Cardiovascular diseases account for a large part of total mortality: in 1974 45.7% of all deaths in the Netherlands were due to these diseases. As at least part of these diseases is man-made, the need for prevention is often stressed. The Netherlands Heart Foundation has many activities which aim at getting people to change their way of life if it increases their susceptibility to cardiovascular disease. One of these activities is a nutrition educational project, started in 1972. Dieticians work with members of various organizations to improve eating habits.
The literature was reviewed to answer the following questions:
- what influences people's nutrition and health behaviour?
- which of these influences can be changed by nutrition and health education?
These two questions are studied to acquire information with which a more systematic policy of nutrition education can be established.
Chapter 2. and 3. deal with nutrition behaviour, roughly defined as 'ways in which people act with regard to their food'. It includes choice of food, how and where food is prepared and consumed etc. (2.1.). As nutrition behaviour is part of human behaviour in general, Chapter 2. sums up some theoretical ideas about changing human behaviour from consistency theories, social judgment theories, functional theories and learning theories (2.2.1.). Implications for nutrition and health education are as far as possible explicitly stated.
Some learning theories are dealt with more extensively (2.2.2.), because:
- their concepts of (selective) reinforcement, modeling etc. can be applied in practice,
- they offer many cause-and-effect relations of behaviour that have been experimentally tested,
- many extension programmes are already based on the applications of these theories.
Chapter 2. ends with a summary of what is known about the development of nutrition behaviour specifically (2.2.3.). The results are not impressive; much more research in this field is needed.
Chapter 3. deals with the factors influencing nutrition behaviour. The data, collected from many different fields - (social) psychology, sociology, extension education, home economics, marketing - have been structured in a model after Langenheder (3.1.). In this chapter a distinction is made between the following factors:
a. 'objective' data in the physical and social surroundings as well as in man himself (3.2.),
b. culture (3.3),
c. indirect communication and direct social interaction (3.4.),
d. internal psychological structure: cognitions, motivation etc. (3.5.).
The 'objective' data roughly fix the limits of nutrition behaviour.
Culture is an important moulding agent, because it permeates all other factors, especially social interaction. It gives rise to typical patterns of nutrition; an ideal-type of Dutch menu is given in section 3.3.
Indirect communication, mainly but not uniquely transferred by mass media, can change a person's nutrition behaviour (3.4.1.), but only if:
- selective processes hardly work,,
- the message of the media covers a field unknown to the receiver (new products for instance),
- persons are already actively looking for the information they accidentally receive via mass media,
- the decisions to be made are relatively unimportant for the individual,
- mass communication contributes - in the long term - to norm setting for certain kinds of (nutrition) behaviour.
Direct social interaction is a very powerful influence (3.4.2.). Nearly every individual strives towards harmonious relations with his or her surroundings by fulfilling role obligations, coming up to expectations, in short by being not too different from 'normal'. Many of the values and norms developed in continuous interaction with others, have become fully internalized and are therefore resistant to change.
In dealing with the influence of cognitions on nutrition behaviour (3.5.1.), a distinction is made between factual knowledge (of ingredients, or categories of food products: the basic five etc.) and the more extensive cognitions, of which experience and all kinds of reality testing are part. A clear relation exists between nutrition behaviour and these extensive cognitions, while the relation between factual, more theoretical knowledge and nutrition behaviour is mostly non-existent.
As second part of the internal psychological structure the relations between people's needs and motives, and nutrition behaviour are analysed (3.5.2.). Four models are presented, two of which relate to nutrition. Generally nutrition has a (symbolic) function in creating physiological security (biologic needs); it fulfils the need for sensoric pleasure, emotional security (attention, acceptance) and for sociological security (status, self-expression).
The third aspect discussed is how people value certain goals and the actions to reach those goals (3.5.3.). Special attention should be paid to the discrepancy that often exists between goals of the extension organization and those of people themselves.
A separate part of section 3.5. is devoted to the question how attitudes - part of the internal structure - relate to behaviour. From much, often contradictory, literature the following conclusions were drawn:
- a relation between attitudes and behaviour exists, but is very complex,
- many more variables than attitudes determine behaviour,
- how and to what extent these other variables interact with behaviour is yet largely unknown.
After the chapters dealing with nutrition behaviour, chapter 4. clarifies the concept of extension. We defined extension as systematically planned communication, to be distinguished from other ways of influencing people's behaviour when high priority is given to the interests and well being of clients. Extension work has been chosen as an instrument for prevention of cardiovascular disease from a practical and ethical point of view, as well as for reasons of effect and efficiency (4.2.).
We defined two sets of goals for nutrition education (4.3.). The first set of goals is that:
- people should realize their actual nutrition behaviour,
- people should become aware of the consequences of that behaviour.
- people should decide on alternative behaviour.
The second set of goals is more structure-oriented, namely:
- to reorganize the existing (structural) forces influencing nutrition behaviour into a direction more positive to health, so that the alternative behaviour meant in the first set is really possible. Thus it is necessary for extension programmes - short-term and long-term - to be directed towards the public as well as towards policy makers (Fig. 10).
