Journal of Pediatric Nursing
Volume 18, Issue 1 , Pages 30-35, February 2003

The utility of Cox's Interaction Model to direct the assessment and prevention of adolescent aggression☆

University of New Hampshire, Durham, NH.

Article Outline

Abstract 

The current study of violence prevention is hampered by a lack of consensus on the definition of violence. There is, however, some agreement about the behavioral cues that may predict violent behavior such as aggression. Although it has been shown that individual-level variables (e.g., race, gender, and ethnicity) are correlated with aggressive behavior, it is clear that they alone are not explanatory of aggressive behavior. This article demonstrates how the Interaction Model of Client Health Behavior is an important health behavior framework for the assessment of aggression in adolescents, offering insight into the contextual nature of adolescent aggression. Victimization and witnessing of violence, frequently identified to be precursors of adolescent aggression in current epidemiologic studies, are examined within this framework. On the basis of the interactional nature of the phenomenon, necessary components for successful prevention programs are suggested. Finally, future research implications calling for a well-designed study that integrates individual and contextual variables with the use of this theory-driven explanatory framework are proposed. Copyright 2003, Elsevier Science (USA). All rights reserved.

 

A growing body of health behavior research is aimed at identifying the factors that amplify and mitigate youth violence (Kann et al., 1995; Prothrow-Stith, 1995; Saner & Ellickson, 1996). Nevertheless, despite substantial research efforts in the field, the Public Health Service suggests that after nearly a decade of research, only a limited amount of knowledge and understanding of both the causes and prevention of violence has been gained (US Department of Health and Human Services, 1990, 1996, and 2000). The prevailing approaches to the study of adolescent violence are primary reasons for this lack of progress. The majority of what is known about “violent youth” is descriptive of violent events and is obtained post hoc by national survey (e.g., Youth Risk Behavior Surveillance [Centers for Disease Control and Prevention Surveillance Summaries, 1998] and National Crime Databases [Earls, 1994]). These descriptive epidemiologic databases simply measure the prevalence of discrete violent events involving adolescents (Elliot, 1994). One clear advantage of these large database overviews is that they make useful recommendations for the expansion of violence prevention research, particularly in the exploration of determinants. However, these databases lack clinical utility in terms of their use in intervention development. In general, large databases do not sufficiently contribute to our understanding of violent behavior because they tend to neglect the context within which adolescents behave violently.

A socioecologic perspective describes context as factors that influence behavior from an interactive rather than person-focused perspective, emphasizing the person, group, and their social milieu (Stokols, 1996). Nurses have long recognized the importance of context in clinical practice. By virtue of this history, the discipline of nursing is in a unique position to contribute to both explanatory and intervention studies in the area of adolescent violence. Despite the multiple community–based practice settings, broad multidisciplinary-based education, and a holistic view of health that support nurse scientists as a potentially dominant force in adolescent violence research, nurses to date have not embraced the issue. As nursing is a practice discipline, nurses involved in research related to adolescent violence have mainly focused their efforts on intervention development and implementation. This is true despite a lack of conceptual coherence on the definition of violence across multiple disciplines and the lack of sound explanatory theory to direct the development and testing of these interventions. To adequately develop and empirically test nursing interventions, it is essential that a multilevel analysis of both individual and contextual variables as they affect behavior be undertaken.

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Theoretical framework 

Although not predictive of violence, there are distinct behavioral cues that should be central to the study of violence reduction. Of the identifiable behavioral cues, a substantial body of literature exists that implicates aggression as the best known and most stable of the predictors of violence (Crick, 1996; Farrington, 1989; Olweus, 1979). It has been stated that aggression is one of the many distinct behavior correlates within a complex set of responsive behaviors that may appropriately be called “violence” (Littrell & Littrell, 1998). Aggression should alert nurses that the potential for a violent act exists, and the Interaction Model of Client Health Behavior (IMCHB) is a framework for the assessment, development, and implementation of prevention programs directed at reducing this potential. The IMCHB (Cox, 1982) is a tested model used as an explanatory framework for health behavior in children (Farrand & Cox, 1993) and has the potential to help nurses make assessments about the context of aggression and direct prevention efforts at its root. The use of the IMCHB for grouping variables conceptually provides an interesting framework for considering conceptual issues that are hampering the current study of aggression in adolescents.

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Interaction model of client health behavior 

The IMCHB (Figure 1) is a client-focused and holistic health behavior model that allows for definitive predictions about health behavior because it considers the individual's unique characteristics together with factors external to the client.

