1. Epi 246 Intro to Theories of Health Behavior/ Health Behavior Change Focusing on Individuals’ Behavior Margaret Handley, PhD MPH Assistant Professor Dept. Epidemiology and Biostatistics and Center for Vulnerable Populations, DGIM-SFGH April 1, 2010

2. Outline of Today’s Lecture 1. Course overview and structure 2. Behavioral theory’s role in implementation sciences 3. A few to start: Health Belief Model Theory of Planned Behavior Trans-theoretical Model-Stages of Change 4. Examples/ Discussion

3. Implementation & Dissemination Sciences “Implementation and dissemination sciences is research aimed at enhancing the adoption and appropriate adaptation (e.g. translation) of best evidence-based practices and policies in clinical care and public health; and the development of best evidence through community engagement.” -UCSF TICR Program in Implementation and Dissemination Sciences

4. Epi 246 Learning Objectives 1.Using an ecological frame for how behaviors change in society, understand how health behavior theory focused on individuals is critical to implementation and dissemination sciences/ real world application 2. Understand key behavioral theory components with strong evidence for effect and HOW they are used 3. Be able to apply different components to planning, implementing and evaluating health-related behavior and behavior change interventions 4. Understand gaps in different approaches to theory

5. Which Health Behavior/Behavior Change Theories are Included? 1.Psychological theories with evidence base in health behavior and behavior change 2. Theories that focus on health communication 3. Theories on dissemination of information 4. Theories related to behavioral economics 5. Theories of community building/empowerment

6. Which Models and Frameworks? 1.Ecological Models 1.Logic models and Intervention Mapping 1.Models with planning and evaluation components 4. Models that integrate across multiple levels

7. Links between Behavior Theory and Improving Evidence-Based Practice “Increasing evidence suggests that public health and health promotion interventions based in social and behavioral sciences are more effective than those lacking a theoretical base” – Glanz and Bishop “Making research more theory-based will improve evidence-based practice” -Green Glanz K and Bishop D. Annu Rev Public Health. 31:3990418. 2010 Green, L.W. American Journal of Public Health 96(3): 406-409, Mar. 2006.

8. Learning Objectives – Lecture 1 1. Understand why health behavior change theory is helpful for implementation and dissemination sciences research and real world application 2. Understand components of Health Belief Model, Theory of Planned Behavior and Trans- Theoretical Model, and how they can be integrated into ecological models 3. Be able to apply components of these theories to health-related behaviors – including both understanding behavior and intervention planning/evaluation

9. Evidence Continuum – Begin with Theory Eccles, M e al, 2005. J Clin Epi 107-112. Medical Research Council, 2000

10. An Individual or a Structural/Ecological Perspective?

11. A Public Health Ecological Perspective “The use of collective action to support personal responsibility is central to public health” Brownell et al, Health Affairs 2010

12. HOW Individual –Focused Health Behavior Theories Can Be Useful 1. Provide a road map for answering difficult questions on which behaviors to target and for whom e.g. Do you target the providers’ behavior re guidelines or focus on structural or policy barriers? Or both? 2.Can understand environmental factors that reinforce or undermine individual behaviors e.g. Neighborhood ‘walkability’, # of TVs per house 3. Help understand the mechanisms underlying effective interventions – then you can tailor/scale up interventions NIH Science of Behavior Change, Meeting Summary, June 15-16, 2009

13. Behavioral Sciences Theory Theory – a set of inter-related concepts, definitions, and propositions that explain or predict events or situations (can also specify relationships among these variables) Behavioral Sciences Theory an amalgamation of approaches, methods, and strategies/tools from social and health sciences that is accessible to both researchers and practitioners -- Glanz and Bishop, Ann Rev Public Health 2010

14. Intensity Continuum for Use of Theory 1. Informed by theory – Framework or constructs identified, but not specifically applied 2. Applied theory - Framework or constructs identified, and at least one construct specifically applied 3. Testing theory - Framework or constructs identified and constructs are tested against one another 4. Building/creating theory – Developing new or revised theory using constructs specified, measured, and analyzed in a study Increasing level of theory in research Painter, et al, 2008

15. A Generalized Ecological Perspective K Glanz and B Rimmer. Theory at a Glance. NCI, 2005

16. Picture from Glanz book

17. 1.Risk appraisal 2.Self perception 3.Emotions 4.Relationships & social influences 5.Environment, community, cultural & structural influences e.g. SOCIAL NORMS e.g. SELF-EFFICACY e.g. PERCEIVED CONSEQUENCES e.g.FOOD POLICIES, TRANSPORTATION

18. K Glanz and B Rimmer. Theory at a Glance. NCI, 2005.

19. Health Belief Model Focus:Key Concepts Individuals’ perceptions of the threat posed by a health problem, The benefits of avoiding the threat, and factors influencing the decision to act - Perceived susceptibility - Perceived severity - Perceived benefits - Perceived barriers - Cues to action - (Self-efficacy) Strong Health Beliefs translates into MOTIVATION and ACTION to prevent, screen for or control illness

20. Action FOCUS ON INDIVIDUAL BELIEFS THAT AFFECT MOTIVATION Perceived susceptibility, perceived severity (combined = perceived THREAT) Perceived benefits Perceived barriers Perceived self-efficacy Motivation Cues to action MODIFYING FACTORS AND ENVIRONMENT Age, gender, socioeconomics, Knowledge personality Health Belief Model

21. Example: TB Treatment Adherence Munro et al, 2007. BMC Public Health; Munro et al, 2007. PlosMedicine

22. Examples- Using HBM ConceptCondom Use EducationSTI Screen or HIV Testing 1. Perceived Susceptibility Youth believe they can get STIs or HIV or create pregnancy. Youth believe they may have been exposed to STIs or HIV. 2. Perceived Severity Youth believe consequences of getting STIs or HIV or creating a pregnancy are significant enough to try to avoid. Youth believe consequences of having STIs or HIV without knowledge or treatment are significant enough to try to avoid. 3. Perceived Benefits Youth believe that the recommended action of using condoms would protect them Youth believe that the recommended action of getting tested for STIs and HIV would benefit them 4. Perceived Barriers Youth identify their personal barriers to using condoms and explore ways to eliminate or reduce these barriers Youth identify their personal barriers to getting tested and explore ways to eliminate or reduce these barriers 5. Cues to Action Reminder cues for action - incentives or reminders 6. Self- Efficacy Youth confident in using a condom correctly in all circumstances Youth receive guidance or training (such as practice in making an appointment).

