40

特集：行動科学研究の発展と展望－理論から実践へ
Perspectives on Behavioral Sciences Research
for Disease Prevention and Control in Populations
Karen GLANZ1）, Neville OWEN2）, Jessica A. WOLD1）
1）
2）

Emory University, Atlanta, GA, USA

The University of Queensland, Brisbane, Queensland, Australia

Abstract
Background: Changing behavior is integral to population-health approaches to disease prevention, particularly for addressing
the metabolic syndrome (metabo ) and HIV/AIDS in Japan. For metabo , the most relevant behavioral changes are improving
diet and increasing physical activity. For HIV/AIDS, changes in behaviors that promote transmission of the HIV virus are
required. Using the most suitable health behavior theories to understand how to change the relevant behaviors in populations
and high risk-groups is a key to effective public health action.
Methods: We describe and analyze important contributions that health-behavior theories and research can make in addressing
the prevention and control of metabo and HIV/AIDS. Theory and application are presented in relation to individual healthbehaviors; in the context of interpersonal relationships, environment, community, and organizational factors; and in relation
to the translation of theory into research and practice.
Results: Addressing complexly-determined behavioral health problems such as metabo and HIV/AIDS requires more than theapplication of a single theoretical model. Determinants of health risk behaviors act at multiple levels and occur in the context
of economic, social, and cultural changes in Japan. Thus, they can be difficult to change, particularly through public healthstrategies that might focus only on informing, educating, and motivating individuals. Broad-reach, comprehensive programs
and public health policy initiatives should be targeted at multiple levels. Examples from research in Japan and selected
examples from Western countries demonstrate the unique contributions of health behavior theories.
Conclusions: Familiarity with the relevant theories of health behavior change is an important ingredient for developing
successful public health programs – the challenge is to use the most relevant elements of the most-suitable theories tocomprehensively address multiple levels of influence on complex health behaviors. We hope that readers will take theperspectives described in this article and use them as they work to address public health challenges in local communities,
workplaces, and other organizations, and at the broad national level to improve those behaviors that are significant
determinants of major health outcomes in Japan.

Keywords:

health behavior, behavior theory, prevention, metabolic syndrome, HIV/AIDS

I . Introduction
Understanding and influencing behavior is a central
element of population-health strategies for disease
prevention and health promotion. Changing the relevant
behaviors is fundamental to the prevention of chronic
diseases such as type 2 diabetes, cardiovascular disease,and the most common types of cancer (most notably, lung,breast, and colon cancer). Behavior change is also

fundamental to reducing the risk of some of the major
infectious diseases in populations, particularly HIV/AIDS.
To address the challenges of behavior change for disease
prevention and control, evidence-based approaches areneeded. In this context, the behavioral sciences are crucial
and relevant to key public health challenges in Japan. We
propose that the most important contribution of the
behavioral sciences is in providing ways of thinking that
help to understand the determinants of key health-related

Karen Glanz, PhD, MPH, Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, Room 530, Atlanta, GA 30322.
Phone 404-727-7536; Fax 404-727-1369; email: kglanz@sph.emory.edu

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9Karen GLANZ, Neville OWEN, Jessica A. WOLD
behaviors, and to develop and evaluate broad-based
programs and policies based on this understanding.
For the most widespread chronic diseases, the relevant
behavioral changes are avoiding tobacco or quitting
smoking, reducing high levels of alcohol intake, increasing
physical activity, and improving diet. One of the central
goals of behavioral changes in relation to physical activity
and encouraging healthy eating patterns is to prevent
weight gain in whole populations and to encourage weight
reduction among those who are already overweight. For
infectious diseases such as HIV/AIDS, safe sexual practices
such as condom use, or avoiding needle sharing among
injecting drug users are the most common targets.
In this paper, our main aim is to provide a broad
perspective and examples of how behavioral science
theories and research can assist in developing more
effective public health approaches to the prevention ofchronic and infectious diseases. These issues will beconsidered within the context of Japanese culture, changing
social environments and norms, and variation acrosssubpopulations within Japan. For our examples, we will
focus mainly on two issues of current public healthimportance for Japan: reducing the prevalence ofoverweight and obesity [i.e., the metabolic syndrome or
metabo ]; and reducing the transmission of the HIV/AIDS
virus.

