Understanding Physician Behavior: Theory, Evidence, Planning Transtheoretical Model; Social Cognitive Theory; Heuristics; Social Marketing - - and Formative.

Understanding Physician Behavior: Theory, Evidence, Planning Transtheoretical Model; Social Cognitive Theory; Heuristics; Social Marketing - - and Formative Research Kitty Corbett, PhD, MPH Faculty of Health Sciences Simon Fraser University Burnaby [Vancouver], BC UCSF April 8, 2008

Objectives Participants will be able to:
MAKING SENSE OF THEORY Define & differentiate among 3 approaches to understanding physician behavior in terms of basic conceptual domains, their components, & methodological approaches Social Cognitive Theory; Transtheoretical Model; Social Marketng Describe where heuristics fit within these approaches EVIDENCE THAT THEORY HELPS Describe the strength of the evidence for the utility of these theories Describe the limitations of these approaches PLANNING/APPLICATION: THEORY-INFORMED FORMATIVE RESRCH Apply constructs from these theories to given situations Describe what formative research is and can offer Employ exploratory, formative, Social Marketing research strategies Challenge of reviewing, synthesis, and distilling a wide array of theoretical perspectives, with the intention of highlighting 3 (whose choice seems a bit random). Step you through a few minutes of Big Picture, & then I’ll situate the 3 I’m highlighting. 2

I. MAKING SENSE OF THEORY
There is theory in everything. Theory often remains unspoken and assumed. Every project has assumptions about how change happens, or why people are the way they are, or why there is human diversity or so much conformity fundamental constructs like "motivation," "emulation“ and “modeling,” "alienation,” “conflict” an underlying model about process, "prime movers" etc. Theory-ladenness of observation Rabbit or duck?

A theory is “a coherent and non-contradictory set of statements, concepts or ideas that organises, predicts and explains phenomena, events, behavior, etc.” [Bem & Looren de Jong 1997 (in Eccles 2005, p.108)] Like empty coffee cups, they have shapes & boundaries, but are useful when filled with practical topics, goals, and problems. * Theories must be applicable to a broad variety of situations. They are, by nature, abstract, & have no specified content . Like empty coffee cups, they have shapes & boundaries, but nothing inside. They become useful when filled with practical topics, goals, and problems. A theory presents a systematic way of understand-ing events or situations. It is a set of concepts, definitions, & propositions that explain or predict these events or situations by illustrating the relationships between variables. *NCI, Theory at a Glance 4

Individual change theory at its most rudimentary
ATTITUDE / MOTIVATION KNOWLEDGE BEHAVIOR [E.g., figure in Cabana article] 5

Rudimentary individual change theory with context added
ATTITUDE / MOTIVATION KNOWLEDGE BEHAVIOR * norms, environmental resources, etc. 6

Negotiation, decision, or action (eg, Rx) about antibiotic use
Cross-sectional model of health care behavior; Social determinants of community-based use of Abx SYSTEM FACTORS Cost of medicines & care Care setting factors (e.g. schedules, formularies) Health plan features Pharmaceutical promotions Pharmacy practices Availability of technology Regulatory environment Community factors Cultural context Media / health information PATIENT FACTORS Symptoms & their meanings Health system experiences Health care coverage or ability to pay Cultural understandings [Dis]trust re advice Abx knowledge Abx experiences CLINICIAN FACTORS Sociodemographics Specialty / training Knowledge re Abx, resistance Knowledge of guidelines Judgment & heuristics Perceived patient expectations Communication style Social determinants of community-based ABx use are many and varied. This figure shows factors that affect a key point in community-based Abx use: the negotiation or decision points that result in a patient’s access to an Abx. In the center you could put the provider’s decision to prescribe, or a patient or parent’s decision to pursue antibiotics. System factors include such things as guidelines and formularies, payment systems, telephone advice lines, duration of visits, and messages about Abx in the media. Patient factors include past experiences having been prescribed antibiotics, ability to pay, and their expectations that antibiotics will work for these infections. Negotiation, decision, or action (eg, Rx) about antibiotic use

4 and 20 theories baked in a pie: how to slice it?
Levels in the social ecology [of a targeted change]: Individual-level, Organization-level, Community, Societal/Population, Multi-level Theoretical domains Risk assessment, self perception, emotions and arousal, relationships & social influence, environmental & structural influences Snapshots vs Moving Pictures Cross-sectional vs. dynamic / iterative theories Inductive (ground up, empirical) vs deductive (applying & testing existing theory): discovery, planning, application Practice-based research vs Theory-based research – or MIXED Interaction-oriented / dramaturgical theory Force-field theory & analysis Cognitive / decision-making: artifacts, heuristics Persuasion Etc.