23. Action APPLICATIONS FOR CHANGING INDIVIDUAL BELIEFS Perceived THREAT: personalize risk, educate on risk Perceived benefits: operationalize specific actions and benefits Perceived barriers: reduce perceptions, problem-solve, incentives Perceived self-efficacy: support and training, goal setting INCREASE MOTIVATION Cues to action: Increase awareness, media/marketing, prompts, reminders Health Belief Model

24. Theory of Planned Behavior Focus:Key Concepts Individual’s attitude towards a behavior, perceptions of norms, and beliefs about ease of difficulty of changes Behavioral intention: - Attitude - Subjective norm - Perceived control and Self-efficacy Strong Planned Behavior translates into INTENTION to ACT to prevent, screen for or control illness

25. Action FOCUS ON BELEIFS THAT AFFECT INTENTION Beliefs, Evaluation of Behavioral Outcomes (combined=ATTITUDES), normative beliefs, Motivation (combined=SUBJECTIVE NORM) Control beliefs, perceived power (self-efficacy) (combined=PERCEIVED CONTROL) MODIFYING FACTORS AND ENVIRONMENT Demographic Attitudes to target Behavior Personality INTENTION Theory of Planned Behavior

26. Action APPLICATIONS TO CHANGE FACTORS THAT AFFECT INTENTION ATTITUDES: Increase exposure to pro-behavior attitudes SUBJECTIVE: Social marketing to ‘naturalize’ desired behavior NORM PERCEIVED CONTROL: Identify behaviors within control, then train and guide, goal setting, reinforce, demonstrate skills INCREASE INTENTION Theory of Planned Behavior

27. Example- Factors influencing compliance with guidelines for induced abortion Measured behavioral intention, attitudes, subjective norm, perceived behavioral control, open-ended barriers Perceived behavioral control was low, perceptions that organizational barriers were important Interventions were recommended to target: Professional control over appointments, staff social marketing re 5 day window, training staff in family planning, more contraceptive choices available Foy R et al Intl J Qual in Healthcare 2005

28. Example- Overall Model to Guide the Study Process of Care Quality Indicator Intermediate health outcomes: HA1C, LDL Blood pressure Retinopathy Nephropathy Patient-Important Outcomes 1. Quality of Life 2. Disabilities 3, Actual adverse health events 4. Functional status 5. Goal attainment 6. Utilization Clinician Factors (Figure 2) Patient Risk Status Age, Co-morbidities Clinical Intervention Patient Factors (Figure 2)

29. Example - Application of TPB to Adherence to Screening Recommendations Attitude toward adherence Adherence intention Beliefs that clinician adherence to recommendations will lead to outcomes and the evaluation of such outcomes Normative beliefs that recommended services should be performed and comply CLINICIAN: External variables: Demographics Attitudes towards targets Attitudes towards patients Subjective Norm PATIENT: External variables: Demographics Attitudes towards targets Attitudes towards providers Beliefs that patient adherence to recommendations will lead to outcomes and the evaluation of such outcomes Normative beliefs that recommended services should be performed and comply Attitude toward adherence Subjective Norm

30. http://www.engenderhealth.org/res/onc/hiv/preventing/hiv6p3.html

31. Prochaska-Driven Intervention Design Pre-Contemplation Preparation Contemplation Action Maintenance Mass Media, Motivational Interviewing, etcSkill-Building, Social Support, etc. Intervention Strategies Education; FeedbackCQI; Incentives; DetailingRegulatory; CQI

32. Transtheoretical Model/Stages of Change ActionMaintenanceContemplationPreparationPre- Contemplation PROCESSESPROCESSES Consciousness raising Dramatic relief Env. reevaluation Self-reevaluation Self-liberation Counterconditioning Helping relationships Reinforcement management Stimulus control *Social liberation- not stage specific

33. Applications to Affect Stage with TTM Chilvers, R British Journal of Psychiatry, 2002

34. Example – Testing/Building/Creating a Hybrid Theory for Understanding Mammography Utilization Testing views about: perceived benefits, susceptibility, self-efficacy, intention and subjective norms among Filipina and Latina women using qualitative interviews and the role of context Found constructs of: relational culture, social capital, and transnationalism, that then were applied to understanding social norms, self-efficacy, and perceived susceptibility in this population Augmentation of Behavioral Theories to Take Diversity Into Account Pasick R, et al. Health Ed and Behavior, 2009

35. Homework For students applying theory to an active project For one of the behaviors relevant to your outcome, complete a table or diagram relating variables relevant to your behavior to theories presented in class. Describe which theory they relate to and your rationale for choosing. How can you expand on these individual factors, to include others at multiple levels? For students not applying theory to an active project Select a behavior of interest to your work. Which levels do you think have the most significant roles? Who would you engage to develop a formative project to understand more about this behavior and how could you include elements of the theories from class? Using examples from theories or frameworks presented in class, create a table or diagram to organize related concepts. Which theory do they relate to and how would you measure them?

36. How am I supposed to think about the consequences before they happen?