II. How Health Behavior Theories Can Inform
Public Health Strategies for Disease Prevention
Theories of health behavior have a key role in informing
practical approaches to health promotion and disease
prevention by focusing the thinking of researchers,
practitioners, and policy-makers on three key questions
about behavior change: 1) What dimensions of the
behavior are most important, for which health outcomes? 2)
What are the modifiable determinants of these dimensionsof behavior, in which settings? 3) What interventions tochange the relevant behavior (including personal, social,environmental, and policy initiatives) are necessary andmost likely to be effective?
Thus, population-based approaches to disease prevention
and health promotion require understanding specificallywhich behaviors should be addressed, identifying thefactors that can influence those behaviors, and knowing
what interventions are likely to be most effective. So, is thebest scientific guidance for behavior-change approaches inpublic health simply a matter of choosing a good theory
and then systematically applying that theory to the problem
at hand? Our answer to this question is‘no’.
In explaining the relevance of health behavior theories to41

major population health problems for Japan, our goal is to
avoid over-simplification, and to convey an integrated
perspective. Our aim is to show how, in a complex publichealth context where it is necessary to think about many
behaviors, for many different individuals and social groups,
in many different settings, it is possible to adopt a coherent
and helpful perspective by using theories of healthbehavior. Furthermore, these theories must be consideredwithin the cultural dynamics of a population – an overarchingtheme we will return to in the next section.
Preventing major chronic and infectious diseases isinherently complex. Any population-based endeavour withthese aims typically will include some or all of thefollowing elements:• health practitioners and others communicating directlywith individuals, with the aim of assisting andpersuading them to change their behavior;• organizational and social strategies through workplaces,
schools, the consumer marketplace, and other settings,
that use rules, regulations, programs, and incentives forthe purpose of health promotion;• public communication strategies using mass media
campaigns that aim to increase knowledge, changesocial norms, and set the agenda for behavioral change;and,• changes to social policy including, for example,
initiatives in health care systems or modifications to thebuilt environment, that are designed to promote somebehaviors and to discourage other behaviors.
Health promotion and disease prevention initiatives for
the Japanese population will involve many different
elements, with choices to be made about which elements
should be emphasized, for which intervention strategies,
and in which organizational, social or environmental
contexts. The use of well-chosen theoretical models of
health behavior is essential for these purposes.
The central challenge is to identify which of the many
available health behavior theories and models are mostappropriate for which purposes, and how best to apply
them. Glanz, Rimer and Viswanath1) provide a framework
to guide the complex endeavor of promoting healthbehavior change in populations. They group theoreticalmodels and their application into four categories: 1) models
of individual health behavior; 2) models of interpersonal
health behavior; 3) community and group models of healthbehavior change; and 4) models to guide the translation oftheory into research and practice.
Models of individual health behavior provide systematic
accounts of why individuals behave as they do, and how
they go about changing their behavior: this includes how

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Behavioral Science Perspectives on Disease Prevention

they perceive their own behavior, evaluate the risks andbenefits of different behavioral choices, absorb new
information, and initiate and maintain the relevant changes.
Models of interpersonal health behavior aim to account for
how personal, family, and professional interactions canpromote certain behaviors and discourage others.
Community and group models of health behavior change
focus on the dissemination and diffusion of new ideas about
health behavior through populations, includingorganizational structures and policies, and how mass media
and other forms of mass communication (including newer
information technologies) may be used to influence
populations. Translation of theories in research andpractice requires taking into account how the determinantsof behavior at multiple levels (individual, interpersonal,social, community, environmental, and policy), andinterventions targeted at those multiple levels, may beorganized in a systematic fashion for improved population
health.