3 sizes of theory (1) Grand Theory - very powerful nomothetic theory, at level of a paradigm perhaps - evolutionary theory - political economy Arches in Basilica of San Zanipolo (Venice) Photo by Giovanni dall'Orto 9

Spencer, Durkheim, Parsons, Merton
Functionalist Theory Spencer, Durkheim, Parsons, Merton The key questions: how parts contribute to the functioning of the whole Society as an organism whose various parts are interdependent Society characterized by cooperation, consensus, and balance Stresses stability

Marx, Weber, other 19th century critics
Conflict Theory Marx, Weber, other 19th century critics Key Q: Where are the tensions? Who benefits what and why? Society seen as constantly changing, with social inequality and social conflict as drivers Emphasis on power, conflict and change; very little on what produces stability

Sizes of theory (2) NOMOTHETIC THEORY – accounts for facts in many cases. [“relating to, involving, or dealing with abstract, general, or universal statements or laws”] What features of social relations and social organization account for the variation in rates laminectomies & lumbar discectomies across regions in the US? (3) IDIOGRAPHIC (elemental) THEORY – accounts for the facts of a particular case What accounts for patients in Ugandan hospitals who have pneumonia getting antibiotics within 6 hours?

Interactionist Perspective (incl. Symbolic Interactionism)
GH Mead, H Blumer, HS Becker, E Goffman Key questions: How people make sense of the world in which they participate Seeks to understand social life and human behavior from the standpoint of the individuals involved in day-to-day interaction Human beings create symbols and interpret the meanings The “definition of the situation” has consequences and affects social interaction

Socialization, status, role, self-interest, & social interaction
Interaction ritual in everyday life: impression management, managing “face,” front-stage & back-stage (Erving Goffman) “…doctors are influenced by a complex itneraction of self-interest, concern for their individual patients, and regard for the well being of society at large.” (Eisenberg 2002, p.1016)

Useful references Theory at a Glance
Communication Theory Clusters Change Theories 15

7 conceptual “families” of useful theoretical models – evidence from STD/HIV lit
Psycho-educational approaches that stress information Cognitive theories that stress internal decision-making processes Behavioral models based on principles from learning theories Theories of motivation & emotional arousal Social influence theories Stage theory Blended theories St. Lawrence and Fortenberry, IN Aral & Douglas, 2007

7 conceptual “families” of theoretical models
Psycho-educational approaches that stress information Cognitive theories that stress internal decision-making processes Behavioral models based on principles from learning theories Theories of motivation & emotional arousal Social influence theories Stage theory Blended theories Social Cognitive Theory Social Marketing Trans-theoretical Model

Relationships & social influence Environmental & structural influences
5 “Theoretical Domains” – These occur in some form, with some related terminology, with some degree of emphasis, in just about every change theory dealing with individuals. Risk appraisal Self perception Emotions and arousal Relationships & social influence Environmental & structural influences Dolcini & Gandelman 18

PERCEIVED CONSEQUENCES
5 “Theoretical Domains” – These occur in some form, with some related terminology, with some degree of emphasis, in just about every change theory dealing with individuals. PERCEIVED CONSEQUENCES Risk appraisal Self perception Emotions and arousal Relationships & social influence Environmental & structural influences SELF-EFFICACY SOCIAL NORMS 19

Trans-theoretical Model & Stages of Change
20

TTM Stage-transition determinants: info (pros/cons), demos, self-efficacy, support

Albert Bandura, the bobo doll, & Social Learning Theory

Add Self-Efficacy  Social Cognitive Theory
Personal inputs-predispositions, gender, ethnicity Can I do this ? What will happen? Past performance Verbal persuasion Vicarious learning Physiological states Contextual influences (supports & barriers) Retention Background Contextual Affordances Application of Social Cognitive Theory (Bandura, 1977) to career choice & behavior (Lent, Brown, & Hackett, 1994) Byars-Winston A, Davis D, et al., 2007.

