Involving Husbands in their Wives' Health Behaviour: Does it Work?

Involving Husbands in their Wives’ HealthBehaviour: Does it Work?aphw_1041 66..86

Yael Benyamini,* Limor Ashery and Shoshana ShilohTel Aviv University, Israel

Health promotion has been expanding to include potential effects of the spouse.A randomised controlled trial examined effects of involving husbands in aself-regulation programme designed to increase wives’ performance of a healthbehaviour (breast self-examination, BSE). Participants were 140 couples(women ages 24–55). At baseline, women received questionnaires, informationabout breast cancer and BSE, and instructions to form an action plan for BSEperformance. For half the women, the instructions called for involving thehusband. Three months later, all women and husbands filled in follow-upquestionnaires. The programme was very effective in increasing BSE in bothgroups. The husband involvement intervention contributed to this increase onlyamong husbands who reported encouraging their wives. Involving husbands inthe programme also resulted in their greater knowledge of their wives’ BSEperformance and encouragement of wives’ BSE performance, according to theirown and their wives’ reports. The greatest changes in women’s behaviour wereapparent among women who at baseline rated their husbands as not involved inissues related to their health. The findings suggest that involving spouses inhealth promotion interventions affects their knowledge and behaviour but mayneed to be tailored to the characteristics of the couple’s coping with healthmatters.

Keywords: health behaviour, implementation intentions, intervention, plan-ning, randomised controlled trial, spouses

INTRODUCTION

Research on the promotion of health behaviours has been expanding its focusin several ways, one of them being the examination of communal coping withhealth instead of focusing on individuals (Lewis et al., 2006). Research hasshown that there are risk factors for disease at the household level, which maybe partly due to selective mating or to shared environments, but may also bedue to shared health behaviours and to the effects of spouses on each other’s

* Address for correspondence: Yael Benyamini, Bob Shapell School of Social Work, Tel AvivUniversity, Tel Aviv 69978, Israel. Email: [email protected]

There are no conflicts of interest.

APPLIED PSYCHOLOGY: HEALTH AND WELL-BEING, 2011, 3 (1), 66–86doi:10.1111/j.1758-0854.2010.01041.x

© 2010 The Authors. Applied Psychology: Health and Well-Being © 2010 The InternationalAssociation of Applied Psychology. Published by Blackwell Publishing Ltd., 9600 GarsingtonRoad, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.

health behaviours (Wilson, 2002). Health promotion interventions have beenfound to have an impact on participants’ spouses. These effects are likely tobe due to shared and mutual efforts to change behaviours (such as diet habits;Sexton et al., 1987). Active attempts to involve spouses in such interventionsmay be even more effective. Support for this claim can be found in the areaof chronic disease, where an extensive review has shown that couple-orientedinterventions have a greater positive effect on patient outcomes comparedwith interventions aimed only at the patients (Martire, Schulz, Helgeson,Small, & Saghafi, 2010). The review suggested that the impact of couple-oriented interventions could be enhanced by targeting spouse actions thatinfluence patient health behaviours. Therefore, the current study will examinethe effects of an intervention that involves husbands in a programmedesigned to increase their wives’ performance of a health behaviour (namely,breast self-examination, BSE) in comparison to wives who participated in theprogramme on their own.

The Marital Relationship and Health BehavioursOne of the explanations for the well-documented association between socialrelationships and health is through the effect of social ties on health behav-iours. The marital relationship is the social tie that is most likely to have suchan effect (Kiecolt-Glaser & Newton, 2001). Social control, or the influence onthe individual to engage in conventional or non-deviant behaviour, is amechanism that can explain how spouses affect one another’s health behav-iours (Umberson, 1987). This mechanism can operate directly, throughreminders, sanctions, or reinforcements (Beverly, Miller, & Wray, 2008), orindirectly, through self-enforcement of norms (as suggested by the Theory ofPlanned Behaviour, which emphasises the role that subjective norms play inthe formation of intentions to act; Armitage & Conner, 2001). The directroute can have both positive and negative effects (Tucker & Anders, 2001),which may explain why social control measured mainly by reports of activeefforts was found to be only weakly related to health practices (Rook,Thuras, & Lewis, 1990). Regarding the indirect route, Umberson (1987)suggested (on the basis of the work of Durkheim, 1951) that it is mainly apositive route that stems from the mutual obligation and sense of meaningand purpose, which unites spouses. Indeed, for most couples, health-relatedsocial control seems to be an ongoing experience in their relationships andmay be best conceptualised as an interdependent communal process betweenhusbands and wives (Lewis, Butterfield, Darbes, & Johnston-Brooks, 2004).

Research has also suggested that in marriage there is greater opportunityfor women to exercise health-related social control over their husbandsthan vice versa (Umberson, 1992). Men received more support from theirspouses in implementing lifestyle changes following a myocardial infarction

INVOLVING HUSBANDS IN WIVES’ HEALTH BEHAVIOUR 67

© 2010 The Authors. Applied Psychology: Health and Well-Being © 2010 The InternationalAssociation of Applied Psychology.

compared with women (Badger, 1992) and women were more likely to assisttheir husbands in skin self-examination than the reverse (Weinstock et al.,2004). In contrast, another study found no gender differences in socialcontrol and suggested that this may be due to the more egalitarian genderroles among young employed adults today (Tucker & Anders, 2001). Indeed,when the marriage was viewed by women as more equal, husbands were lesslikely to use unilateral strategies of social control (Butterfield & Lewis, 2002).Even if health-related social control still occurs naturally more in the direc-tion from women to men, an intervention that structures men’s involvementcould encourage the opposite direction.