III. Health Behavior Theory and Public
Health in Japan’s Cultural Milieu
It is important to recognize that while health behavior
theories are designed to provide general explanations of
why people do and do not engage in certain health-related
actions, their relevance -- how they might or might not
apply -- varies significantly from country to country andculture to culture. Thus, there are cultural factors to betaken into account in translating for Japan what is known
from research that has been mainly carried out in Western
populations. Throughout this paper, we will touch upon
what we see as relevant“translational nuances”for the usesof health behavior theories in the context of public healthinterventions in Japan. Our sources are limited to Englishlanguage publications, discussions with Japanesecolleagues and Westerners who have lived in Japan, andfrom our own few visits to Japan. Therefore, please excuse
us for any inaccuracies or misunderstandings that we might
convey, as we try to take into account what we have learned
about Japanese cultural patterns and trends.
Several key issues are potentially relevant to translating
health behavior theories into action strategies in Japan.
Traditionally, Japanese society is considered to have ahighly collectivistic orientation that emphasizes
interdependence in human relationships, conformity,
compliance, and striving for harmony2). This orientation
contrasts with the individualistic orientation of many
Westernized societies that often emphasize individuala c h i e v e m e n t o v e r s o c i a l r e l a t i o n s h i p s . F a m i l y,neighborhood, and group activities are central to Japanesechildren ’s socialization. Hierarchical relationships
traditionally begin with parent-child ties and respect for
elders, and extend to doctor-patient relationships andcooperative group efforts in the workplace. Avoidance of
conflict, deference to authority, and a non-confrontational
style are long-honored norms in Japan3).
However, economic, social, and cultural transitions inJapan over the past century have brought change in families
and other social relationships – some of which bear directly
on health behaviors. Gender roles as they are experienced
by Japanese men and women have evolved across recent
generations from the mid-twentieth century to the present,with succeeding generations bringing greater equality towomen by Japanese standards3). Further, in more recent
generations, Japanese women are more likely to workoutside the home, and this can contribute to changes infamily eating routines. Relationships to work have changed
with industrialization and concentrations of population inlarge cities, which has been associated with a decrease in
the numbers of extended multigenerational families living
together2). Urban and rural lifestyles have diverged so thatrural populations are more automobile-dependent and thus
less physically active in their daily lives than are citydwellers, many of whom walk or use bicycles to get to andfrom public transit. This may be contributing to higher
rates of childhood obesity in rural areas4). Increasingly,
such interactions with the built and natural environment
may influence health behavior and individuals’interactions
with their communities may make certain behavioral
choices easier, or more difficult.
We now turn to examples of how behavioral science
theory, research, and practice can be informative in
addressing two issues of current public health importancein Japan: reducing the prevalence of overweight andobesity (metabo ) in the Japanese population, and preventing
the transmission of the HIV/AIDS virus among susceptible
population groups.

IV. Metabolic Syndrome (Metabo ): Healthy Diet,
Physical Activity and Too Much Sitting
In the past fifty years, a period of rapid economic andindustrial development in Japan has brought major changes
in lifestyle, including work, transportation patterns, thefood supply, and physical activity. The combined influenceof these changes is believed to have led to increases inobesity in both Japanese children and adults. An estimated
23 million of Japan’s 128 million inhabitants are obese5).
Public health concern has recently become focused on
overweight and obesity under the description of metabolic
syndrome or“metabo”, because of its role as a major risk

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Karen GLANZ, Neville OWEN, Jessica A. WOLD
factor for type 2 diabetes, cardiovascular disease, and somecancers4, 5) – all diseases being addressed by current healthpolicy initiatives in Japan. The ethnic-specific definition ofobesity in Japan is a body mass index (BMI) of 25 orhigher, based on the level of excess weight associated withincreased prevalence of obesity-related diseases6, 7). Key
behavioral contributors to metabo include eating too muchof the wrong type of food (foods higher in fat than the
traditional diet that is centered on rice and fish), lack ofphysical activity (not taking regular exercise and doing
very little walking as an integral part of daily routines or inrecreational time), and also the amount of time that people
spend sitting5).
The increases in metabo in Japan are seen in the young
and the old, and in men and women, though the prevalenceof metabo is more pronounced in middle-aged and oldermen, and among children living in rural areas 4, 5) .
Interesting insights on the effects of industrialization andWesternization can be seen in Okinawa, where a paradox
can be seen: increasing socioeconomic status (SES) is
becoming associated with shorter life expectancy.
Researchers hypothesize that traditional diet, daily active
lifestyles, and high levels of social support account for
greater longevity of traditional-living but lower SES
Okinawan adults8). One study found dramatic changes overa 15-year period in which the prevalence of diabetes in asmall town in Okinawa correlated with use of motorizedtransportation and shopping in supermarkets (rather thansmall shops)9). Supermarkets provide a wide range of more
Western-style foods, whereas smaller local stores may be
more likely to provide traditional Japanese foods. Also,supermarkets are typically farther away from people ’shomes. Recent research in Australia has shown that where
destinations are more distant from people's houses, they areless likely to walk as part of their daily routines10).
Physical activity is fundamental to public healthstrategies for the prevention of most of the common chronic
diseases. A public health focus on physical activity11) is
fundamental to current concerns in Japan about theprevention of metabo . Successful initiatives require
identifying the types of physical activity that are most
relevant to contemporary public health concerns. Early
approaches to physical activity and health emphasized
aerobic fitness training through vigorous exercise at least
three times per week for more than 20 minutes. Now,
public health recommendations on physical activity for the
USA propose moderate-intensity activity (typically brisk
walking) on at least 5 days per week, for at least 30 minutes(which may be accumulated in the shorter bouts).
Importantly, in relation to the prevention and control of

