Even with the dramatic advances in our understanding of the biological processes that determine health and illness, it has never been more clear that rates of disease morbidity and premature mortality reflect people's behavioral practices. [1
] The benefits, both for individuals and the societies in which they live, that would come from systematic improvements in diet, physical activity, and use of substances such as tobacco, alcohol, and illicit drugs are tantalizing and provide ample motivation to develop initiatives to elicit changes in health behavior. Yet, health behavior change has proven a worthy adversary. Despite the commitment of considerable time and effort, innovations and advances in our ability to improve health behaviors have been modest. In particular, the specification of methods that produce sustained improvements in behavior have been elusive [2
]. At the same time, innovations in theories of health behavior have also been modest. Investigators continue to advocate for a broad range of theories and there has been limited progress in demonstrating the unique value of any specific theory. [6
Although there may be consensus in the professional community that there are considerable gaps in our understanding of health behavior change, critiques of the current state of affairs more often that not reflect the professional interests of the critic. Investigators who strive to specify the structural and psychological processes that regulate people's behavior lament the fact that too many interventions are not guided by a theoretical framework that specifies how they are supposed to elicit health behavior change. At the same time, investigators who design and implement health behavior interventions lament that the preponderance of theories of health behavior make it difficult to discern what factors are likely to be the most effective targets for intervention. Moreover, it is argued that theories are not sufficiently specified to determine when or how to modify factors that are to be targeted in an intervention.
Of course, concerns regarding the link between theory and practice are not new and efforts to address this problem have taken several forms. Considerable effort has been given to provide practitioners with a comprehensive and concise understanding of the array of theories that have been developed to address health behavior. [9
] Moreover, conceptual frameworks such as PRECEDE-PROCEED [10
] and Intervention Mapping [11
] have been developed to provide investigators with a structured process to improve the accuracy and ease with which theoretical concepts are used to address a practical problem. In both cases, these efforts have targeted improving how
theoretical principles are applied and, in doing so, have relied on the assumption that current theories of health behavior are useful and productive. Is this assumption valid? Could the often repeated plea for investigators to ground their intervention efforts in theory be a sign that there are significant limitations to the practical principles that can be derived from current theories of health behavior? If so, merely improving how people use theories will not be sufficient. What is needed is a shift in how we engage the interplay between theory and practice, with an emphasis placed on developing initiatives that target opportunities to develop, test, refine health behavior theory.
In this paper, I describe and advocate for a model of collaboration between basic and applied behavioral scientists. Although I recognize the value of improving the manner in which theoretical principles are matched to problems and methods, I propose that innovations in our understanding of and ability to promote health behavior change will not arise if theory is construed as a fixed entity that is delivered to interventionists for implementation. To date, although theories may fluctuate in their popularity, their properties have remained strikingly static over time. I believe greater attention must be paid to refining and, when necessary, rejecting theoretical principles. For this process to take shape, there needs to be an on-going series of exchanges between theorists and interventionists in which theory is treated as a dynamic entity whose value depends on it being not only applied and tested rigorously, but also refined based on the findings afforded by those tests.
A fundamental implication of this perspective is that improvements in both health behavior theory and intervention methods depend on each other. If investigators are more receptive to the opportunities interventions afford for theory testing, there will be a dramatic increase in data that can reveal the adequacies and inadequacies of a given theory. These data will, in turn, enable theorists to improve the quality of the theoretical models available to guide subsequent intervention efforts.