Use of the model as a framework allows for the simultaneous incorporation of an extensive set of variables that address psychological, environmental, and sociological determinants of behavior. The major elements of the model are client singularity, client-professional interaction, and client health outcomes. Client singularity elements as described by Farrand and Cox (1993) are relevant in explaining health behavior. These elements describe the individual on the basis of his or her sociodemographic characteristics (such as age, gender, and ethnicity), social influences (such as family, peers, and community), environmental resources (such as income and residential stability), and previous health experiences at a single point in time. Three additional variables complete the client singularity element. These are the more dynamic variables intrinsic motivation, cognitive appraisal, and affective response to a health concern/issue. These constructs are considered the best estimates of the individual's ability to make choices and his or her perceptions that influence these choices. In terms of prevention, these variables are dynamic and, therefore, are most amenable to health promotion programs. Focused client-professional interactions directed at modifiable behaviors have been successfully derived from the model to effect behavior change. Successful interventions to date have been directed at smokers (Solheim, 1989), African American women at risk for breast cancer/obesity (Phillips, 1993; Walcott-McQuigg, Sullivan, Don & Logan, 1995), fitness and absenteeism in hospital workers (Cox & Montgomery, 1991), and low-income women's decision to breast-feed (Finnegan, 1998).

Two important assumptions are made in the IMCHB that maximize its utility in the study of aggression in adolescents. They are as follows: (a) the model assumes that individuals have inherent human needs that act as causal factors of behavior, and (b) the model assumes that human emotions affect the behavioral responses of individuals. The first assumption distinguishes innate needs based on Deci's theory of self-determinism (1975) as autonomy, self-determinism, and competency (Cox, 1982). Individuals should be given the maximum amount of control within the limitations of their internal and external environments in determining their health and actions to maintain that health state (Cox, 1982). Intrinsic to this model is the idea that individuals are capable of making independent, informed, and competent choices about their health behavior. Adolescence is an important time to begin fostering decision making regarding health behavior (Dickey & Deatrick, 2000). Various aspects of the individual's internal and external resources (demographic, psycho-socio-behavioral characteristics) affect these decisions, acknowledging the contextual influences surrounding health behavior. Influenced by Deci (1975), the IMCHB incorporates the concept of intrinsic motivation as important to the manifestation of overt behavior. The extent to which the individual has volitional control around meeting innate human needs determines the amount of intrinsic motivation the client may or may not exhibit.

The second assumption of the model, that of affective response and the acknowledgment of the influence of human emotions, supposes that such things as stress, anxiety, and guilt may, in fact, alter the individual's cognitive appraisal of a situation. The important notion is that affective response can, apart from cognitive appraisal and motivation, direct a specific behavior. As an explanatory framework of adolescent aggression, the model indicates that affect plays a central role in the expression of behavior. This is clearly a significant construct, particularly in terms of adolescence, when the most notable characteristics of this developmental stage have been described as negative mood and mood swings (Koenig & Gladstone, 1998; Moneta, Schneider, & Csikszentimihalyi, 2001).

These underlying fundamental assumptions of the IMCHB, consistent with the developmental trajectory of the adolescent, offer a basis for the development of nursing interventions targeting aggression. The meaning of behavior often comes in terms of background variables including personal, developmental, and situational factors. A comprehensive assessment that includes the contribution of self-perception and motivation orientation may guide clinicians toward the development of specific prevention programs. By acknowledging the importance of the role of contextual elements in the path to adolescent aggression, our knowledge of adolescent aggression is advanced.

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Victimization and adolescent aggression 

What follows is an explanation of the utility of the IMCHB as a tool for nurses to understand the multidimensionality of antecedents to aggression. This understanding may lead to prevention efforts that will potentially effectively modify the course of violent behavior by identifying the appropriate type of prevention (Tolan, Guerra, & Kendall, 1995). The model's utility can be illustrated by examining the relationship between victimization and aggression. A simple linear model cannot explain the development of aggressive behavior. From an epidemiologic standpoint, victimization and witnessing of violence are two of the most frequently cited precursors to adolescent aggression (Cotten et al., 1994; Dykeman, Daehlin, Doyle, & Flamer, 1996; Farrington, 1989; Felson, Liska, South, & McNulty, 1994; Finkelstein, Von Eye, & Preece, 1994; Fitzpatrick, 1997; O'Keefe, 1997; Paschall, Ennett, & Flewelling, 1996; Pastore, Fisher, & Friedman, 1996; Saner & Ellickson, 1996). When victimization is considered within the IMCHB framework as a predictor of aggression, it is important for nurses to understand that this measure may in actuality be of little value, particularly when designing prevention programs. The IMCHB as a framework for the assessment and mapping of victimization within its context is shown in Figure 2.

For example, within the framework of the IMCHB, the possibility is raised that the adolescent who is victimized is also subject to contextual variables, such as parental disharmony, that may be highly correlated with aggression. Furthermore, the influence of both environmental resources (such as poverty, income loss, unemployment, and neighborhood unemployment) and previous health experiences (such as child maltreatment) should also be assessed as influential contextual variables.

Another example of the importance of assessing context is exemplified by examining the variables race and gender. Consider that sociodemographic variables are bound to their cultural context, and extracting their main effect may be very difficult. Aggression that may be attributed to race alone may in fact be a result of an interaction between race and conditions of economic disparity. This interaction effect is also evident between gender and role expectations or social pressures. Group gender differences in aggression may result from the possibility that internalizing behaviors as a result of social pressures mask overt aggression in girls. Considering these interaction effects may for example influence the motivation orientation of specific prevention programs.