43

metabo , 60-90 minutes per day is proposed as being
optimal to maintaining a significant weight loss (e.g., 13 to
23 kg) and preventing repeated weight gain in adults12).
New evidence on an important aspect of physical activity
with major relevance to the prevention of metabo is
emerging from health-behavior studies on the high volumesof time that adults spend sitting in most aspects of their
daily lives. It now appears that contemporary changes intransport, occupations, domestic tasks, and leisure activities
have had negative effects on daily energy expenditure13).
Sedentary behavior (from the Latin sedere - 'to sit') is theterm now used to characterize those behaviors for whichenergy expenditure is extremely low, such as prolonged
periods of sitting time in transit or driving, sitting at a desk
and working at a computer in the workplace, watching
television at home, and so on.
For example, a prospective study in Australia showedthat self-reported sitting time was a predictor of weight gain
in women, even after adjustment for energy intake andleisure time activity14). Observational studies show that
prolonged television-viewing time is associated with anincreased risk of having metabo 15-16), and that taking more
breaks from sitting time is associated with reduced
likelihood of having metabo17). Recent findings also suggestthat leisure-time physical activity, in the context ofotherwise sedentary lifestyles involving higher volumes ofsitting, is unlikely to be sufficient to prevent metabo , andits associated risks of major chronic diseases13, 18). Too muchsitting (as opposed to too little exercise) may havedeleterious physiological effects on the metabolism ofblood fats in ways that increase the risk of developing
metabo 19).
These new perspectives on the role of a lack of physicalactivity and the unique influences of sedentary behavior(too much sitting) on the risk of developing metabo haveimportant implications for the major health initiatives inJapan. Public health officials have recently updated and refocused government-sponsored efforts to address metabolic
syndrome following the Healthy Japan 21 interim
assessment which found increases in sedentary lifestyles,
diabetes, and overweight and obesity – especially among
middle-aged and older men (Yuriko Doi, personalcommunication). The government mandate requires
medical insurance providers to screen insured individuals
with metabolic syndrome and provide them with weight
management programs for at least three months (Yuriko
Doi, personal communication). Companies and local
governments are required to measure the waistlines ofadults aged 40 to 74 and to provide dietary guidance to help
them lose weight, and they face financial penalties if they
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Behavioral Science Perspectives on Disease Prevention

fail to meet specific targets20). While these initiatives will
be important in drawing attention to the changes that
individuals need to make, and which have a strong andentirely appropriate emphasis on dietary improvement, it
will also be important to take into account the changes thathave occurred in people's environments which result in too
little exercise and too much sitting.

We will next examine how the population healthcampaign uses available information about the individuallevel, interpersonal level, organization/community level,
and translation issues that might inform successful metabo
prevention in Japan’s population.