Social Cognitive Model (Albert Bandura)
Behaviour Knowledge of health risks I know what TB is Benefits of change Taking the medication will make me feel better Self efficacy I am confident that I can take my medication Outcome expectations If I take my medication I will feel better, & I want to Facilitators and barriers It is easy to take my medication

Social Cognitive Theory -- Key Constructs
Observational Learning: Learn by watching actions of another person; the outcomes, and reinforcement received; more efficient way to learn compared to operant learning (classical conditioning) Self-Efficacy: Self-confidence/determination about performing a particular activity; feeling of having control over one’s behavior; KEY for behavior change Outcome expectancies: “incentives,” value a person places on an outcome; hedonic principle (max. + or min-) Outcome expectations: what an individual expects will occur as a result of certain behaviors in specific situations (as learned through previous experience, observational learning, & physical & emotional responses to situations) Behavior capabilities: knowledge about & the skills needed to perform the behavior Self-control: self-regulation of goal directed behavior or performance Managing emotional arousal: some situations can create fear and anxiety which impair learning and performance. Individuals use different techniques to deal with this (stress management, cognitive reappraisal) Environment: factors external to the individual; social (family & friends= models for behavior), physical (urban/rural, room temperature) Reciprocal determinism: dynamic interaction of the person, behavior and environment in which the behavior is performed

Stepwise Implementation Model – to achieve a change
The amount and type of interactive guidance should be adjusted to people’s level of self-efficacy & motivation to achieve a desired change. Level 1: individuals with high self-efficacy and positive out-come expectations Level 2: individuals with self-doubts about both their efficacy and benefits of outcome Level 3: individuals have no sense of self-efficacy Succeed with minimum guidance. Half-hearted decisions; Give up when barriers arise. Habits are beyond their personal control; Need personal guidance & changes in context. (Bandura, 2004)

Heuristics Our brains and behaviors evolved to (1) not change strategies too quickly; (2) rely on our own personal observations; (3) be biased towards recent experience; (4) be influenced by a small number of cases, especially if recent and outcomes are severe… (Brass 2003, p. 120) 27

Appropriate vs questionable cognitive aids [& cognitive artifacts]
“Fast and frugal” heuristics Folk maxims Expert-vetted and disseminated heuristics Guidelines The “5 As” etc. (ask, arrange, advise, assist, etc.) Calls for more study!

Let sleeping dogs lie. [changing behavior of established physicians]
Safety in numbers [so what the standard of care says] The patient is a case of one. When you hear hoofbeats, think horses not zebras. Common things occur most commonly. Follow Sutton’s law [go where the money is] One has to think of the disease to recognize it. See one, do one, teach one.

Stage-transition determinants: info (pros/cons), demos, self-efficacy, support
Role models, demos, social support, skills-building, incentives, heuristics Social support, rewards, heuristics Information, mass media, motivational interviewing

Fig. 1 A stages of change model.
HEURISTICS CHILVERS, R. et al. Br J Psychiatry 2002;181:99-101 Copyright © 2008 The Royal College of Psychiatrists

Social Learning Theory
HEURISTICS HEURISTICS

Social Cognitive Model (Albert Bandura)
Behaviour Knowledge of health risks I know what TB is Benefits of change Taking the medication will make me feel better Self efficacy I can take my medication Outcome expectations If I take my medication I will feel better, & I want to Facilitators and barriers It is easy to take HEURISTICS HEURISTICS HEURISTICS

II. EVIDENCE THAT THEORY HELPS
“There is nothing so practical as a good theory.” (Kurt Lewin, Field theory in social science, 1951, p. 169)

“Stages of Change” / TTM
Very appealing! Brief High face validity Easy to explain Readily applicable for understanding & interventions Useful for distinguishing between motivation phase & volition phase Stages of change interventions appear in the short term at least to be somewhat more effective than non-stage matched interventions

Limitations of TTM The bad news:
Rather weak evidence, mostly from cross-sectional studies Stages of change may be unstable over time Few studies about using TTM in changing providers’ behavior Need for prospective studies -- longitudinal, experimental designs Sutton S. Interpreting cross-sectional data on stages of change. Psychol Health. 2000;15:163–171. Adams JWM. Why don't stage-based activity promotion interventions work? Health Educ Res. 2004;20:237–243.

