Theory

What is theory? “… a set of interrelated concepts, definitions, and propositions that presents a systematic view of events or situations by specifying relationships among variables in order to explain and predict the events or the situations.” (Glanz, Rimer, and Lewis, p. 25)

Theory “Effective health promotion and education depends on practitioners’ marshaling the most appropriate theory and practice strategies for a given situation.” “The gift of theory is that it provides conceptual underpinnings for well-crafted research and practice.” (Glanz, Rimer, & Lewis, pp. 30-31)

Theory Generality Testability Shape and boundaries, but not specific topic or content Variables

Theories are used to … Guide the search for why people behave in certain ways Help pinpoint information needed before developing and organizing an intervention program Provide insight as to how to shape strategies to reach people Help identify what should be monitored, measured, and compared

Concepts & Constructs Concepts: Constructs: Major ideas Concepts that have been developed and defined for use in a particular theory

Models “… draw upon a number of theories to help understand a specific problem in a particular setting or context.” (Glanz, Rimer, & Lewis, pp. 27)

More theory “Habit is habit, and not to be flung out of the window, but coaxed downstairs a step at a time.” Mark Twain

Planning Models Like a road map Present all possible routes you might take to develop, implement, and evaluate a program.

Planning Models PRECEDE/PROCEED MATCH CDCynergy

PRECEDE/PROCEED Model

MATCH (Multilevel Approach To Community Health) Developed in late 1980s Used by U.S. Government Applied when behavioral & environmental risk & protective factors for disease / injury are known & general priorities determined Includes ecological planning – levels of influence

MATCH Figure 4.16: MATCH: Multilevel Approach To Community Health (Pearson Ed, 2012)

CDCynergy Developed by the Office of Communication at the CDC in 1997 First issued in 1998 Developed initially for public health professionals at CDC with responsibilities for health communication Developed for health communication but can be used with all health promotion planning Available on CD-ROM; many versions (Pearson Ed, 2012)

CDCynergy P 6: Implement Plan P 3: Plan Intervention (Is communication dominant or supportive?) P 6: Implement Plan P 5: Plan Evaluation P 4: Develop Intervention P 2: Analyze Problem (causes, goals, intervention strategies P 1: Describe Problem (identify & define) (Pearson Ed, 2012)

Generalized Model for Program Planning (GMPP) Figure 4.18: Generalized Model for Program Planning (Pearson Ed, 2012)

Theories and Levels of Influence Behavior is very complex Influenced and supported in multiple ways

The Ecological Model Emphasizes the links and relationships among multiple factors (or determinants) affecting health

Ecological Model Public Policy Community Institutional or Organizational Interpersonal Individual

Individual / Intrapersonal factors Knowledge, attitudes, beliefs (KAB) Skills Motivation Self-concept Age, gender, genetics

Interpersonal factors Social support / social networks Social norms, cultural environment Religious affiliation Access to social and health services

Institutional or organization factors Educational system Access to health care Social Interactions

Community factors Living and working conditions Public safety Local public health Housing Economic development Environment

Public Policy Factors Federal, State & Local Policy and Law Zoning Taxes Public Health System Educational System

Behavior Change Theories The specific route(s) you will take to reach your destination – they suggest a road to follow.

Behavior change theories with individual focus The Health Belief Model (HBM) ** The Transtheoretical Model (TTM) ** Theory of Planned Behavior (TPB) ** Other Theories: Elaboration Likelihood Model of Persausion Information – Motivation – Behavioral Skills Model Health Action Process Approach

Health Belief Model (HBM) Developed in the early 1950’s by social psychologists in the U.S. Public Health Service. Hochbaum & Rosenstock TB screening

Constructs of HBM Perceived threat Perceived susceptibility Beliefs about one’s chances of getting a condition Perceived severity Beliefs about how serious the condition might be

Constructs of HBM Outcome Expectations Perceived Benefits Beliefs that the advised action will reduce risk or seriousness of the condition. Perceived risks/barriers Beliefs about the “costs” of taking the advised action

Constructs of HBM Cues to Action Self-Efficacy Strategies to activate one’s “readiness” Self-Efficacy Confidence in one’s ability to take action