Elements in the IMCHB including cognitive appraisal, intrinsic motivation, and affective response are acutely influenced by context. These model elements represent the behavioral manifestations of one's thoughts, feelings, attitudes, and beliefs. Evidence suggests that behaviors such as aggression arise from preventable social, environmental, and behavioral lifestyle-related factors (Gillis, 1993). To understand these thoughts, feelings, attitudes, and beliefs that result in aggression, the nurse must first understand the circumstances of the aggressor. Determinants of aggression cannot be wholly operationalized at the individual level; instead, a complex interaction model must be hypothesized.

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Clinical implications 

It has been argued that the lives of individuals are as much affected by personal characteristics as by the characteristics of the groups to which they belong (Diaz-Roux, 1998). The IMCHB offers a systematic integrated approach to changing context needed to reduce aggression in adolescents. Risk literature suggests that different types of violence prevention (e.g., primary, secondary, and tertiary) may be warranted. The key to a successful prevention program designed to reduce adolescent aggression is the development of a program that acknowledges the context within which adolescent behavior exists and directs programs toward these important predictors of health behavior.

The IMCHB describes four elements of client-professional interaction as essential components that must be translated to intervention design. The first three can direct different types of primary prevention initiatives including health education, affective support, and decisional control. The other element, professional competency, is particularly important for the development of secondary and tertiary prevention. Elements of client singularity, specifically those more modifiable elements, intrinsic motivation, cognitive appraisal, and affective response are most amenable to primary prevention strategies. The existing multiple community–based settings within which nurses practice including primary care clinics, school-based health centers, full service schools, and visiting nurse associations are just a few vehicles for these efforts. In addition, nurses can begin to look outside of their traditional realms to develop programs in sites that may include after-school programs or summer camps. Examples of these components in primary prevention programs include mentoring programs that provide affective support, health information enhancing skill building, and social action programs that enhance the adolescents' intrinsic motivation.

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Policy implications 

The key to the professional and technical competence of nurses to develop and direct secondary and tertiary programs is the recognition of the importance of context in clinical practice. The IMCHB informs nurses that it is not sufficient to target interventions at individual behaviors; instead, program impact must be spread across risk categories (Symons, Cinelli, James, & Groff, 1997). These comprehensive efforts require policy initiatives that are congruent with prevention programs. Consider the assumptions of the IMCHB, particularly that of intrinsic motivation. The assumption that autonomy in adolescence influences health behavior choice has important policy implications for nurse clinicians. Nurses developing programs should involve adolescents in the early planning stages and long-term management of programs. Policy initiatives that are directed at changing context to reduce adolescent aggression must also target education, community, and health care reform. The most important element of these initiatives must recognize the adolescents' need for autonomy and involve them at the policy table.

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Future research 

The degree to which individual variables exert an influence on behavior has thus far been difficult to discriminate and therefore has made it difficult to design targeted prevention initiatives. Clearly, more research is warranted to better understand how social influences affect violent behavior. Nursing research of battered women (Hoff, 1995) has helped us to understand that it is not sufficient to simply measure the prevalence of violence to understand violence. Evidence presented here illuminates the need for a well-designed study that integrates individual level and controls for contextual variables with the use of a theory-driven explanatory framework. Although the IMCHB has been used extensively to direct clinicians to target modifiable variables (cognitive appraisal, affective response, and intrinsic motivation) for intervention when attempting to change behavior, they have had the least empirical study by nurses focused on intervention development related to aggression in adolescents. Because of their particular importance at this developmental stage, there is the need to more clearly understand the role of variables such as cognitive appraisal and affective response in mediating behavior. Future research that is directed at identifying the specific causal pathways from antecedent variables, specifically social influences, through these modifiable individual variables to outcomes must be addressed. Diaz-Roux (1998) acknowledges that it may be difficult to decide whether a given variable is an independent or an intermediary cause; it is nonetheless an important research question. The element of affective response (emotion) as correlated with risk behavior is a particularly understudied variable because of this difficulty.

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Conclusion 

Previous health behavior frameworks have found it difficult to account for both of the units of interest, individual health behavior and the individual and contextual variables that may account for behavior (Von Korff, Koepsell, Curry, & Diehr, 1992). These interactions have not been adequately described and considered in violence prevention efforts. Consideration must be given to a multidisciplinary explanatory model of violence that describes both the intrinsic and extrinsic factors contributing to the cycle of violence. This should serve to set the future direction for nursing research in this area of inquiry.

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☆ Address correspondence and reprint requests to Pamela Pershing DiNapoli, RN, PhD, University of New Hampshire, 247 Hewitt Hall, Durham, NH 03824.

PII: S0882-5963(02)43906-1

doi:10.1053/jpdn.2003.5

Journal of Pediatric Nursing
Volume 18, Issue 1 , Pages 30-35, February 2003

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