Table 1. Influences on Metabolic Syndrome and Prevention/Control Strategies

Issue or Level of Analysis

Key Factors

Implications for Population Health Interventions

Epidemiology and trends

Increasing rates of obesity
Westernization of Japanese diet
Reduced daily physical activity
Increases in prolonged sitting time

Increasing public’s perceptions of relevant risks
Broad-based advocacy for traditional cuisine
Promoting physically active transport
Innovative workplace regulations

Individual level

Knowledge of metabo risk
Attitudes to eating and activity
Motivation to change

Informative mass media communications
School-based and family-oriented education
Promoting short and long-term benefits of healthy weight

Interpersonal level

Family beliefs and practices
Behaviors of friends, co-workers
Social support of family and others

Initiatives through schools and community groups
Mass-media messages emphasizing social norms
Encouraging family and collective social responsibilities

Community models

Mass-media communications
Prompts from health care system
Workplace policies and programs

Using prominent role models
Health care provider assessment and feedback
Education of managers and workers

Translating theory into researchand practice

Availability of healthier options
Interventions on multiple levels
Broad-based public policies

Engaging the food industry and urban planners
Applying an ecological perspective to health planning
Engaging all relevant government sectors

V . Metabo : Application of Individual-Level
Health Behavior Theories
The dietary education, physical activity, and healthy
weight management components of the metabo -prevention
strategy of Japan can be directly informed by models of
individual health behavior that address why individuals
behave as they do and in turn, how their behavior can bechanged. Behavioral determinants of metabo that are in therealm of discretionary personal choices are likely to include
lack of knowledge about healthy food choices. Suchchoices must, however, be seen in the context of broader
cultural changes in general eating patterns. The traditional
Japanese adage of“Hara hachi bunme”or“stop eatingwhen you’re 80% full”21) seems less resonant in modern
Japan. Several studies have found that eating quickly andeating until full are associated with getting fatter,
independent of total energy intake 22-24) . Models of
individual health behavior suggest that in this context, thereis the need for particular approaches that focus on how
individuals perceive their own behavior, evaluate the risks

and benefits of these different behavioral choices, how they
absorb new information, and how they go about initiating
and maintaining the relevant changes. In this context, theTheory of Planned Behavior (TPB) is an individual-level
health behavior theory that emphasises the importance ofpeople’s attitudes to the particular food choices that they
may or may not make. People's confidence about making
behavioral changes (perceived behavioral control or self
efficacy ) when their attitudes are positive towards doing so,
act together as major determinants of intention , which
precedes the initiation of any relevant behavioral change.
TPB also highlights the important role played by what
people observe in the expressed beliefs and behavior
patterns of others (social norms ).
Lower levels of physical activity, and too much sitting,increasingly accompany the focus on academic
achievement (for children and youth) and long work days
(for adults, especially men), as well as children’s increased
use of video games and television-watching25). Shorter
sleep duration has also been associated with increasing

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obesity23). Within the framework of the Theory of Planned
Behavior or TPB, these factors would be identified as
barriers , which intervene between people's intentions andtheir actual behavior. While how much time is devoted to
study, to the recreational use of video games or television
watching, or to how long a child or adult spends sleeping,may be seen as matters of personal choice and within thecontrol of individuals, these behaviors are also sociallydetermined.
Thus, educational programs alone – without the strong
support of others who are able to be influential – willprobably be insufficient to achieve health-promotingchanges. It is therefore important to also take into accountinterpersonal factors that can influence health-related
behavioral choices.

VI. Metabo : Applications of Interpersonal
Health Behavior Theories
Models of interpersonal health behavior account for how
interpersonal and family relationships, social relationships
in the workplace setting, and broader social networks canact to promote certain health-related behavioral choices andmay strongly discourage others. Social Cognitive Theory26)
which emphasizes the reciprocal relationships between
people and their social environments, and theories of social
networks27) are other useful frameworks for thinking about
these influences. Social networks provide practical, or
instrumental, sources of social support as well as emotional
support and structured expectations and rules27) that can
influence eating and activity patterns.
Changes in family relationships and broader social
networks may be contributing to the increasing rates ofmetabo in Japan. Japan ’s falling birth rate, increasing
indulgence of children, increased consumerism, and acultural shift away from families spending time together5)interfere with structured routines for healthful eating andactivity. The time pressures of modern life find fewer
families eating together regularly, more families eating
meals out at restaurants, and people more often turning toconvenience foods that are higher in calories and fat5, 25).
Interpersonal factors act particularly through the
influence of families. The increase in two-parent working
families, where children spend a considerable amount oftime outside of their immediate family environment
attending nursery school or other forms of outside care, hasbeen argued to be associated with higher levels ofchildhood obesity28). And in the workplace, obesity was
found to be associated with job stress (higher demands, lowdecision latitude) among Japanese males in factory jobs,
and with eating fast and eating until full24).