Limitations of SCT So many constructs that researchers can use them to describe almost any phenomenon need to narrow down which phenomena they apply to (thru empirical evidence) & in which situations it doesn’t apply Many of the constructs have modest reliability Improvements in measurement procedures could improve the constructs’ ability to explain behavior & the effects of interventions. Little evidence in interventions with physicians

What makes “good” theory?
Application & scientific merit “a theory is a good theory if it satisfies two requirements: It must accurately describe a large class of observations on the basis of a model that contains only a few arbitrary elements, and it must make definite predictions about the results of future observations.” (Stephen Hawking in ‘A Brief History of Time’) Theory that is 38

Theoretical advances in patient behavior change
Large literature, especially for: Smoking HIV prevention

Academic Literature on Changing Physician Behavior
Education Not very useful on its own Feedback (audit/feedback, academic detailing/outreach, reminders) Clinical Opinion Leaders / champions Administrative Mandates Incentives

What helps people succeed in making and maintaining change?
Basic conditions/prerequisites for change include, according to many: Perceived consequences / positive expectancy Response expectations/ response efficacy Self efficacy Behavioral capability / skills Incentives/ Reinforcement/ punishment Supportive environment & social norms

Rubinson L, et al. Why is it that internists do not follow guidelines for preventing intravascular catheter infections? Infect Control Hosp Epidemiol Jun;26(6): Clinician experience and subspecialty, awareness of CDC guidelines, and external influences (eg, time to collect equipment) did not affect maximal barrier precautions adherence. The only independent predictor of adherence was high outcome expectancy for the use of large sterile drapes (OR, 5.3; CI 95, ). Availability had the greatest influence on internists' selection of specific antiseptic agents, whereas cost was the least important determinant. CONCLUSIONS: Despite established efficacy, use of maximal barrier precautions and chlorhexidine gluconate is low among internists. Because improved adherence to these practices will require increased outcome expectancy for maximal barrier precautions and availability of chlorhexidine gluconate, targeting these areas through focused education and systems modifications is essential.

Cabana MD, Rushton JL, Rush AJ
Cabana MD, Rushton JL, Rush AJ. Implementing practice guidelines for depression: applying a new framework to an old problem. Gen Hosp Psychiatry. 2002;24(1):35-42. Six primary barriers relate to providers (lack of awareness, lack of familiarity, lack of agreement, lack of self efficacy, lack of outcome expectancy, and inertia of previous practice). In addition, factors related to patient, guideline, and practice environment factors encompass external barriers to adherence. Different physicians and practice settings may encounter a variety of barriers, multifaceted interventions that are not focused exclusively on the physician tend to be most effective.

Maue SK, et al. Predicting physician guideline compliance: an assessment of motivators and perceived barriers. Am J Manag Care Jun;10(6): Some variables, particularly perceived barriers to guideline implementation, predicted a provider's practice intentions and self-reported behavior.

Cabana MD, et al. Barriers pediatricians face when using asthma practice guidelines. Arch Pediatr Adolesc Med Jul;154(7): Efforts to improve adherence to asthma guidelines should consider the range of barriers that pediatricians face, such as lack of awareness, familiarity, or agreement, and external barriers owing to environmental, guideline, or patient factors. In addition, this study documents barriers not previously considered, such as lack of self-efficacy, lack of outcome expectancy, and inertia of previous practice, that prevent adherence. Because type of recommendation and physician demographics are related to which barriers are prominent, interventions to improve NHLBI guideline adherence should be tailored to these factors.

Cochrane LJ, et al. Gaps between knowing and doing: understanding and assessing the barriers to optimal health care. J Contin Educ Health Prof Spring;27(2): Review of 256 studies While many studies are methodologically weak, there are indications that designs are becoming more aligned with the complexity of the health care environment. The review provides support for the need to examine multiple factors within the knowledge-to-action process.”

Bloom BS. Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews. Int J Technol Assess Health Care Summer;21(3):380-5. 26 reviews met inclusion criteria, that is, were either formal meta-analyses or other systematic reviews. Interactive techniques (audit/feedback, academic detailing/outreach, and reminders) are the most effective at simultaneously changing physician care and patient outcomes. Clinical practice guidelines and opinion leaders are less effective. Didactic presentations and distributing printed information only have little or no beneficial effect in changing physician practice. CONCLUSIONS: Even though the most-effective CME techniques have been proven, use of least-effective ones predominates.

