Theory

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Theory
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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)

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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)

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Theory

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

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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

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Concepts Constructs

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

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Models

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

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More theory

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

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Planning Models

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

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Planning Models

• PRECEDE/PROCEED
• MATCH
• CDCynergy

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PRECEDE/PROCEED Model
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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

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MATCH

• Figure 4.16 MATCH Multilevel Approach To
  Community Health

(Pearson Ed, 2012)
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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)
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CDCynergy
P 6 Implement Plan
P 3 Plan Intervention (Is communication dominant
or supportive?)
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)
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Generalized Model for Program Planning (GMPP)

• Figure 4.18 Generalized Model for Program
  Planning

(Pearson Ed, 2012)
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Theories and Levels of Influence

• Behavior is very complex
• Influenced and supported in multiple ways

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The Ecological Model

• Emphasizes the links and relationships among
  multiple factors (or determinants) affecting
  health

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Ecological Model
Public Policy
Community
Institutional or Organizational
Interpersonal
Individual
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Individual / Intrapersonal factors

• Knowledge, attitudes, beliefs (KAB)
• Skills
• Motivation
• Self-concept
• Age, gender, genetics

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Interpersonal factors

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

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Institutional or organization factors

• Educational system
• Access to health care
• Social Interactions

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Community factors

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

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Public Policy Factors

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

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Behavior Change Theories

• The specific route(s) you will take to reach your
  destination they suggest a road to follow.

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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

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Health Belief Model (HBM)

• Developed in the early 1950s by social
  psychologists in the U.S. Public Health Service.
• Hochbaum Rosenstock
• TB screening

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Constructs of HBM

• Perceived threat
• Perceived susceptibility
• Beliefs about ones chances of getting a
  condition
• Perceived severity
• Beliefs about how serious the condition might be

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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

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Constructs of HBM

• Cues to Action
• Strategies to activate ones readiness
• Self-Efficacy
• Confidence in ones ability to take action

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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
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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

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TRA Cont.

• Beliefs and Subjective Norms help predict
  Intentions
• Your Intentions predict your actual Behavior

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TRA
Attitude toward behavior
Intention
Behavior
Subjective Norm
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Theory of Planned Behavior (TPB)

• Developed by Fishbein Ajzen
• An extension of the Theory of Reasoned Action
  (TRA)

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TPB versus TRA

• Adds the construct
• Perceived Behavioral Control
• Belief about personal control in combination with
  belief about the ones ability to do what needs
  to be done.
• Actual Behavioral Control have the skills and
  resources needed to quit.

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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.

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TPB
Attitude toward the behavior
Intention
Behavior
Subjective Norm
Perceived Behavioral Control
Actual Behavioral Control
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Transtheoretical Model (TTM)

• AKA Stages of Change
• Developed by Prochaska DiClemente
• Major Constructs
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Decisional Balance
• Self-Efficacy

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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.

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Contemplation

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

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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

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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

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Maintenance

• Shoes go on every day.
• Sustaining the behavior change for over 6 months.

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Decisional Balance

• The costs and benefits of changing.

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Self-Efficacy

• Confidence that one can be successful in the new
  behavior across different challenging situations.

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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)

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

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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)
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Adapted fromAutobiography in Five Short
Chaptersby 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.

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• II
• I walk down the same street.
• There is a deep hole in the sidewalk.
• I pretend I dont see it.
• I fall in again.
• I cant believe I am in the same place.
• It still takes a long time to get out.

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

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• 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.

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Behavior change theories with interpersonal focus

• Social Cognitive Theory (SCT)
• Social Network Theory (SNT)
• Social Capital Theory

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Social Cognitive Theory (SCT)

• A behavior change theory with an Interpersonal /
  Social network focus.

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

• Behavior Capacity
• Expectations
• Expectancies
• Self-Control / Self-Regulation

• Self-Efficacy
• Reinforcement
• Observational Learning
• Emotional Coping Responses

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Principles of Modeling

• Attention
• Remembering
• Repetition
• Motivation

• Model Similarity
• Age
• Gender
• Status
• Competence

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Reinforcement

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

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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

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Framework Social Determinants of Health
Political Population Level
Community
Organizational/Institutional
Social Networks Interpersonal
Individual
Ecological Model
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Behavior theories with community focus

• Diffusion of Innovation Theory (DF)
• AKA Diffusion Theory
• Community Readiness Model (CRM)

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Diffusion of Innovations Theory

• Rogers, 1983
• A behavior change theory with a community focus

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Diffusion of Innovations

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

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Categories of Adopters

• Innovators (lt3)
• 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

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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

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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 dont hold
  leadership positions.

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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
• Dont like risk and uncertainty

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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

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Adoption Curve
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Determinants of Diffusions 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?

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A few more pieces

• Predisposing, Reinforcing, and Enabling Factors
• Barriers to change
• PRECEDE/PROCEED behavioral diagnosis phase

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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.

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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

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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).

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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

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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.