45VII. Metabo : Application of Community andGroup Models of Health Behavior Change
Community and group models of health behavior change
focus on organizational, institutional, and built environment
factors. For understanding how the social and built
environment attributes of communities may act to influence
health-related behavioral choices, ecological models of
health behavior highlight the interplay in community
settings between environmental, policy, interpersonal, andindividual level factors29). Four core principles of ecologicalmodels of health behavior have been proposed: 1) thatmultiple influences at the intrapersonal, interpersonal,organizational, community, and public policy levels affecthealth behavior; 2) influences on behaviors interact acrossthese different levels; 3) ecological models should be
behavior-specific; and 4) multi-level interventions should
be most effective in changing behavior.
Ecological models emphasize the role of behavior
settings , the physical and social aspects of situations inwhich people spend their time that act to promote andencourage certain behaviors, and to restrict or prohibit otherbehaviors. For example, college students in Japan havebeen found to eat more often in response to environmental
cues30); this may be related to the increased availability of
convenience foods and fast food. Also, in modern Japan,
the behavior settings that traditionally have provided
frequent opportunities for physical activity as part of daily
life have changed dramatically, both in large cities and inrural areas. For example, childhood obesity appears to be agreater concern in rural areas than in urban areas, as thoseliving in rural locations are becoming increasingly
automobile-dependent and lacking in walkable
destinations4). Adults living in rural locations in Japan are
known to be less physically active nowadays: the nature ofwork in rural areas has shifted from more active
occupations such as farming and construction work toservice industries with much lower levels of occupational
physical activity5).
These observations are consistent with evidence fromstudies in the USA and Australia, and show the importanceof certain aspects of the built environment as influences on
how much physical activity people get, and how much timethey spend sitting. We now know that communities where
people are largely dependent on using automobiles for theirtransport will significantly reduce their physical activity
and increase their risk of being overweight or obese31, 32).
For people who live in such communities, the built
environment offers too few opportunities for walking, few
useful destinations (such as shops, public transport stops, or
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Behavioral Science Perspectives on Disease Prevention

recreational facilities) in the local area, and streets that are
not well connected to each other so that routes for walking
and cycling are limited. Adults living in low-walkablecommunities are less physically active and walk less often
for transport than do those who live in communities that aresupportive of physical activity 32-34). Another study inAustralia found that women in low-walkable communities
also spent more time watching television than those inhigh-walkable communities35).

VIII. Metabo : Translating Theory into Researchand Practice
These examples indicate the need for comprehensive
public health initiatives to address how influences acting atseveral levels may work together, and how they may bemost effectively changed. In particular, there is a need tofocus on how changes to the physical and social
arrangements where people spend their time (behavior
settings ) make health-promoting choices more likely.
There is also a need to focus on multiple levels of
influence, addressing the many factors that work together toinfluence how individuals in different populations anddifferent places make choices about food and physicalactivity.

IX. HIV/AIDS Prevention, Testing, and Control
The number of reported cases of HIV/AIDS in Japan isrelatively low compared to other developed countries andneighboring Asian countries36), but the number of cases

continues to increase and reached record high levels withover 1,300 cases in 2005 and 2006 37). The most often
affected individuals are men in the 20-30 year age range,
predominantly in large cities, and the most common routeof transmission is sexual transmission, especially byhomosexual contact between men37). Policies for HIV/AIDS surveillance and prevention were enacted in 199936)
but were substantially updated in 200638).
The three pillars of the revised AIDS Prevention
Guideline include the redefinition of HIV/AIDS from“anincurable special disease ”to a“ controllable generaldisease”; clarification of responsibilities so that the national
government provides support and local governments(especially in the 47 prefectures) implement prevention andcontrol systems; and prioritization and planning of policies
to target higher-risk populations including homosexual men
and youth38). The national government intends to placehigher priority on the 16 local governments with more than
70% of HIV/AIDS cases in Japan, mainly in large
population centers 38). Specific prevention and control
measures to be undertaken under the revised Guideline
include: 1) providing the right message and information; 2)enhancing voluntary HIV counseling and testing systems;
and 3) rebuilding the medical care system.
We next examine how the pillars and specific measuresrelate to individual level, interpersonal level, organization/community level, and translation issues that might inform
successful prevention and control initiatives in the coming
years.