At the moment health education is given by various groups of people (4.4.). A distinction is made into four categories:
a. those working in the health system for which education is an integral part of their job: general practitioners, dentists, (district)nurses etc.,
b. those working in specialized health fields for which education is an important part of their job: dieticians, drug educators, dental hygienists etc.,
c. those not working in the health system but whose work touches on health aspects: teachers, youth leaders etc.,
d. those working as advisers and consultants for the professionals, mentioned under a., b. an c.: health education consultants.
A more integrated health education is essential for long-term success.
Most of what has been said in Chapter 1. to 4. about nutrition behaviour applies to health behaviour. Yet Chapter 5. explicitly deals with health behaviour, mainly because many efforts to influence nutrition behaviour are part of more extensive health education activities. We can say every nutrition behaviour is health behaviour, because all nutrition behaviour eventually influences people's health. Then we talk about health-related behaviour. If nutrition behaviour is purposefully meant to maintain or promote health, we talk about health-directed behaviour (5.1. and 5.2.).
Section 5.3. presents two social-psychological models and some more sociological ideas about health behaviour and their implications for influencing it. The two models are the health belief model (HBM) and a related model after Jaccard. Variables in the HBM are:
- the perceived susceptibility to a certain disease,
- the perceived seriousness,
- evaluation of actions and their benefits,
- evaluation of barriers to action.
Jaccard's model puts more emphasis on an individual's intention for certain health behaviour, determined by:
- his perception of the consequences of performing that behaviour,
- the value he attaches to these consequences,
- his beliefs about what relevant others think he should do,
- his motivation to comply with those others.
In both models, most clearly in Jaccard's one, the influence of social norms is very important.
In addition to the HBM the role of fear is discussed. Three kinds of variables determine the effects of a fear-approach:
- characteristics of the receiver: vulnerability, self-image, self-confidence, tolerance of stress etc.,
- the degree of fear: a certain degree of emotional arousal seems necessary for success (behaviour change) but the relationship is not linear. The optimum degree of fear depends on personality and situational variables,
- characteristics of the specific message: simple changes in behaviour can be brought about by a high-fear-approach. To achieve more complex (more important?) changes, a low-fear-approach seems more effective.
The results of our search for an integrated sociological view on health behaviour have been somewhat disappointing. With a few exceptions we only found ideas about certain role-configurations in relation to health, but mostly with the emphasis on disease or illness. More research is needed into the processes underlying unhealthy habits of large parts of the population and into changes in these habits (consumption of too much alcohol, preference for too many calories etc.).
The final chapter (6.) integrates a number of considerations and ideas from earlier chapters, resulting in a model for a nutrition and health educational policy (Fig. 15.). In section 6.1. a few views on the concept of strategy are mentioned. A division into three kinds of strategy is presented:
- power strategy,
- persuasive strategy,
- re-educative strategy.
The power strategies use sanctions and control to change behaviour, the persuasive strategies use rational, emotional and moral appeals.
The re-educative strategies try to change values and norms, so that internalization of changed values leads to changes in behaviour.
Section 6.2. gives 14 barriers to changing people's nutrition behaviour, where possible with implications for extension programmes.
To give an idea of nutrition education at present, section 6.3. presents a selection of three kinds of programmes: person-oriented, structure-oriented and integrated programmes. Special attention is given to the methods used in the treatment of obesity.
Section 6.4. 'towards a policy of nutrition education' is organized according to the stages of the model (Fig. 15): a. information and diagnosis, b. goals and target groups, c. content, d. methods, e. structure of the extension organization and f. evaluation.
Each stage is discussed in general and in relation to the nutrition educational project of the Netherlands Heart Foundation.
The stage of collecting information is aimed at problemdiagnosis, as well as at getting a rough idea of the kind of strategy one is going to choose: power, persuasive or re-educative. Not only health-related date have to be collected but also extension-related data.
The goals of an extension programme (communication goals!) are distinguished into changes in knowledge, attitudes or behaviour. Within target groups a distinction is made between final groups: clients and institutions, and intermediary ones: the public, government, commercial firms and professionals.
We categorize the content of the extension programme according to whether the goal is to make people aware of something, to inform, to advise or to persuade.
For the methods the usual distinction into mass, group and individual methods is used. Because we summarized which method is suitable for certain goals, it is possible to deduce special combinations of methods from (communication) goals stated.
Every extension programma must be backed by some kind of a structured organization. Whether the structure is permanent or temporary, certain functions have to be fulfilled: leaders (managers, advocates, financers, technicians, administrators, organizers) and supporters (workers, donors, symphatizers).
Evaluation is possible from various aspects; we can consider the input into a programme, the results, the adequacy of the results, the balance of performance to input and the process.
The appendix lists considerations to be taken into account in designing a policy of nutrition and health education.