In practice, some attempts to involve spouses in programmes aimed atpromoting health behaviours have been successful (regarding loweringcholesterol levels, see Bandura, 1998; regarding skin self-examination, seeRobinson, Turrisi, & Stapleton, 2007) while other attempts have not beeneffective (Lichtenstein & Glasgow, 1992; McBride et al., 2004). The latterattempts were in the area of smoking cessation, which may be more complex.We focused on involving the husbands of employed, young and middle-agedwomen in a programme intended to promote BSE performance among theirwives. The programme addressed motivational aspects by providing infor-mation about breast cancer, BSE, and its benefits. However, knowing thatintentions to conduct BSE are often high yet performance is low (Luszczyn-ska & Schwarzer, 2003), the main focus was on activities intended to promoteself-regulation skills—planning and self-monitoring. Planning was empha-sised due to accumulating evidence regarding its role in mediating therelationship between intentions and behaviour (Gutiérrez-Doña, Lippke,Renner, Kwon, & Schwarzer, 2009). To this end, we employed a manipula-tion known to be effective in promoting women’s BSE performance—forming implementation intentions (action planning). The purpose of thecurrent study was to assess the independent effect of actively adding spouseinvolvement to the BSE programme.

Implementation Intentions / Action PlansImplementation intentions are “if–then” plans that link anticipated criticalsituations with goal-directed responses and thus promote the attainment ofthese goals (Gollwitzer, 1999). Interventions that instruct people to form suchintentions have been found to be effective in promoting a wide range ofbehaviours (see meta-analysis by Gollwitzer & Sheeran, 2006) including BSE(Orbell, Hodgkins, & Sheeran, 1997). Partner involvement in BSE has beenfound to be even more effective than an implementation intentions manipu-lation: 83 per cent of the women who involved the partner conducted BSE inthe next month, compared with 63 per cent who formed implementationintentions (and 26% in the control group); both interventions together led to

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100 per cent success in performing the behaviour within a follow-up period ofone month (Prestwich et al., 2005). However, the latter study provided onlyweak support for the effectiveness of partner involvement since women chosewhether to involve their partners and because of the relatively short follow-upperiod of one month. In addition, the sample comprised undergraduatestudents (mean age 22), who are mostly in relatively short-term intimaterelationships that could be very different from marital relationships.

Implementation intentions are assumed to overcome the problems thatprevent women from performing BSE and are not sufficiently solved byproviding health education information. Underperformance is related to bar-riers against BSE (e.g. embarrassing, time-consuming) and low confidence inBSE performance (Erblich, Bovbjerg, & Valdimarsdottir, 2000). Additionalbarriers include perceptions of cancer as lethal and the perceived threat itposes to women’s femininity, which lead to reluctance to perform the exami-nation (Kearney, 2006), as well as more “technical” problems, such as theneed for a reminder (Salazar, 1994). Information provided by the health caresystem on BSE, the ease of performing it, and the benefits of early detection,targets some of these barriers (e.g. BSE is time-consuming; cancer is lethal)but is insufficient in handling others. This explains why implementationintentions manipulations have been successful in promoting this behaviour:One of the mechanisms purported to account for the effectiveness of imple-mentation intentions is their contribution to action initiation. There is evi-dence that implementation intentions assist in all three main problems thatmitigate action initiation: remembering to act, seizing opportunities, andovercoming initial reluctance (Gollwitzer & Sheeran, 2006).

There are several reasons to assume that involving husbands willstrengthen the effect of implementation intentions on all three problems.First, remembering to act may be easier when the action plan has beenprepared as a joint effort (and the other person may also provide reminders).Second, implementation intentions work by enhancing the accessibility ofspecific opportunities and automating the respective goal-directed responses.Forming an action plan with the spouse could result in a plan that spells outthe opportunities to act in an optimal way since it is better suited to thecouple’s lifestyle. Implementation intentions effects can be increased byboosting self-efficacy and by administering the manipulation in anautonomy-supportive manner, which leads participants to process the imple-mentation intentions exercise more fully and to integrate the implementationintentions in a self-concordant way (Koestner et al., 2006); involving thespouse could increase effectiveness in similar ways through the same mecha-nisms. Third, initial reluctance to perform BSE is related to practical issues ofperformance, which could be handled by providing clear instructions, and toemotional and cognitive issues related to breast cancer. Talking about theseissues with a partner could be intimidating. A husband who raises the issue of



BSE performance could be perceived as exerting undesired control or pro-viding criticism (similar to dilemmas reported by couples coping with lifestylechanges following a cardiac event; Goldsmith, Lindholm, & Bute, 2006).However, a structured programme initiated by an external agent could reduceanxiety by providing concrete advice and turning the issue into a legitimatetopic for discussion between the partners.