Table 2. Key Factors in HIV/AIDS Prevention and Control

Issue or Level of Analysis

Key Factors

Implications for Population Health Interventions

Epidemiology and trends

Increasing rates of HIV/AIDS
High-risk groups
Geographic distribution

Redefinition of HIV/AIDS as a controllable disease
Targeting homosexuals, young adults
Focus more efforts in and near large cities

Individual level

Knowledge of HIV/AIDS
Beliefs about risks/protection
Misconceptions and prejudice

Clear, widely accessible information (mass media, web)
Increase awareness, skills, access (e.g. testing, condoms)
Building understanding and compassion for people withAIDS

Interpersonal level

Relationships, social networks
Observational learning
Acceptance of counseling/testing

Use social events to get out prevention messages
Celebrities providing prevention messages
Link social events to voluntary HIV counseling/testing

Community models

Mass media + testing systems
Healthcare system change

HIV Testing Promotion Week activities and structures
Establishing specialized HIV/AIDS hospitals with
inpatient and outpatient services

Translating theory into research andpractice

Understanding complex causes
Disenfranchised groups
Stigmatized groups
Cultural attitudes to sexuality

Systematic planning of prevention/control activities
Working with organized NGO’s and local groups
Address discrimination against homosexual men, increase
women’s safe sex negotiating skills
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X. HIV/AIDS: Application of IndividualLevel Health Behavior Theories
The measure of“ providing the right message andinformation”can be best informed by models of individual
health behavior that address why individuals behave as they
do and how they go about changing their behavior. This
includes how they perceive their own behavior, evaluate therisks and benefits of different behavioral choices, absorb
new information, and initiate and maintain the relevantchanges. A study of female college students in Nagasaki
found that they had fairly high levels of knowledge about
AIDS, and used the mass media as their main source of
information, but also had common misconceptions andprejudices about people with HIV/AIDS39). The plans toprovide accurate messages through a combination of mass
media (on the national level), and local events and publicity
in targeted areas38) , use several individual-level theories
such as the Health Belief Model, Theory of Planned
Behavior, and value-expectancy theories to underpin
assumptions about media effects and strategies for social
marketing40, 41).

47

communication and systems development and have nearly
doubled the number of persons tested from one year to thenext 38) . Increased attention to building a combined
inpatient and outpatient specialized care system for HIV/AIDS in the prefectural hospitals is an importantundertaking in treating this infectious yet controllable
condition in a compassionate manner.

XIII. HIV/AIDS: Translating Theory into
Research and Practice

The prevention messages developed for public healthapproaches to HIV/AIDS also draw on models ofinterpersonal health behavior by highlighting how
interpersonal relationships and broader social networks canact to promote certain behaviors and discourage others.
This is an especially promising approach with young
people, who are more attentive to the behaviors of theirpeers, and thus can be influenced through‘observational
learning,’a key construct of Social Cognitive Theory26).
Events like“Red Ribbon Live 2006”bring together large
groups of people, involve celebrities conveying prevention
messages, and may link with voluntary HIV counselling
and testing events38), thus applying ideas from interpersonallevel theories.

For HIV/AIDS prevention in Japan, translating theory
into research and practice in a comprehensive fashion is an
important and significant challenge. It requires drawing on
an understanding of the many and complex determinants of
behavior (individual, interpersonal, social, community,
environmental, and policy). Ecological models of healthbehavior suggest that HIV/AIDS prevention and control
measures targeted at multiple levels are likely to be mostsuccessful29). These comprehensive strategies need to beorganized in a systematic fashion for improved population
health. Some key aspects of this challenge are unique toJapan and both traditional and changing cultural norms forbehavior. Among the issues that have been raised are thelack of personal identifiers in case reporting for HIV/AIDS 42) ; the challenge of testing and educating sex
workers36, 42); the difficulty of reaching disenfranchised andstigmatized populations with public health measures36); andthe need to reduce discrimination against gay men, andincrease heterosexual women’s ability to negotiate for safe
sex36, 42).
Both research and coordinated planning can reveal
solutions for these important and difficult challenges. Asinternational HIV/AIDS prevention experts have pointed
out, a comprehensive national prevention program requires
addressing environmental and cultural factors invulnerability, linking prevention and treatment, deliveringhigh-quality interventions on a large scale, and ensuringaccountability in evaluating the success of individual andcombined initiatives43).

