Behavioral Research in Health Care
What Is Behavioral Research?
An examination of behavioral research is best begun by examining what it is and differentiating it from related areas of research. Behavioral research within nursing generally refers to the study of health-related behaviors of persons. Studies may include the following areas:
(a) health-promoting behaviors such as exercise, diet, immunization, and smoking cessation.
(b) screening behaviors such as mammography, breast self-examination, and prostate examination.
(c) therapeutic behaviors such as adherence to treatment regimen, blood glucose monitoring, participation in cardiac rehabilitation programs, and treatment-related appointment keeping.
The research spans medical and
psychiatric populations. It is directed towards an understanding of the nature
of behavior and health relationships and to the modification of behaviors that
affect health. It has been estimated that over half of premature deaths could
be prevented if health behaviors were altered.
Behavioral Research And Nursing Theories
Behavioral research has its roots in learning theories that arose in the early part of the 20th century. Classical or respondent conditioning was followed by instrumental or operant conditioning and evolved into the co-native behavioral theories that dominate the field today.
In classical conditioning an un-conditioned stimulus is paired with a conditioned stimulus, resulting in the development of a conditioned response. Much of the research emphasizes conditioned physiological responses.
An example is found in the study of anticipatory nausea and vomiting during chemotherapy. In this case, chemotherapy (unconditioned stimulus) may induce nausea and vomiting. After several exposures to chemotherapy in a particular setting (conditioned stimulus), the setting itself may induce nausea and vomiting (conditioned response) prior to and independent of the actual administration of the chemotherapy (unconditioned stimulus).
Another example is
reciprocal inhibition or desensitization in which anxiety is viewed similarly
as a conditioned response to stimuli. An incompatible response (relaxation) is
paired with progressively stronger levels of the conditioned stimulus in order
to inhibit anxiety responses.
Behavioral Research And Mental Health Nursing
With instrumental or operant conditioning, behavior is seen as arising from environmental mental stimuli or random exploratory actions, which are then sustained by the occurrence of positive reinforcement following the behavior.
Laws have been established that address the identification of enforcers, the schedules of administration of enforcers for initiation and maintenance of behavior, and strategies for the extinction of behavior. In this model, motivation is seen as a state of deprivation or satiation with regard to reinforcers.
Numerous strategies have evolved from this work, including but not
limited to contracting and tailoring, which have been used in studies of
patient adherence; token economies, which have been used in studies on unit
management with the mentally ill or developmentally delayed; and contingency
management, which has been used in the promotion of treatment behaviors such as
exercise.
Self Management And Behavioral Research
As the operant model has expanded over time, self-management has evolved as a special case of contingency management. With self-management the individual is responsible for establishing intermediate goals, monitoring progress toward those goals, and administering self-reinforcement for success.
Self-management
has been studied particularly for chronic, long-term regimens such as those for
diabetes, asthma, and cardiovascular disease.
Comparison Between Behavioral And Motivational Theories
In both of these models there is an emphasis on behavior rather than motivation or personality or relationships, beyond that of the reinforcing behaviors of significant others. The history of the behavior is of less interest than the factors that currently sustain the behavior.
An empirical model is used with an assessment of the frequency or intensity of the behavior over time, the stimulus conditions that precede the behavior, and the consequent or reinforcing events that follow the behavior. Intervention is then directed to the specific areas targeted by the initial assessment.
Detailed assessment
continues through the course of intervention and often through a period
following intervention to assess maintenance or generalization.
Outcomes Of Comparison
Each of the cognitive-behavioral models identifies a cognitive feature as a major motivational determinant of behavior. Self efficacy theory postulates the role of perceived ability to engage in a behavior under various conditions.
The theory of reasoned action postulates that intention to engage in a behavior is significant and is influenced by beliefs regarding behavioral outcomes and attitudes toward the behavior.
The health belief model postulates that one's perceptions about the illness in terms of its threat (severity and susceptibility), as well as the perception of the benefits and barriers to engaging in the behavior, influence intentions and subsequently behavior.
However, the commonsense model of illness proposes that the individual's own
model of the illness influences his or her illness or treatment-related behaviors.
Behavioral And Psychosocial Theories
Behavioral research can be distinguished from psychosocial research, which tends to emphasize adjustment and coping as well as predictor and moderator variables arising from the psychological state or the social environment of the person. Behavioral research, including cognitive-behavioral studies, emphasizes behavior.
In the classical and instrumental models, observable behavior is stressed. In the cognitive-behavioral model, both observable and covert behaviors are stressed.
Within nursing much of the behavioral research has addressed participation in treatment, exercise, sexual behaviors, health promotion, breast self-examination and mammography utilization, childbirth and maternal behaviors, behavioral symptoms of dementia, self-management in chronic conditions, management of alcohol or drug dependence, and the role of biofeedback in such behaviors as pelvic floor muscle exercise in incontinence and heart rate variability.
Unlike psychosocial studies, factors such as
personality, coping strategies, and socioeconomic status are not primary
interests; however, they may be of interest in determining reinforcers and
stimulus conditions.
There is an additional body of behavioral research that tends to be interdisciplinary in nature and is of relevance to nursing. There are studies in the community to modify health behaviors within populations and studies within multicenter clinical trials that attempt. to influence the health behavior or protocol-related behaviors of research participants.
Also there is a broad set
of studies to identify the relationship between behavior and disease etiology,
such as studies of the role of exercise on the maintenance of function in the
older adult, mechanisms of addiction in smoking behavior, and the effect of
neuro-transmitters on eating behaviors.
Given the prevalence of lifestyle behaviors that adversely affect health and the management of illness, research to understand and modify those behaviors would benefit the individual as well as the population.
There is a need for nursing research to expand into the interdisciplinary arenas, particularly in the examination of health behavior change in the community, studies within multicenter clinical trials, and the etiological relationship between behavior and health and illness. Furthermore, many of the studies in nursing have been descriptive in nature or have focused on the development of assessment instruments.
Although few of the studies have examined how to intervene with
behaviors that contribute to the development or progression of illness, this
research would be useful to better direct interventions with patients.
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