The Health Belief Model, social learning theory (recently relabelled social cognitive theory), self-efficacy, and locus of control have all been applied with varying success to problems of explaining, predicting, and influencing behavior. Yet, there is conceptual confusion among researchers and practitioners about the interrelationships of these theories and variables. This article attempts to show how these explanatory factors may be related, and in so doing, posits a revised explanatory model which incorporates self-efficacy into the Health Belief Model. Specifically, self-efficacy is proposed as a separate independent variable along with the traditional health belief variables of perceived susceptibility, severity, benefits, and barriers. Incentive to behave (health motivation) is also a component of the model. Locus of control is not included explicitly because it is believed to be incorporated within other elements of the model. It is predicted that the new formulation will more fully account for health-related behavior than did earlier formulations, and will suggest more effective behavioral interventions than have hitherto been available to health educators.

The concept of self-efficacy is receiving increasing recognition as a predictor of health behavior change and maintenance. The purpose of this article is to facilitate a clearer understanding of both the concept and its relevance for health education research and practice. Self-efficacy is first defined and distinguished from other related concepts. Next, studies of the self-efficacy concept as it relates to health practices are examined. This review focuses on cigarette smoking, weight control, contraception, alcohol abuse and exercise behaviors. The studies reviewed suggest strong relationships between self-efficacy and health behavior change and maintenance. Experimental manipulations of self-efficacy suggest that efficacy can be enhanced and that this enhancement is related to subsequent health behavior change. The findings from these studies also suggest methods for modifying health practices. These methods diverge from many of the current, traditional methods for changing health practices. Recommendations for incorporating the enhancement of self-efficacy into health behavior change programs are made in light of the reviewed findings.

In this article two new methods for building and evaluating e-health interventions are described. The first is the Multiphase Optimization Strategy (MOST). MOST consists of a screening phase, in which intervention components are efficiently identified for selection for inclusion in an intervention or rejection, based on their performance; a refining phase, in which the selected components are finetuned, and questions such as optimal component dosage are investigated; and a confirming phase, in which the optimized intervention, consisting of optimal doses of the selected components, is evaluated in a standard randomized confirmatory trial. The second is the Sequential Multiple Assignment Randomized Trial (SMART) which is an innovative research design especially suited for building time-varying adaptive interventions. A SMART trial can be used to identify the best tailoring variables and decision rules for an adaptive intervention empirically. Both the MOST and SMART approaches use randomized experimentation to enable valid inferences. When properly implemented, these approaches will lead to the development of more potent e-health interventions.There are good reasons to believe that interventions based on e-health principles have the potential for considerable public health impact. Perhaps the most obvious reason is the reach of these interventions. Once an electronic intervention has been designed and programmed, delivery occurs via methods such as the Internet or by mailing a CD, and therefore is extremely convenient. Moreover, the incremental cost of delivering an intervention to additional people is usually negligible, certainly in comparison to traditional interventions where in order to reach more recipients it becomes necessary to add additional physicians, therapists, health educators, peer counselors, and so on to deliver the program. The limiting factor for reach of an eintervention is less likely to be a shortage of resources for delivering the program electronically than access to computers on the part of potential recipients. However, access to computers continues to increase in all strata of American society, suggesting that e-health interventions hold growing promise. 1Correspondence and reprint requests: Linda M. Collins

Printed health education materials frequently consist of mass-produced brochures, booklets, or pamphlets designed for a general population audience. Although this one-size-fits-all approach might be appropriate under certain circumstances and even produce small changes at relatively modest costs, it cannot address the unique needs, interests, and concerns of different individuals. With the advent and dissemination of new communication technologies, our ability to collect information from individuals and provide feedback tailored to the specific information collected is not only possible, but practical. The purpose of this article is to: (a) distinguish between tailored print communication and other common communication-based approaches to health education and behavior change; (b) present a theoretical and public health rationale for tailoring health information; and (c) describe the steps involved in creating and delivering tailored print communication programs. Studies suggest computer tailoring is a promising strategy for health education and behavior change. Practitioners and researchers should understand the approach and consider the possibilities it presents for enhancing their work in disease prevention.

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MOST has the potential to husband program development resources while increasing our understanding of the individual program and delivery components that make up interventions. Considerations, challenges, open questions, and other potential benefits are discussed.

OBJECTIVES. To achieve the Healthy People 2000 objectives, public health professionals must develop effective dietary interventions that address psychosocial and behavioral components of change. This study tested the effect of individually computer-tailored messages designed to decrease fat intake and increase fruit and vegetable intake. METHODS. Adult patients from four North Carolina family practices were surveyed at baseline and then randomly assigned to one of two interventions or to a control group. The first intervention consisted of individually computer-tailored nutrition messages; the second consisted of nontailored nutrition information based on the 1990 Dietary Guidelines for Americans. Patients were resurveyed 4 months postintervention. RESULTS. The tailored intervention produced significant decreases in total fat and saturated fat scores compared with those of the control group (P < .05). Total fat was decreased in the tailored group by 23%, in the nontailored group by 9%, and in the control group by 3%. Fruit and vegetable consumption did not increase in any study group. Seventy-three percent of the tailored intervention group recalled receiving a message, compared with 33% of the nontailored intervention group. CONCLUSIONS. Tailored nutrition messages are effective in promoting dietary fat reduction for disease prevention.

Rationale: Urban African-American youth, aged 15-19 years, have asthma fatality rates that are higher than in whites and younger children, yet few programs target this population. Traditionally, urban youth are believed to be difficult to engage in health-related programs, both in terms of connecting and convincing. Objectives: Develop and evaluate a multimedia, web-based asthma management program to specifically target urban high school students. The program uses "tailoring," in conjunction with theorybased models, to alter behavior through individualized health messages based on the user's beliefs, attitudes, and personal barriers to change. Methods: High school students reporting asthma symptoms were randomized to receive the tailored program (treatment) or to access generic asthma websites (control). The program was made available on school computers. Conclusions: A web-based, tailored approach to changing negative asthma management behaviors is economical, feasible, and effective in improving asthma outcomes in a traditionally hard-to-reach population. Measurements and Main