We tested BSE performance as reported three months following the BSEprogramme among married women randomly assigned to undergo the pro-gramme alone or with their husband. We also assessed the effects of thespouse involvement intervention on men’s involvement in their wives’ healthbehaviour in two respects: Their knowledge of their wives’ BSE performanceand the extent to which they supported and encouraged their wives toperform BSE (as reported by women and their husbands). Finally, we alsocontrolled for women’s initial ratings of support from their husband, in orderto account for the possibility that the results are related to the quality of therelationship and/or to the husbands’ previous involvement in their wives’health behaviour. Note that the study was not aimed at testing the effect ofthe BSE programme because its main component was an implementationintentions manipulation, for which ample evidence exists, showing its effec-tiveness in a variety of health behaviours (Gollwitzer & Sheeran, 2006) as wellas specifically in promoting BSE (Orbell et al., 1997). The intervention testedhere is the addition of spouse involvement.

Our hypotheses were: (1) Women will increase BSE performance in thethree months following an information and self-regulation programme forpromoting BSE performance and this increase will be greater among womenwhose husband was involved in the programme; (2) men who were involvedin the programme will report greater knowledge of their wives’ BSE perfor-mance, compared with men who were not involved; and, (3) at follow-up,men who were involved in the programme will report greater encouragementof their wives’ BSE performance and will be rated by their wives as moresupportive of this behaviour, compared with men who were not involved inthe programme.

METHOD

ParticipantsOne hundred and sixty married women, ages 24–55, were recruited to par-ticipate in a programme for the promotion of BSE and were randomlyassigned to two groups: An experimental condition, in which both womenand their husbands were involved in the programme, and a control condition,in which women alone were involved in the programme. None refused at theinitial stage, which only required that they accept an envelope with brochures

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and study materials. Refusals to participate in the study included nine womenin the experimental group and ten in the control group who did not return theforms and questionnaires after reminders. One woman’s data were excludeddue to her report of performing daily BSE, leaving 70 women in each group.The groups did not differ in their age (M = 35.59, SD = 8.74), years of edu-cation (M = 15.26, SD = 2.54), the number of couples with children (73% ofeach group), or the number of years married (about half the couples in bothgroups were married over 5 years; a third were married over 10 years).

Five women in the experimental group and eight in the control group filledin only the baseline questionnaires. The remaining 127 women (91% of thebaseline sample; 65 and 62 women in the experimental and control groups,respectively) filled in questionnaires at baseline and three months later. Thewomen who did not fill in the follow-up questionnaires did not differ signifi-cantly from those who did in any of the socio-demographic or baseline studymeasures (according to independent samples t-tests; all t-values < 1.60, allps > .10) with one exception: those who did not fill in the follow-up question-naire reported higher spouse health involvement (see below for the definitionof this measure; M = 4.46, SD = .78 for these 13 women compared withM = 3.87, SD = .96 for the remaining 127; t(138) = 2.14, p = .04). Where rel-evant, analyses were carried out on an intention-to-treat (ITT) basis, toinclude women who dropped out from the follow-up.

Husbands of the women in the experimental group also participated atbaseline and filled in a short questionnaire. At follow-up, three months later,husbands of women in both groups were requested to fill in a questionnaire.Husbands’ mean age was 39.72 (SD = 9.42) and their average years of edu-cation were 15.28 (SD = 2.24). Husbands from the experimental and thecontrol groups did not differ in their age or education.

MeasuresBSE performance was assessed by asking women: (1) Have you ever per-formed a BSE; (2) If yes, was it: (i) in the past, but not in the past year, (ii) inthe past year, rarely, (iii) in the past year, once in a few months, (iv) in the pastyear, monthly; (3) How often have you performed a BSE in the past 3months? 0, 1, 2, 3, more than 3 times (coded as 4).

Perceived spouse support was assessed with an eight-item scale fromVinokur and Vinokur-Kaplan (1990). The items questioned women aboutemotional (e.g. “Your husband listens to you when you need to talk”) andinstrumental support (e.g. “Your husband does things for you or gives youthings that you need”) from their husband (rated on a scale from1 = “strongly disagree” to 5 = “strongly agree”; a = .83). The mean of theresponses to these eight items was used as an index of perceived “generalspouse support”. Two additional items were constructed for the current study



and used separately (with the same response options): “Your husband isinvolved in issues related to your general health” (labelled “spouse healthinvolvement”); and, “Your husband encourages you to perform BSE everymonth” (labelled “spouse BSE support”). These three measures were mod-erately correlated: Spouse health involvement correlated with general spousesupport (r = .48, p < .001) and with BSE support (r = .33, p < .001) and BSEsupport correlated with general spouse support (r = .32, p < .001).

Spouse reported knowledge and support of BSE performance were assessedby asking men the following questions: (1) “Does your wife perform BSE?”(yes / no / don’t know); (2) “Do you encourage your wife to perform BSE?”(yes / no). At follow-up they were provided with several response options forthe second question: “In the past three months, how much did you encourageyour wife to perform BSE? Intensively (4), encouraged (3), encouraged a little(2), or not at all (1)”. In practice, responses ranged between 1 and 3.