Likelihood of taking recommended action Health Belief Model Modifying Factors: age, race, ethnicity, SES, personality Outcome Expectations: Perceived Benefits vs. Perceived Risks/Barriers Perceived Susceptibility & Perceived Seriousness Perceived Threat Likelihood of taking recommended action Cues to Action Self-efficacy

Theory of Reasoned Action (TRA) Constructs: Attitude toward the behavior Beliefs about the behavior Evaluation of behavioral outcomes Subjective norms What others think about your behavior How motivated you are to comply with the expectations of others

TRA Cont. Beliefs and Subjective Norms help predict Intentions Your Intentions predict your actual Behavior

Attitude toward behavior TRA Attitude toward behavior Intention Behavior Subjective Norm

Theory of Planned Behavior (TPB) Developed by Fishbein & Ajzen An extension of the Theory of Reasoned Action (TRA)

TPB versus TRA Adds the construct: Perceived Behavioral Control Belief about personal control in combination with belief about the one’s ability to do what needs to be done. Actual Behavioral Control: have the skills and resources needed to quit.

TPB Cont. People will perform a behavior if: They believe the advantages of success outweigh the disadvantages of failure. They believe that other people with whom they are motivated to comply, think they should perform the behavior. They have sufficient control over the factors that influence success or ability to perform the behavior.

Attitude toward the behavior Perceived Behavioral Control TPB Attitude toward the behavior Intention Behavior Subjective Norm Perceived Behavioral Control Actual Behavioral Control

Transtheoretical Model (TTM) AKA: Stages of Change Developed by Prochaska & DiClemente Major Constructs: Precontemplation Contemplation Preparation Action Maintenance Decisional Balance Self-Efficacy

Precontemplation “The shoes are still at the store” Not thinking about changing behavior in the next six months. May be unaware of risks or problems. Needs some work “under the hood.”

Contemplation “Shoe shopping” Seriously thinking about making a behavior change, but have not yet made a commitment to action

Preparation “You bought the shoes” Ready to take action in the very near future (next 30 days) Have a plan of action Experimenting with new behaviors

Action “Wearing your shoes on a regular basis” Actively engaged in new behavior(s) for less than six months. Efforts are sufficient to reduce risk of disease

Maintenance “Shoes go on every day.” Sustaining the behavior change for over 6 months.

Decisional Balance The costs and benefits of changing.

Self-Efficacy Confidence that one can be successful in the new behavior across different challenging situations.

Relapse More likely when you are stressed, anxious, or feeling depressed. More likely if you lack social support or are experiencing interpersonal conflicts More likely if you return to a setting (environment) that “cues” your old behavior(s)

Transtheoretical Model (TTM) Precontemplation Decisional Balance Contemplation Decisional Balance Preparation Self-Efficacy Action Self-Efficacy Maintenance

Pro’s of TTM Encourages less “labeling” terms. (Precontemplation rather than “loser” or “lost cause”) Must accept people “where they are” Behavior change is not viewed as linear It is easy to stage clients It is not based on an instant gratification mentality Allows for stage-matched interventions

How to stage a person using TTM Do you exercise regularly? No Yes Do you intend to in the next 30 days? Have you been doing so for more than 6 months? Yes No Yes No Do you intend to in the next six months? Preparation Action Maintenance Yes No Precontemplation Contemplation (Pearson Ed, 2012)

Adapted from: Autobiography in Five Short Chapters by Portia Nelson I I walk down the street. There is a deep hole in the sidewalk. I fall in I am lost … I am helpless It takes forever to find a way out.

II I walk down the same street. There is a deep hole in the sidewalk II I walk down the same street. There is a deep hole in the sidewalk. I pretend I don’t see it. I fall in again. I can’t believe I am in the same place. It still takes a long time to get out.

III I walk down the same street. There is a deep hole in the sidewalk III I walk down the same street. There is a deep hole in the sidewalk. I see it is there. I still fall in … it’s a habit. My eyes are open. I know where I am. I get out immediately.

