1. Developing a Theory of Change For a Comprehensive Tobacco Control Program A Webinar Presented by Larry L. Bye Vice President/Senior Research Director Field Research Corporation June 18, 2009

2. Intended Outcomes Understand what a theory of change is and why it is useful Learn about some leading theories Learn about the social norm change theory and how it has been applied in CA tobacco control work Understand how theories of change impact planning (objective setting and selection of intervention elements) Learn what an effective theory of change statement is within a TCS grantee scope of work

3. Agenda Overview Theory of Change: What is it? How is it useful? Some Leading Theories and How They Impact Planning Zeroing in on the Social Norm Change Theory and Its’ Implications for Planning Case Studies: Effective Theory Components of TCS Scopes of Work

4. A Theory of Change: What is it? Why is it important?

5. Theory of Change: What is it? Your view of how change is going to come about; the mechanism through which it occurs It is the strategy you’ve decided to pursue; it dictates your objectives and activities A theory of change always contains a set of concepts + specifies how they are related It has generalized relevance and applicability; is not tied to just one issue or problem

6. Some Simple Examples Strong intention + knowledge + skill acquisition = adoption of new behavior Beliefs about outcomes of new behavior + positive evaluation of outcomes = adoption of new behavior Strong intention + belief in self efficacy + knowledge + supportive physical and social environment = adoption of new behavior

7. Why a Theory is Important Without one, you are shooting in the dark – you may or may not accomplish the change you want It’s like setting out on a journey to a new place with no map or directions Without one, you have no basis for selecting one message or activity over another when you design your intervention We want to be effective because we care about people and the problems we are addressing; a-theoretical interventions rarely work

8. Program Design and Evaluation Basics To be successful all programs must have a clearly specified target audience/population and objectives that are: Specific Measurable Achievable Realistic Timely

9. Program Design and Evaluation Basics (cont’d) Rule #1: All intervention messages, activities and other elements must plausibly contribute to the achievement of the SMART objectives you have specified; and, Rule #2: All the objectives must be consistent with the theory you have selected

10. Examples of Leading Theories of Change

11. The Current Health Promotion Paradigm: The Social/ Ecological Approach 5 levels of influence (McLeroy and colleagues, 1988) Individual/intrapersonal factors: knowledge, attitudes, beliefs Interpersonal factors: family, friends and peers who provide social identity, support and role definition Institutional factors: rules, regulations and policies in schools, workplaces and other organizations Community factors: social networks and norms Public policy factors: government policies and laws

12. Selecting a Theory Selection of right theory is of key importance The right theory is one that fits the problem you are addressing and the situation you find yourself in; it responds to your assessment of the community environment (e.g. CX) Ground yourself in the science i.e. the evidence base; adapt an existing theory if you want but start by understanding the range of existing theories None of us are smart enough to make up a theory from scratch!

13. Selecting a Theory (cont’d) Consider the whole ecology Work on the individual level if the critical determinants are knowledge, skills, or attitudes Don’t pick a purely individual-level theory if you have reason to believe that institutional/community- level factors are the most important behavioral determinants

14. Selecting a Theory (cont’d) What has already been accomplished on the issue? What is the next most logical step to take in order to advance the field? What constraints are imposed by the donor, organizational setting or your assessment of where the best targets of opportunity are?

15. Examples of Some Leading Theories Individual Level Theories Health Belief Model Stages of Change Interpersonal Level Social Cognitive Theory Organizational/Community Level Health Communications Theory Diffusion of Innovations Theory Community Organizing Theory

16. Individual Level: The Health Belief Model (U.S. Public Health Service) Perceived susceptibility: “I am threatened” Perceived severity: “the threat is a serious one” Perceived benefits: “there is an action I can take that will reduce/eliminate the threat” Perceived barriers: “after considering the barriers, the benefits outweigh them” Cue to action: “what prompts me to take action” Self efficacy: “ I am confident of my ability to act”

17. The Health Belief Model : Implications for Program Objectives and Elements What type of intervention objectives would one expect to see if a program were being guided by this theory of change? What type of messages, activities or other elements?