ProcedureThe study was approved by the research ethics committee at the Departmentof Psychology of Tel Aviv University. Power analyses (conducted withGPower; Erdfelder, Faul, & Buchner, 1996) were used to determine thesample size: For a = 0.05 and a medium effect size (d = .50, lower than theoverall effect size of .65 found for implementation intentions according toGollwitzer & Sheeran, 2006), these calculations showed the sample sizeshould include 70 women in each group for a power level of .90 and 51 for apower level of .80. Taking into account some drop-out by follow-up, recruit-ment was continued until we reached 160 women. Eligible women (i.e.married and 20–55 years of age) were approached at workplaces andrecruited through the snowball method. Women were asked to participate ina study about BSE. They received an envelope that included an informedconsent form and a questionnaire, which included women’s reports of BSEperformance and spouse support, and an envelope, which they wereinstructed to open only after filling in the questionnaire. The inner envelopecontained the following materials: (1) a brochure with information aboutbreast cancer and its risks, the importance of early diagnosis and of conduct-ing BSE, and the phone number of the information line of the NationalCancer Society; (2) a brochure explaining how to perform BSE; (3) an Imple-mentation Intentions “Instructions for Performance” sheet (describedbelow); and (4) a self-monitoring table (see below). The questionnaires andinformed consent forms were collected a few days later.

Half the envelopes also included an informed consent form and a ques-tionnaire for the husband regarding his knowledge and support of his wife’sBSE performance and additional materials for the husband (see below). Allenvelopes were pre-prepared and sealed by one of the researchers, mixed and

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handed to contact persons in workplaces and social groups, who handedthem to other women. The contact persons were blind to the study condi-tions. In this way, women were randomly allocated to either the experimentalor the control group, without their awareness of the existence of the othergroup. Note that women in both groups underwent the programme. Thelabels “experimental” and “control” refer solely to the spouse involvementcomponent tested in this study.

Three months later, all women were given two questionnaires, one for eachspouse. The women’s follow-up questionnaire included questions about BSEperformance and spouse support. The husbands’ follow-up questionnaireincluded questions about their knowledge and support of their wife’s BSEperformance and was administered to husbands in both groups. In thecontrol group, an informed consent form for the husbands was also included.The questionnaires were collected from them a few days later.

Implementation Intentions Manipulation. All women received an“Instructions for Performance” sheet, in which they were asked to readinstructions “which will help you form an action plan that is intended to assistyou in performing BSE and adopting it as a life-long habit”. First, they wereasked to read the brochure with the explanations about performing BSE verycarefully and to call the information line if anything was unclear. Then, theywere asked to form an action plan by “deciding about the following thingsand writing them down: 1. What is your preferred time for performing BSE(before you go to bed, when you wake up in the morning, during the daywhen you have time)? __; 2. What is the order of stages of BSE you prefer tofollow (in front of the mirror, in the shower, lying down)? Please write downthe order that seems most convenient for you: __; 3. Where should you leavethe BSE explanation brochure so that it will stand out and serve as areminder? Please think of several options and then write down the one placeyou chose: __; 4. Prepare a list of reminders that you will use in order to makesure that you do not forget to perform the examination: __.”

Self-Monitoring. Women were provided with a table that includedcolumns for the number of the month (1, 2, 3), BSE performance (yes / no)and date of each exam, and the instruction to “Fill in the following table oncea month in the next three months”. Following the table, there was an addi-tional reminder that “The action plan is very important and is intended tohelp you learn how to perform the examination once a month and turn thisinto a habit”.

In the experimental group only, the inner envelope clearly indicated that itwas intended for both partners to open together and also included an infor-mation page for the husbands about cancer and BSE. At the end of this page,it was noted that “in order for your wife to perform BSE in the best possible



way, we have enclosed a brochure with a description of BSE performance. Itis important that your wife reads this brochure and practices the variousstages of BSE. Please help your wife fill in the ‘Instructions for Performance’sheet that is attached to the brochure.” The latter sheet was similar to the onedescribed above but it was addressed to both spouses and began with asentence emphasising that it was important that both partners fill in this sheettogether.

RESULTS

Baseline BSE PerformanceWomen’s retrospective reports of BSE frequency of performance at baselineare presented in Table 1. Thirty-three per cent of all women had never per-formed BSE, another 16 per cent had not performed it in the past year andonly 8 per cent percent performed monthly BSE. In both groups, rates ofBSE performance fell far below the monthly exam recommended at thetime of the study. However, even though overall rates of BSE performancewere low and women were randomly assigned to the study groups, therewas a significant difference (p = .04, see Table 1) between the groups:Women in the experimental group reported at baseline an average of 0.76BSEs in the past three months compared with 0.40 exams in the controlgroup.