IV I walk down the same street. There is a deep hole in the sidewalk IV I walk down the same street. There is a deep hole in the sidewalk. I walk around it. V I walk down another street.

Behavior change theories with interpersonal focus Social Cognitive Theory (SCT) ** Social Network Theory (SNT) Social Capital Theory

Social Cognitive Theory (SCT) A behavior change theory with an Interpersonal / Social network focus.

Characteristics of the Person Reciprocal Determinism Characteristics of the Person Environment in which the behavior is performed Behavior of the person

Constructs of SCT Behavior Capacity Expectations Expectancies Self-Control / Self- Regulation Self-Efficacy Reinforcement Observational Learning Emotional Coping Responses

Principles of Modeling Attention Remembering Repetition Motivation Model Similarity Age Gender Status Competence

Reinforcement Any action or event that increases the desired behavior Present something positive Money New clothes Remove something negative Nagging Teasing

Punishment Any action or event that decreases the likelihood that the desired behavior will occur. Present something negative Criticize Policies or laws Remove something positive Praise Privilege

Organizational/Institutional Social Networks Interpersonal Framework: Social Determinants of Health Political Population Level Community Organizational/Institutional Social Networks Interpersonal Individual Ecological Model

Behavior theories with community focus Diffusion of Innovation Theory (DF) ** AKA: Diffusion Theory Community Readiness Model (CRM)

Diffusion of Innovations Theory Rogers, 1983 A behavior change theory with a community focus

Diffusion of Innovations The progressive adoption by members of a community or society of an idea or practice over time.

Categories of Adopters Innovators (<3%) Independent, risk-takers, eager to try new ideas Not necessarily the most respected members of the community Seek info on their own, rely on their own judgment in making decisions about adoption Try out new ideas and provide the first tests of the utility of the innovation

Categories of Adopters Early Adopters (14%) Respected members of the community Opinion leaders Powerful influence on other potential adopters Trendy … like to be up on what is good and new Seen as opinion leaders

Categories of Adopters Early Majority (34%) Greatly influenced by mass media and opinion leaders By virtue of their numbers, they begin to form a new norm Lots of contact with peers, but don’t hold leadership positions.

Categories of Adopters Late Majority (34%) Skeptical of change Tend to wait until an innovation is established as a norm before adopting Motivation is greatly influenced by peers Don’t like risk and uncertainty

Categories of Adopters Laggards (16%) Very traditional and conservative Tend to have less education and lower SES Socially and geographically mobile Narrow and restricted communication networks Suspicious of innovations and adverse to risk

Adoption Curve

Determinants of Diffusion’s Speed and Extent Is the innovation better than what it will replace? Does the innovation fit with the intended audience? Is the innovation easy to use? Can the innovation be tried out before adopting? Are the results of the innovation observable and easily measured?

A few more pieces Predisposing, Reinforcing, and Enabling Factors Barriers to change PRECEDE/PROCEED behavioral diagnosis phase

Predisposing Factors Provide the rationale or motivation for a person or group to act KAB (knowledge, attitudes, beliefs) Personal preferences Existing skills Self-efficacy beliefs Individual level theories Intrapersonal are most appropriate for addressing these factors.

Reinforcing Factors Factors that provide reinforcement and reward for actions and encourage repetition of the action Social support Peer influence Significant others (family, spouse, partner) Employers, teachers, health providers, community leaders, decision-makers

Reinforcing Factors Continued Interpersonal level theories are most appropriate in addressing these factors Interpersonal level theories suggest communication channels (e.g. significant others or social networks) and methods (e.g. incentives or social supports).

Enabling Factors Factors that provide the means or make the action possible. Availability of programs or services or skills training Accessibility of programs or services or skills training

Activity Pick a theory (Health Belief Model, Theory of Planned Behavior, Transtheoretical Model, Social Cognitive Theory OR Diffusion of Innovation Theory) Map out the constructs of the theory Where do these constructs fit into the Ecological Model? Give a brief (at least one sentence) explanation of each construct Provide examples for each construct that relates to your topic List as many predisposing, reinforcing, and enabling factors as you can think of for the topic. Keep this model for the next class.