Chaillet N, et al. Evidence-based strategies for implementing guidelines in obstetrics: a systematic review. Obstet Gynecol Nov;108(5): Prospective identification of efficient strategies and barriers to change is necessary to achieve a better adaptation of intervention and to improve clinical practice guidelines implementation. In the field of obstetric care, multifaceted strategy based on audit and feedback and facilitated by local opinion leaders is recommended to effectively change behaviors.

Predictive theories vs frameworks
“More problematically, there are problems in the concepts underlying attempts to change professional behavior.” (p.107; from Grol) “…theories that identify modifiable predictors or explain how to change behavior are most likely to be useful in implementation research.” (p.108) (Eccles et al. 2005)

“Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another.” (Cabana et al 1999)

“It is amazing how little we know about how to induce behaviour change
“It is amazing how little we know about how to induce behaviour change. Most of us accept this and are appropriately modest when we consider how effective we might be in convincing a family member to stop an irritating habit or a patient to quit smoking. But it is harder to accept when we are considering the need to change professional behaviour.” (Flottorp & Oxman 2003)

“Cafeteria-style” theorizing
“We did not rely on any specific theory of behaviour change, but we used elements from adult learning theories, theory of innovation, the transtheoretical model of behaviour change, and social influence theory. We used a pragmatic approach with a series of largely qualitative methods to identify barriers and tailor interventions to address these.” (Flottorp & Oxman 2003)

But perhaps choosing from a menu makes sense -?
Bandura’s input was most instructive about the dangers of mixing constructs… in a cafeteria-style manner. (Lent, Hackett, Brown, 1998) But perhaps choosing from a menu makes sense -?

Challenges to considering THEORY -1
To a large degree, how intervention programs are constructed is a reflection of the theory they are based on, whether overtly or implicitly Yet theoretical premises are often unmentioned or unexamined. 54

Challenges to choosing & using theory - 2
No single theory is sufficient to meet the multiple challenges of a health problem Various theories or models may be appropriate at different times and for addressing different problems. Each theory addresses only part of the picture. 55

Theory-based interventions have tended to draw on psychological explanations & mechanisms for behavior change Neglect of situational & social context, environment, and structural constraints Still shots – rarely moving pictures 56

Our model is incomplete… we haven’t included the important roles that society & health care organizations play in providing and limiting resources for health services. Rather, our focus has been purposely on the decisions made by patients and their immediate health care providers, leaving the “bigger picture” for another discussion… (Haynes, Devereaux, p.386) 57

“Theory”  may not be interesting to people who have previously been confused or over/under-whelmed by it Elitism of academic disciplines: each considers its own approach to theory is best Program planners and providers may regard theory as irrelevant to their work; they think that addressing a real-life problem in an efficient manner is not about theory. 58

“Although these studies have been valuable in describing how medicine should be practiced, they have contributed less to an understanding of how it is practiced.” (Eisenberg 2002, p.1028) 59

What makes “good” theory?
NOT JUST Application & scientific merit “a theory is a good theory if it satisfies two requirements: It must accurately describe a large class of observations on the basis of a model that contains only a few arbitrary elements, and it must make definite predictions about the results of future observations.” (Stephen Hawking in ‘A Brief History of Time’) Branding and persuasiveness “Propaganda is of the essence” in theoretical arguments. (Feyerabend, Against Method, p. 157) Theory that is 60

“There is nothing so practical as a good theory.” But is that true?
Very few studies have employed theory in the design of provider change interventions. Most studies have implicit theory but lack explicit theory. Few studies have tested theory. Most research has entailed practical, problem-centered studies. If theory is mentioned -- Many people employ a hodge-podge of theoretical constructs. (Is that OK?) What IS used frequently are conceptual and planning frameworks, e.g., PRECEDE-PROCEED; Social Marketing; Diffusion of Innovations

III. PLANNING/APPLICATION

Ralph’s Roadmap for Designing Theory-Based Interventions
“Theory-based intervention design starts with a comprehensive needs assessment” (R. Gonzales, last week) Ralph’s Roadmap for Designing Theory-Based Interventions Needs Assessment Understanding the Problem within a Theoretical Framework Designing Multifaceted Intervention within a Theoretical Framework …