Baseline rates of BSE performance in the past three months were related togeneral spouse support (r = .21, p = .001), spouse health involvement (r = .18,p = .02), and spouse BSE support (r = .44, p < .001; all ps one-tailed). Hus-bands’ reports (available at baseline only for the experimental group) sup-ported these findings: BSE performance was significantly higher among wivesof husbands who reported encouraging their wife to perform BSE compared

TABLE 1Baseline Reports of Past Performance of Breast Self-examinations (BSE)

GroupExperimental

(n = 70)Control(n = 70)

Frequency of BSE (% of respondents in group) c2(4) = 5.80, nsNever 23 (33%) 23 (33%)Not in the past year 9 (13%) 14 (20%)In the past year, rarely 14 (20%) 20 (29%)In the past year, once in a few months 16 (23%) 10 (14%)In the past year, monthly 8 (11%) 3 (4%)

Number of BSE in past 3 months (meanand standard deviation)

0.76 (1.19) 0.40 (0.81) t(138) = 2.09, p = .04

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with wives whose husbands reported that they do not encourage their wives(mean BSE performance in past three months 1.31 � 1.44 versus 0.63 � 1.10,t(68) = 1.89, p = .03, one-tailed). Thus, spouse support, whether reportedby husband or wife, was related to greater BSE performance before theprogramme.

The Effects of the BSE Programme with and withoutSpouse Involvement on BSE PerformanceThree months after baseline, women in both groups reported a similarnumber of BSEs performed in the past three months: In the experimentalgroup, a mean of 1.69 and in the control group, a mean of 1.60 (SD = 1.26 inboth groups). In order to test the effects of spouse involvement, we conducteda multivariate analysis of variance (ANOVA) with repeated measures on BSEperformance in the past three months, with group and a group by timeinteraction included. The descriptive information above refers only to womenwho provided that information but the statistical analysis was carried out onan intention-to-treat (ITT) basis: Women who dropped out were includedunder the conservative assumption that their behaviour at follow-up had notchanged, i.e. was equal to their baseline report. The results showed a signifi-cant main effect for time (F(1, 138) = 78.38, partial h2 = .36, p < .001) andnon-significant effects for group and for the group by time interaction. Inlight of the lack of group differences, we combined the two groups andcomputed the effect size over time, which was large (d = .85). Thus, the firstpart of Hypothesis 1, that the programme would be effective in increasingBSE performance, was supported, but not the second part: The increase wasnot greater among women who participated in the BSE programme with theirhusbands. The analysis was also repeated controlling for baseline levels of thethree perceived spouse support measures. The results showed significanteffects only for time (F(1, 135) = 5.21, partial h2 = .04, p = .02), and for theinteraction of time and spouse health involvement (F(1, 135) = 24.63, partialh2 = .15, p < .001). The data show that was high spouse health involvementthat was related to lower effectiveness of the programme. This was apparentmost clearly among women who had not performed BSE at all in the threemonths prior to the baseline: 77 per cent of 55 women who rated theirspouse’s health involvement as medium or low (3 or lower) performed BSEafter the intervention, compared with 54 per cent of the 85 women who ratedtheir spouse’s health involvement as high (4 or 5). This issue will be furtherexplored below. In addition, there were no significant interactions betweengroup and spouse support measures and no three-way interactions (group,time, and support). Removal of the few women who reported monthly BSEperformance at baseline did not change any of the results.



Since there were differences in the baseline rates of BSE performancebetween the groups and because of the smaller range for expected change(ceiling effect) among women who reported performing BSE in the threemonths prior to baseline, we also examined the outcomes specifically amongthe 88 women who reported no BSE performance at baseline (41 were in theexperimental group and 47 in the control; six additional women who had notconducted BSE in the three months prior to the baseline did not fill in thefollow-up questionnaire). In this sub-sample, the maximal rate of change,from none to monthly performance, was possible for all women. At T2, 30 ofthese 88 women (34%) reported no BSE performance in the three monthsbetween baseline and follow-up, 31 (35%) reported performing BSE once ortwice during this period, and 27 (31%) reported performing BSE three ormore times. There were virtually no differences between the experimental andcontrol group women in this sub-sample in BSE performance reported atfollow-up. Controlling for the three spouse support measures did not changethe results: The only significant predictor was spouse health involvement(F(2, 91) = 31.88, partial h2 = .26, p < .001), with no interaction with group.

Effects of Inclusion in the BSE Programme onHusbands’ Reported Knowledge and SupportTo test our second and third hypotheses, we compared the experimental andcontrol groups in the following measures assessed at follow-up: (a) Hus-bands’ reported knowledge regarding their wives’ BSE performance; (b)wives’ reports of spouse support; and (c) husbands’ reports of support. Wealso examined the changes in the experimental group from baseline tofollow-up on these measures.

Husbands’ Reported Knowledge Regarding their Wives’ BSE Perfor-mance. At follow-up, husbands’ reports of whether their wife performedBSE were available for both groups and are presented in Figure 1. Thesefindings suggest that involving husbands in the programme did have an effect:In the experimental group, 63 per cent of the men reported that their wifeperformed BSE and only 15 per cent did not know whether she did; in thecontrol group, 34 per cent reported that she performed BSE and 40 per centdid not know whether she did. These differences are significant (c2(2) = 12.95,p = .002), in line with our second hypothesis: Husbands who were involved inthe programme were more likely to report knowledge of their wives’ BSEperformance compared to husbands who were not involved. Note thatamong those who reported that their wife did or did not perform BSE, themajority in both study groups were accurate in their report, that is, it corre-sponded with their wife’s report (84% of the experimental group and 78% ofthe control group). Thus, the difference between men from the two groups

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was not in the accuracy of the report of those who knew whether their wifehad performed BSE but in their possession of such knowledge, which wasmuch lower in the control group.

