise, reduce dietary fat, refrain from smoking,
keep blood pressure down, and develop effective ways of managing stres-
sors. By managing their health habits, people can live longer, healthier, and
retard the process of aging. Self-management is good medicine. If the huge
benefits of these few habits were put into a pill it would be declared a
scientific milestone in the field of medicine.
Current health practices focus heavily on the medical supply side. The
growing pressure on health systems is to reduce, ration, and delay health
services to contain health costs. The days for the supply-side health system
are limited. People are living longer. This creates more time for minor
dysfunctions to develop into disabling chronic diseases requiring health
services. In addition, growing public interest in health matters linked to
expensive health care technologies, and the medicalisation of problems of
living with aggressive public marketing of drug remedies for them, are add-
ing to the burdensome costs. Demand is overwhelming supply.
The social cognitive approach, rooted in an agentic model of health pro-
motion, focuses on the demand side (Bandura, 2000, 2004a). It promotes
effective self-management of health habits that keep people healthy through
their life span. Psychosocial factors in uence whether the extended life is
lived efficaciously or with debility, pain, and dependence (Fries & Crapo,
1981; Fuchs, 1974).
Aging populations will force societies to redirect their efforts from
supply-side practices to demand-side remedies. Otherwise, nations will be
swamped with staggering health costs that consume valuable resources
needed for national programs.

Individuals continuously preside over their own behavior. Hence, they are
a key locus in the development and successful maintenance of health pro-
motive habits. Whatever other factors may serve as guides and motivators,
they are unlikely to produce lasting behavioral changes unless individuals
develop the means to exercise control over their motivation and health-
related behavior.
Maes and Karoly (2005) report the growing shift from the medical man-
agement model centered on prescriptive regimens and compliance with
them, to a collaborative self-management model. They also identify a corres-
ponding change in the conception of health management in psychological
theorising. Trait approaches, that ascribe health behavior to personal char-
acteristics usually represented by clusters of behavior, are being supplanted
by process models that focus on psychosocial means and the mechanisms
through which they produce their effects.
Health habits are not changed by an act of will. Self-management requires
the exercise of motivational and self-regulatory skills. Self-regulation models
differ somewhat in particulars but they are rooted in three generic subfunc-
tions. These include self-monitoring of health-related behavior and the
social and cognitive conditions under which one engages in it; adoption of
goals to guide one s efforts and strategies for realising them; and self-
reactive in uences that include enlistment of self-motivating incentives and
social supports to sustain healthful practices.
Maes and Karoly conceptualise self-regulation in terms of a triadic pro-
cess by which individuals bring their in uence to bear on their health habits.
In their goal-guidance model, goal adoption sets the stage for self-directed
change; implementation strategies convert goals into productive actions;
and maintenance strategies help to sustain achieved behavioral changes. The
authors review numerous health-related cognitions that can affect each of
the three generic self-regulatory processes. They describe the scales designed
to measure them, many of which are cast in trait terms, and evaluate the empirical evidence for their predictiveness. The article provides a thoughtful,
critical overview of the extant body of literature on the role of health-related
cognitions in the various self-regulation models.

The models of self-regulation are founded on the common metatheory that
cognitive factors are significant contributors to health behavior. The chal-
lenge in this field is to bring theoretical order to the vast array of posited
cognitive determinants reviewed by Maes and Karoly. The issues center on
theoretical incompatibilities, redundancies of factors given different names,
fractionation of the facets of higher-order constructs into seemingly differ-
ent determinants, evaluation of the unique contribution of factors when
tested in concert rather than singly, and the model of theory building that is
Consider, for example, the incompatibility of the goal-setting practices
prescribed by Locke and Latham s (1990) Goal Theory and by Ryan and
Deci s (2000) Self-Determination Theory. The goal practices verified empir-
ically by Locke and Latham as providing optimal guides and motivators are
regarded by Deci and Ryan as underminers of motivation. Regression
analyses reveal redundancy of predictors bearing different names. For ex-
ample, after the contributions of perceived self-efficacy and self-evaluative
reactions to one s health behavior are taken into account, neither intentions
nor perceived behavioral control add any incremental predictiveness
(Dzewaltowski, Noble, & Shaw, 1990). Factors that predict health behavior
when considered singly may not add any unique predictiveness when tested
in conjunction with other factors. Meyerowitz and Chaiken (1987) exam-
ined four possible mechanisms through which health communications could
alter health habits: By transmitting information on how habits affect health;
arousing fear of disease; increasing perceptions of one s personal vulner-
ability or risk; or by raising people s beliefs in their efficacy to alter their
habits. Self-efficacy beliefs emerged as the predictor of adoption of healthful
Were one to delve beneath the labels affixed to the cognitive factors and
address the redundancies among them, the seeming diversity would prob-
ably shrink to a small set of generic factors. They would most likely include
knowledge of health risks and benefits of different health practices; per-
ceived self-efficacy that one can exercise control over one s health habits;
outcome expectations about the expected material, social, and self-evaluative
costs and benefits for different health habits; the health goals people set for
themselves and the concrete plans and strategies for realising them; and the
perceived sociostructural facilitators and impediments to the changes
they seek. Structural models of the paths of in uence would specify the functional dependencies among these key determinants and their direct and
mediated effects on health behavior.

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