Social Marketing offers a useful formative phase
“Social marketing is a process for influencing human behavior on a large scale, using marketing principles for the purpose of societal benefit rather than for commercial profit” Bill Smith 1999 = "the application of marketing technologies developed in the commercial sector to the solution of social problems where the bottom line is behaviour change." It involves: "the analysis, planning, execution and evaluation of programs designed to influence the voluntary behaviour of target audiences to improve their personal welfare and that of society." Alan Andreasan

Social marketing IS AUDIENCE CENTERED
SM researches the audience to find out what segments make sense to target, and what they believe, perceive as norms, want, fear, and need IS CONCERNED WITH “UPSTREAM” AND “EXTERNAL” (STRUCTURAL & SYSTEM) FACTORS Change those first if you can EASILY LINKS WITH CHANGE THEORIES IS COMMITTED TO GOOD MESSAGE DESIGN

Change theories – key domains for SocMarktg
Do I know about & value it? Do I have the confidence & skills to do it whatever the circumstances? Is it easy to do? PERCEIVED ADVANTAGES e.g., positive expectancies; predisposing factors (aware, know, agree); acceptability, compatibility, low complexity SYSTEM / STRUCTURAL FACILITATORS e.g., clarity of what is “ideal”;“cues” to do XYZ; easy information flow & access within & across reference groups; a clear institutional policy; feedback with data; champions; opp’ties to observe, to try, & to be rewarded SELF-EFFICACY e.g., confidence in behavioural capability/skills and sense of control regardless of complexity or difficulty of situations PERCEIVED CONSEQUENCES e.g., outcome expectancies; perceived severity of threat; personal susceptibility to neg. & pos. consequences PERCEIVED SOCIAL NORMS e.g., normative beliefs about what peers and persons whose opinion matters to you believe Who matters to me? Do they endorse it & do it? Are they paying attention? What bad or good things happen if I do it or don’t? What do I have to give up? What do I get in exchange? Also: segmentation & stage

Steps/Principles in Social Marketing
Do theory-informed, empirical, formative research to understand the problem, the context, and who the players are, what they do & think, & what matters to them. Figure out what you can do or offer the key players that makes XYZ easy and important from their perspective. Apply the highest structural/system action possible first. Develop and deliver messages to persuade players that by doing XYZ they will get benefits that they want.

What kinds of messages are most likely to reach the audience, be memorable, be actionable, and actually make a difference? Here is Katya Andresen’s recommendation, from her new book, Robin Hood Marketing: Stealing Corporate Savvy to Sell Just Causes Messages should establish a Connection promise a Reward inspire Action, and stick in Memory CRAM

Found googling images for <“hand washing” hospital>

Is it memorable? Will people notice it? Will they remember it? Will they read the small print? Will they act on it? Does the msg resonate with a benefit that people want?

WILL HE REACH 20? billboard
KEY MESSAGES: You don’t need AB’s every time you get sick. Ask you doctor to be sure. Taking Abs today when you don’t need them means they may not work in the future when you really do need them. Our AB’s are becoming less effective & it’s a serious public health issue

SM - What Makes an Effective Campaign?
Conducting Formative Research – garnering feedback from and about the target audience on the behavior under study, initial versions of campaign messages, &campaign channels under consideration for use. Using Theory – employing a behavioral theory as a conceptual guide Segmenting Audiences – dividing audiences into one or more homogenous groups for purposes of targeting campaign messages. Effective Message Design – using message design theory & formative research to create msgs thought to be effective w particular audience segments. Effective Channel Placement – strategically placing messages in appropriate channels (e.g., TV, radio, print media) widely viewed by the target audience, in order to ensure high exposure to campaign messages. Process Evaluation – following campaign implementation closely to ensure that a campaign plan is effectively put into action, as well as making “mid-course corrections” where necessary. Outcome Evaluation – where possible, employing a sensitive outcome evaluation design that allows firm causal conclusions regarding the impact of the campaign to be made.