Husbands’ Support of their Wives’ BSE Performance. At follow-up, allhusbands rated their level of encouragement of BSE in the past three months.Their responses were distributed over three categories ranging from “not atall” to “encouraged”. A multinomial logistic regression showed a significantdifference between the groups in rates of encouragement: Husbands whowere involved in the programme were 2.64 times more likely to report thatthey encouraged their wives rather than not encouraged, compared withhusbands in the control group (p = .026, one-tailed); they were also 2.42 timesmore likely to have encouraged rather than only “a bit encouraged” (p = .059,one-tailed). In addition, we examined changes in encouragement of wives’BSE performance among men in the experimental group, who were askedabout this both before and after the intervention: At baseline, only 13 men inthe experimental group (19%) reported that they encouraged their wives toperform BSE; at follow-up, this rate increased to 33 men (51% of the experi-mental group at T2) who reported that they encouraged their wives (thedifference in these proportions is significant according to the binomial test,p < .001).

When BSE encouragement reported by husbands at follow-up was addedto the repeated measures ANOVA predicting changes in BSE performanceover the follow-up period, it interacted with study group in its effect onchanges in BSE performance (F(1, 121) = 2.94, partial h2 = .05, p = .03, one-tailed). To interpret this interaction, we collapsed “encouraged” and “a bitencouraged” into one group and found that rates of BSE performance

Does you wife perform BSE?

15

22

63

4034

26

0

10

20

30

40

50

60

70

Yes No Don't know

Per

cen

t o

f H

usb

and

s

Experimental

Control

FIGURE 1. Husbands’ knowledge of wives’ breast cancer examination (BSE)performance at follow-up: percent of respondents (from n = 65 in theexperimental group and n = 62 in the control group).



increased very little among women in both groups whose husbands did notencourage them to perform BSE. However, among women whose husbandsreported encouraging them, increases in BSE performance were greater in theexperimental group (1.58) compared with the control group (1.32).

Women’s Perceptions of Spouse Support. At baseline, there were nodifferences between the groups in the three perceived spouse support mea-sures. At follow-up, there were no significant differences in general spousesupport and spouse health involvement. Regarding BSE support, there wasno difference across time in the control group and a significant increase in theexperimental group (see Figure 2). A multivariate analysis of variance withrepeated measures on spouse BSE support showed a significant group by timeinteraction (conducted on an ITT basis: F(1, 138) = 9.53, partial h2 = .07,p = .002). Thus, the findings also support our third hypothesis: Husbandswho were involved in the intervention showed greater encouragement of theirwives’ BSE performance according to their own and their wives’ reports.When wives’ follow-up reports of spouse BSE support were added to theANOVA, they predicted changes in BSE performance (F(1, 123) = 3.60,partial h2 = .03, p = .03, one-tailed). However, in contrast with the findings onhusbands’ follow-up reports of encouragement, wives’ reports did not inter-act with study group in their effect on changes in BSE performance over time(and adding them to the ANOVA with husband encouragement did noteliminate its interaction with study group).

Exploratory Analyses of the Relation between BSEPerformance and Spouse Health InvolvementSpouse support measures were added to the study as control variables, inorder to test whether the results are related to the quality of the relationship

2.37

1.95

1.62

1.87

1

1.4

1.8

2.2

Baseline 3-months follow-up

Per

ceiv

ed B

SE

su

pp

ort

Experimental

Control

FIGURE 2. Women’s ratings of spouse encouragement of breast cancerexamination (BSE) performance, according to group and data wave.

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and/or to the husbands’ previous involvement in their wives’ health behav-iour. The significant association of spouse health involvement with changes inBSE performance led us to further explore this finding. Post-hoc comparisonsrevealed that it was low spouse health involvement in their wife’s generalhealth, according to her report at baseline, that predicted a greater increase inBSE performance. Mean spouse health involvement at baseline for the 27women who increased from zero to monthly performance was 3.00 � 0.56,compared with 4.06 � 0.89 for the 31 women who increased only to 1–2 timesin the three months and 4.07 � 0.91 for the 30 women who still did notperform any BSE. Thus, the women whose husbands were not involved intheir health prior to the study seemed to benefit the most from the pro-gramme in terms of an increase in this health behaviour, regardless of studygroup.

In order to further corroborate these findings, we turned to men’s baselinereports of whether their wives perform BSE, which were available only for theexperimental group. Among the husbands of the 12 women in this group whobenefited most from the intervention, i.e. those who went from zero tomonthly BSE performance, only one (8%) reported at baseline that he knewwhether his wife performed BSE. Among the 15 women who slightly ben-efited from the intervention, i.e. who went up from no BSE performance to1–2 times, ten (67%) of the husbands reported that they knew whether theirwives performed BSE. Among women who continued to report no BSEperformance, 93 per cent of the husbands reported that they knew whethertheir wife performed BSE. These findings also suggest that women whosehusbands were not involved in their health behaviours prior to thestudy benefited the most from the programme in terms of increase in BSEperformance.