XII. HIV/AIDS: Application of Community andGroup Models of Health Behavior Change

XIV. Final Thoughts on Using Behavioral Science
to Inform Disease Prevention and Control

Initiatives that focus on disseminating new ideas about
health behavior through populations require guidance from
community models of health behavior change . For HIV/
AIDS, such initiatives include working within community
organizational structures and their policies, and the use ofmass media, cut across all three specific measures of thecurrent policies for HIV/AIDS prevention and control. The
mass efforts for HIV Testing Promotion Week blend

It will be clear from the examples we have describedabove that addressing complex health problems like metaboand HIV/AIDS requires more than the application of one
particular theory of health behavior. The determinants ofthe behaviors that increase people's risk of developing
metabo or contracting HIV/AIDS act at multiple levels( i n d i v i d u a l , i n t e r p e r s o n a l , s o c i a l , c o m m u n i t y,environmental, and policy), and are part of circumstances

XI. HIV/AIDS: Application of Interpersonal
Health Behavior Theories

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Behavioral Science Perspectives on Disease Prevention

that have evolved over time through economic, social, andcultural changes. Thus, they will be difficult to change,
particularly through strategies that might focus only on
informing, educating, and motivating individuals.
Comprehensive interventions that are targeted at multiple
levels are needed, and they must be organized in asystematic fashion for improved population health.
For example, if the cornerstone of new public healthstrategies for metabo only involve measuring workers’
waist circumferences and exhorting them to eat less andexercise more, this will probably not be sufficient toproduce successful health outcomes. Even widespreadmeasurement and advice on personal behavior change willnot‘roll back’the economic, social, and cultural changes
that have resulted in more and more Japanese people being
affected by metabo . However, it may be feasible tomitigate the effects of these influences by new, multi-level
health-promoting policies guided by ecological models of
health behavior 29). These could include, for example,
incentives for people to make changes to their diet;innovations in transportation and urban planning to makewalking a more viable option; ensuring that food andagriculture policies support healthier eating; providing
information on caloric and fat content for prepared foods atthe point of purchase; and so on.
Much research has revealed that individual-level
psychological factors are not sufficient to explain
entrenched diet and physical activity behaviors44). Also,
there is little evidence that public education alone will
result in significant weight loss in adult populations, so
combination strategies that focus on the social and built
environments are likely to be necessary. Anotherperspective suggests that focusing on prevention ofchildhood obesity may be more promising as adults may beable to“re-engineer”children’s food and activity patterns
5)and environments .
Familiarity with the relevant theories of health behavior
change is an important step toward developing successfulprograms – the next challenge is to use then within acomprehensive planning process. Other key elements ofeffective programs for population health are accessible andpractical information, active learning and involvement, agood program-to-audience match, and reinforcement ofdesirable behaviors45). Health education materials should
be appropriate for, and ideally matched to, the educationaland reading levels of particular target audiences, and becompatible with their ethnic and cultural backgrounds46).
In addressing significant public health problems, there isno substitute for“knowing the audience.” This applies tothe conduct of fundamental research to understanddeterminants of health behavior as much as it applies todeveloping health promotion programs for specificindividuals, groups, and communities. Participatory
research and program design improve the odds of success45).
We hope that readers will take the perspectives describedin this article and use them as they work to address local
and national public health challenges. Our hope is thatthese ways of approaching behavior change in public healthwill help in asking critical questions, thinking conceptually
about the determinants of behavior and how to approach
them, and reaching beyond the temptation to use lesscomplex, single-focus, and formulaic strategies to address
important population health problems1).

Acknowledgments
Dr. Karen Glanz ’s effort was supported in part by aDistinguished Scholar Award from the Georgia Cancer
Coalition. Dr. Neville Owen ’s work on this article ispartially supported by a Program Grant (# 301200) from the
National Health and Medical Research Council ofAustralia, and by a Research Infrastructure Grant from
Queensland Health. The authors have no conflicts ofinterest to declare.

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