OBJECTIVE = increase daily physical activity [sustained brisk walk or more] to a minimum of 30 minutes a day, 5 times a wk AUDIENCE SEGMENTATION = including “staging” participants Seminar students – healthcare providers THEORY: 3 basic constructs + structural/environ’l factors DOER – NONDOER ANALYSIS Formative research OTHER OPTIONS -- Spending 30 quality min/day with your child OR -Handwashing before seeing every patient

From AED, Comparing Doers and Non-Doers: A Rapid Assessment Tool for Social Marketing Programs, 1998. These 3 determinants are … almost always a good place to start, if you have limited resources. perceived consequences self-efficacy social norms Within each of these, distinguish which are structural/ environmental factors and which are cognitive & interactional factors The Doer Non-Doer rapid assessment tool translates these determinants into a set of simple questions. Helps you determine differences between these groups

What do the players know & understand about what’s expected [the target behavior]? Do they accept it? What advantages & consequences do they perceive? Do they have the self-efficacy to do it right? (confidence & skills, in complex situations) Are there social norms that support & reinforce the behaviors? (& Who is paying attention? Who matters?)

Theory in a Doer – NonDoer Analysis
Perceived consequences Knowledge, attitudes Pros/cons, risk perception, decisional balance Self-efficacy Do I have not just the skills but also the confidence to do XYZ in complex situations? Social norms Is this the kind of thing a person like my peers and I do? Does it matter to people who are important to me?

The perceived consequences questions
Question No. 2: What do you see as the advantages or good things that would happen if …XYZ…? Question No. 3: What do you see as the disadvantages or bad things that would happen if …XYZ…?

The self-efficacy questions
Question No. 4: What makes it difficult or impossible for you to …XYZ…? Question No. 5: What makes it easier for you to …XYZ…?

The social norm questions
Question No. 6: Who (individuals or groups) do you think would object or disapprove if you …XYZ…? Question No. 7: Who (individual or groups) do you think would approve if you …XYZ…? Question No. 8: Which of these individuals or groups in either of the two questions above is most important to you?

DOER – NON-DOER QUESTIONS TO ASK
Do you get at least 30 minutes of exercise (a sustained brisk walk or more] a day, at least 5 days a week? What do you see as the advantages or good things that would happen if you got exercise 5 days each week? What do you see as the disadvantages or bad things that would happen if you got exercise 5 days each week? What makes it difficult or impossible for you to get exercise 5 days every week? What makes it easier for you to get exercise 5 days/wk? Who do you think would object or disapprove if you get exercise 5 days every week? Who do you think would approve? Which of these individuals or groups in either of the two questions above is most important to you?

Social marketing exercise summary
Ask: For what % of the doers is X an issue, and for what % of the non-doers is X an issue? Social marketing exercise summary FINDINGS DOER NON-DOER

FINDINGS DO NO-DO IMPLICATIONS ADVANTAGES: DISADVANTAGES: FACILITATORS/ EASY: BARRIERS / HARDER: WHO APPROVES: WHO DISAPPROVES: PERCEIVED CONSEQUENCES SELF EFFICACY SOCIAL NORMS

Social marketing exercise – Example
FINDINGS DO NON-DO IMPLICA-TIONS ADV - More energy 60% 20% ADV - Feeling good 70% 45% ADV – Appearance 50% DISADV - Stress of doing it 40% DISADV - Time, takes up time 80% DISADV - Injury, soreness, pain EASIER: - Enabler (Ipods, weather, car, shower) EASIER: - Time, having the 30% EASIER: - Social interaction

FINDINGS DO NO-DO IMPLICATIONS ADV: DISADV: FACIL: BARR:

FINDINGS DO NO-DO IMPLICATIONS APPROVES: DISAPPROVES:

What do you do with this diagnostic information?
First see if there are “umbrella” approaches – e.g., structural, systems, organization-based interventions - to addressing contextual, environmental barriers & facilitators Then assess the cognitive & interactional factors Employ constructs from theoretical domains or a “name-brand” theory Design multi-faceted approaches to address the factors that differentiate doers & non-doers

Pressing need for improvement -- but no clear path for how to do it

Understanding Physician Behavior: Theory, Evidence, Planning Transtheoretical Model; Social Cognitive Theory; Heuristics; Social Marketing - - and Formative.

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Understanding Physician Behavior: Theory, Evidence, Planning Transtheoretical Model; Social Cognitive Theory; Heuristics; Social Marketing - - and Formative.

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