DISCUSSION

The motivational and self-regulatory programme was effective in increasingwomen’s BSE performance over the following three months, as expected.However, involving husbands in this programme did not have an indepen-dent effect on performance. These findings support only the first part ofHypothesis 1. Additional findings shed more light on possible mechanismsthat could have been affected by spouse involvement in the programme: First,involving husbands in the programme resulted in an increase in their reportedknowledge of their wives’ BSE performance (Hypothesis 2). Second, theirinvolvement in the programme led to greater support and encouragement oftheir wives’ BSE performance, according to their own reports as well as theirwives’ reports (Hypothesis 3). Husbands’ follow-up reports of encouragingtheir wives as well as wives’ follow-up reports of spouse BSE support were



related to greater increases in BSE performance over the follow-up period.However, only husbands’ reports interacted with study group, i.e. greaterhusband encouragement reported at follow-up was more strongly related toan increase in their wives’ BSE performance in the experimental group. Inaddition, controlling for several types of spouse support revealed that thegreatest changes in women’s behaviour were apparent among women whorated their husbands at baseline as not involved in issues related to theirgeneral health. This latter finding was not among our initial hypotheses andis based on a one-item measure of spouse health involvement and thereforeshould be interpreted with caution.

Why did the intervention that included husband involvement have noeffect on wives’ health behaviour? First, the intervention did have an effect onthe behaviour of women whose husbands reported at follow-up that theywere involved (i.e. encouraged their wife to perform BSE). Although allhusbands in the experimental group filled in the baseline questionnaire andtherefore we assume that they were exposed to the study materials, it isentirely possible that some of them did not become very involved. Thosehusbands were probably more likely to be among those who later reportedthat they did not encourage their wives to perform BSE and their wivesreported lower increases in BSE performance over the follow-up period.Thus, the overall group effect was nil, whereas the interaction between studygroup and husbands’ follow-up reports of encouragement showed thathusband encouragement contributed to increased performance especially inthe experimental group.

Note that average group differences may have also diminished due to theopposite effect of wives in the control group who involved their husbands ontheir own initiative. Another study had reported that when husbands wereexposed to a health promotion intervention, their wives’ health behaviourhad also improved (Sexton et al., 1987). However, though it is likely that thishad occurred to some extent, there were indications that the active requestposed to the husbands by the study instructions had effects which were notfound in the control group: Husbands in the experimental group were morelikely to report knowing whether their wife performed BSE compared withhusbands in the control group. Moreover, they reported greater encourage-ment of their wife in BSE performance and their wives reported an increase intheir encouragement following the intervention. Therefore, it is unlikely thatwife-initiated husband involvement in the control group can explain the lackof a difference between the groups or that one can rely on the involvement ofthe husband in an intervention aimed at his wife: Active involvement of thehusband seems to be more effective.

Second, it may be that the programme, which included both a motiva-tional component (information) and a volitional one (an implementationintentions / planning manipulation), was so effective that there was no room

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for much additional increase due to spouse involvement. Change in BSEperformance between baseline and follow-up, across the entire sample,amounted to a large effect size of .85 (> d = .65 as reported by Gollwitzer &Sheeran, 2006, in their meta-analysis of implementation intentions). Thismay have been due to the instructions which were more elaborate thanin most studies: They called not only for a plan of when, where, and howto carry out the behaviour but also for planning reminders and for self-monitoring, i.e. recording the behaviour during the follow-up period.Prestwich et al. (2005), who found that partner involvement added to thelikelihood of women performing BSE, even when combined with an imple-mentation intentions manipulation, had instructed their participants to formthe typical one-sentence plan of when and where they would conduct BSE.However, it is difficult to compare our findings directly to theirs as theyasked women to choose whether to involve partners and their involvementwas in performing BSE and not in planning it.

In addition, the lack of group differences could partly reflect a ceilingeffect, arising from the limited change that can be exhibited in a monthlybehaviour over a period of three months. However, this cannot fully accountfor the findings because study group had no effect on increases in BSEperformance even among women who had not performed BSE at all beforebaseline and potentially had the full range of possible change in three months(and therefore also more room for spouse involvement to contribute to thechange). A third of the women did not change their behaviour at all and mostof them were women who had not performed BSE in the months before orafter the manipulation. Quite a few other women had only tried BSE once inthe follow-up period (in contrast with the instructions to perform it on amonthly basis). Thus, though it seems that there is still room for improve-ment, there may be a “hard core” of women whose reluctance to perform BSEor to maintain the behaviour stems from reasons that cannot be affected byeducational materials or by self-regulation instructions (e.g. emotionalreasons) and therefore we have reached a “ceiling” effect for increase in BSEperformance in this sample.