18. Individual Level: Stages of Change Theory (Prochaska and DiClemente) Pre-contemplation: interest but no immediate intention to act Contemplation: immediate intention to act Preparation: action imminent; some initial steps already taken Action: person has changed behavior, but not for too long; still in process of change Maintenance: changed behavior in place for some time

19. Stages of Change Theory : Implications for Program Objectives and Elements What type of intervention objectives would one expect to see if a program were being guided by this theory of change? What type of messages, activities or other elements?

20. Interpersonal Level: Social Cognitive Theory (Bandura) Reciprocal determinism: person, behavior and environment interact and affect each other in a dynamic process Behavioral capability: person must have knowledge and skill to perform behavior Expectations: the anticipated outcomes of behaviors

21. Interpersonal Level: Social Cognitive Theory (Bandura) (cont’d) Self efficacy: confidence in one’s ability to take action and overcome barriers Observational learning: learning by watching the actions and outcomes of other’s behavior Reinforcements: whether responses increase or decrease the likelihood of recurrence

22. Community Level: Health Communications Theory (consensus model) Audience-centered Research driven Messages Source (credibility, trust) Channel (mass media + others)

23. Community Level: Health Communications Theory (consensus model) (cont’d) Effects (funding matters; influences reach and frequency) Agenda setting (what media cover, what public thinks about and what policymakers address) Framing: how to think about an issue

24. Community Level: Diffusion of Innovation (Rogers) Diffusion is the process by which an innovation is communicated through certain channels over time among members of a social system. What impacts the speed/extent of diffusion: relative advantage, compatibility, complexity; trial-ability, observe-ability (results)

25. Community Level: Diffusion of Innovation (Rogers) (cont’d) Channels: media as well as modeling/imitation within social networks Adoption is bell curve: innovators (very few) followed by early adopters (few) followed by early majority adopters and then late majority adopters (biggest groups) and then laggards (few)

26. Community Organizing (various schools and approaches) Community/most affected groups are empowered to initiate changes; public health professionals act as catalysts and resource providers Critical reflection and analysis about social forces causing problems and what solutions might look like Assets (e.g. money, staff, public concern/interest, readiness of organizations to act) are identified and exploited to increase the chance of success

27. Community Organizing (various schools and approaches) (cont’d) Partnerships are formed with key stakeholder groups in order to increase the chance of success Broad participation in order to accelerate change; often the focus is on grassroots participation Some approaches emphasize conflict, direct action and the building of power to redress inequities Policy advocacy is often a main focus

28. Community Organizing: Implications for Program Objectives and Elements What type of intervention objectives would one expect to see if a program were being guided by this theory of change? What type of messages, activities or other elements?

29. The Social Norm Change Theory

30. The Social Norm Change Theory of Change Definition: What is it? What are the key elements?

31. Social Norms Social norms: what the culture says we should do and/or not do; group/community sanctioned values and standards We are all greatly influenced by social norms; they affect in behaviors in multiple domains including the health area

32. Social Norms (cont’d) Cultural values are always in sync with socio- economic and policy factors; the relationships are reciprocal; changes in one domain affect changes in the others

33. Norm Change Theory as Applied to Tobacco Control Changed social norms + changed legal climate = reduced smoking and exposure to second hand smoke In other words, de-normalize tobacco use Changed norms: tobacco use is less desirable and acceptable and, hence, less accessible

34. Norm Change Theory as Applied to Tobacco Control (cont’d) Legal changes: (1)increase tobacco taxes; (2)regulate tobacco production, manufacturing, marketing, and sales; (3)reduce access to tobacco products, especially by youth; (4)ban smoking even in homes and cars

35. Norm Change Theory as Applied to Tobacco Control (cont’d) Reveal and counter tobacco industry influence; “point fingers, name names” Provide cessation services but view cessation more as “an outcome, not an intervention” Organize/engage communities so that change is ground-up, not top-down. This accelerates norm change and generates support for legal/policy changes

36. Applying the Social Norm Change Theory What type of intervention objectives would one expect to see if a program were being guided by this theory of change? What type of messages, activities or other elements?

37. Case Studies and Discussion