A third explanation could be that involving spouses had opposite effects indifferent couples: It increased social control, which in some couples led tobetter and in others to worse health practices (Lewis & Rook, 1999). Evencaring partners with good intentions could have difficulties supporting life-style changes without being perceived as controlling or critical (Goldsmithet al., 2006). Cardiac patients in one study viewed a critical spouse as non-supportive while spouses seemed to employ support and criticism as twoindependent forms of caring (Benyamini, Medalion, & Garfinkel, 2007).Diabetes patients and their partners attested to the importance of spouseinvolvement in dietary control but some also disclosed difficulties in thisprocess (Beverly et al., 2008). Positive, bilateral, and direct social control



tactics from a spouse predict better health practices, in contrast with negative,unilateral, or indirect tactics (Lewis & Butterfield, 2007). Thus, social controlcould enhance spouse health behaviour but at the same time it could alsocreate distress and induce reactance (Lewis & Rook, 1999; Tucker & Anders,2001). These effects could differ among couples and, in general, could elimi-nate the observed effects of an intervention because they operate in opposingdirections.

Support for this idea also comes from social support research which sug-gests that the protective effects of the perceived availability of support whenencountering a stressor could be countered by negative effects of receivingsupport. This research shows that support is effective to the extent that it is“invisible”, i.e. outside of the awareness of the recipient (Bolger, Zuckerman,& Kessler, 2000). Women who reported high spouse involvement in theirhealth may have been affected by the costs of this visible spouse involvement,which may have led to lower motivation to adhere to health behaviours. Thismay also explain why husband reported encouragement at follow-up inter-acted with study group in its effect on greater increase in BSE performance,even after controlling for wives’ reports of spouse BSE support (i.e. the effectwas due to husbands’ invisible support, that which was left after controllingfor what their wives reported).

The findings should also be considered within a more general view ofcommunal coping among spouses, such as the theoretical framework pro-posed by Lewis et al. (2006). The programme was more effective amongwomen who reported that their husbands were less involved in their healthin general (regardless of study group). It is possible that these couples areless likely to discuss preventive health practices, thus lowering the chancesthat they will be performed and maintained over time. The information andself-regulation programme may have served as a trigger that led thesewomen to increase performance. In contrast, in couples for whom commu-nal coping, as expressed by husband involvement in general health, hadalready existed, the programme was less effective: These couples may havealready had a clearer view of the wife’s performance or non-performanceof BSE.

The increases in husband knowledge and support suggest that it may bepossible to initiate greater communal coping among couples by activelyinvolving spouses in a health promotion intervention in general and spe-cifically in planning how to carry out the behaviour. Though we onlyassessed changes that were specifically related to BSE, spouse involvementin health promotion interventions could trigger more communal copingwith health in general. The increase in the performance of a health behav-iour could further promote perceptions of outcome efficacy and couple effi-cacy, which together with the use of communal coping are hypothesised tolead to greater initiation and maintenance of health behaviours (Lewis

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et al., 2006). These effects may even be stronger with implementation inten-tions manipulations aimed at behaviours that both spouses can perform,such as attendance at general medical check-ups or engagement in physicalactivity. Future studies should focus on additional behaviours, on oppositegender effects (such as those involved in promoting testicular self-examination), or even on a cluster of behaviours. Another avenue couldbe to study BSE and other female health behaviours in female homo-sexual dyadic relationships, where the behaviour is equally relevant to bothpartners.

There are several limitations to the current study. First, our sample isrelatively highly educated, which may explain their high level of cooperation(as indicated by the relatively low refusal and drop-out rates) as well as theirinitial levels of BSE performance. Future studies should assess the feasibilityof such an intervention with a more diverse sample. Second, though thefollow-up period allowed for more than one performance of the behaviourand was longer than most studies assessing implementation intentions effects,a longer follow-up may provide additional insights into possible mechanismsof communal coping within couples. Third, although participants were ran-domised into the study groups, these groups differed in the number of BSEsconducted in the three months prior to the study (though not in their overallreports of BSE in the past year). Fourth, as mentioned earlier, spouseinvolvement in health matters was assessed with a single item and therefore itsrole is speculative and requires further study. Fifth, we asked both partnersabout spouse encouragement of BSE but not about specific spouse behav-iours that would ascertain spouses’ extent of involvement as well as specificways in which this was expressed. Finally, the data were collected beforedoubts arose about the effectiveness of BSE in reducing mortality (Thomaset al., 2002). Since then, formal recommendations vary between countries,ranging from clear instructions that routine BSE should be performed bywomen as the first line of screening, through viewing it as an optional exami-nation or emphasising “breast awareness” with no clear instructions as to aroutine examination in a set method. Therefore, in some countries the find-ings cannot be applied to current attempts to change BSE and cannot bedirectly compared with later attempts. Yet, their implications could be takeninto account when planning other studies of spouse involvement in healthpromotion interventions.

In sum, the current study replicates the finding that implementation inten-tions manipulations are very effective at promoting health behaviour andprovides evidence for the effects of involving spouses on their knowledge andbehaviour. This evidence suggests that health promotion interventions aimedat couples should be tailored to the characteristics of the couple, taking intoaccount the extent to which they already cope with health as a couple or,conversely, do not view health as a mutual matter. Future studies can test the



effectiveness of specific spouse social control strategies and test ways to assistcouples in viewing health threats in a partner-centred way, which can lead tocollaborative coping.

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Involving Husbands in their Wives' Health Behaviour: Does it Work?

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