Transcript Sp14 HE385 Theory

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)
Theories are used to …

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
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:
 Major

ideas
Constructs:
 Concepts
that have been developed and defined for
use in a particular theory
More theory

“Habit is habit, and not to be flung out of the
window, but coaxed downstairs a step at a time.”
 Mark Twain
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
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Knowledge, attitudes, beliefs (KAB)
Skills
Motivation
Self-concept
Age, gender, genetics
Interpersonal factors

Social support / social networks
 Formal
and informal
 Family,

friends, peers
Social norms, cultural environment
Institutional or organization factors

Social institutions with organizational characteristics
and formal (and informal) rules and regulations for
operations. (ACHA, 2012)
Community factors

The geographic, cultural or social community.
 May
include:
 Community
 Local
organizations
laws
 Physical characteristics/attributes of location
 Available (or unavailable) services
Public Policy Factors

Local, state, national and global laws and policies.
(ACHA, 2012)
 May
promote or restrict behavior
Ecological Model
Concept
Definition
Intrapersonal Factors
Individual characteristics that influence behavior, such
as knowledge, attitudes, beliefs, and personality traits.
Interpersonal Factors
Interpersonal processes, and primary groups including
family, friends, peers, that provide social identity,
support, and role definition.
Institutional/Organizational Factors
Rules, regulations, policies, and informal structures,
which may constrain or promote recommended
behaviors.
Community Factors
Social networks and norms, or standards, which exist as
formal or informal among individuals, groups, and
organizations.
Public Policy
Local, state, federal policies and laws that regulate or
support healthy actions and practices for disease
prevention, early detection, control, and management.
NIH, Theory at a Glance
Ecological Model
Public Policy
Community
Institutional or
Organizational
Interpersonal
Individual
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
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The Health Belief Model (HBM) **
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The Transtheoretical Model (TTM) **
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Theory of Planned Behavior (TPB) **
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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
 Beliefs
about one’s chances of getting a condition
 Perceived
 Beliefs
susceptibility
severity
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
 Beliefs
risks/barriers
about the “costs” of taking the advised action
Constructs of HBM

Cues to Action
 Strategies

to activate one’s “readiness”
Self-Efficacy
 Confidence
in one’s ability to take action
Health Belief Model
Modifying Factors:
age, race, ethnicity,
SES, personality
Perceived
Susceptibility
& Perceived
Seriousness
Perceived
Threat
Cues to Action
Outcome Expectations:
Perceived Benefits vs.
Perceived Risks/Barriers
Likelihood of taking
recommended action
Self-efficacy
Health Belief Model
45 y/o Caucasian
male, married, 2
children, works fulltime, desk job, does
not seek health
information
Strong family
history of heart
disease /
strokes; feels it
could “happen
to him” and
ultimately lead
to serious
disability/death
Perceived
Threat
Doctor diagnosed him
as hypertensive, started
on medication
Outcome Expectations:
Perceived benefits: no HTN
medication, delay or
prevent heart
disease/stroke, live longer,
better quality life.
Perceived barriers/risks:
time, money, injury?
Likelihood of taking
recommended action
Self-efficacy:
moderate
Health Belief Model
Construct
Definition
Perceived
Susceptibility
One’s opinion of chances of getting Personalize risk based on a person’s
a condition.
feature or behavior; heighten
perceived susceptibility if low.
Perceived
Severity
One’s opinion of how serious a
condition and its effects are.
Perceived
Benefits
One’s opinion of the efficacy of the Define action to take; how, where,
advised action to reduce risk /
when; clarify the positive effects to
seriousness of impact.
be expected.
Perceived
Barriers
One’s opinion of the tangible and
psychological costs of the advised
action.
Identify and reduce barriers through
reassurance, incentives, assistance.
Cues to Action
Strategies to activate “readiness”
Provide how-to information, promote
awareness, reminders.
Self-Efficacy
Confidence in one’s ability to take
action.
Provide training, guidance in
performing action.
NIH, Theory at a Glance
Application
Specify consequences of the risk and
the condition.
Theory of Reasoned Action (TRA)
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Constructs:
 Attitude
toward the behavior
 Beliefs
about the behavior
 Evaluation of behavioral outcomes
 Subjective
 What
norms
others think about your behavior
 How motivated you are to comply with the expectations of
others
TRA Cont.
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Beliefs and Subjective Norms help predict Intentions
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Your Intentions predict your actual Behavior
TRA
Attitude
toward
behavior
Intention
Subjective
Norm
Behavior
Theory of Planned Behavior (TPB)
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Developed by Fishbein & Ajzen
An extension of the Theory of Reasoned Action
(TRA)
TPB versus TRA
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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.
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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.
TPB
Attitude
toward the
behavior
Intention
Behavior
Subjective
Norm
Perceived
Behavioral
Control
Actual
Behavioral
Control
TPB
Healthy eating
takes time, extra
money and a lot
of energy
Friends / family
do not exercise
and junk food is
always
abundant
“Not much
I can do”
Intention
Eating
healthier/
exericse
Nearby grocery stores
often have good sales,
lives near farmer’s market.
Lives near park and
walking trails
Theory of Planned Behavior
Construct
Definition
Application / Approach
Behavioral
Intention
Perceived likelihood of
performing behavior
Are you likely or unlikely to perform the
behavior?
Attitude
Personal evaluation of the
behavior
Do you see the behavior as good, neutral or
bad?
Subjective
Norm
Beliefs about whether key
Do you agree or disagree that most people
people approve or
approve of/disapprove of the behavior?
disapprove of the behavior;
motivation to behave in a way
that gains their approval
Perceived
Behavioral
Control
Belief that one has, and can
exercise, control over
performing the behavior
NIH, Theory at a Glance
Do you believe performing the behavior is up
to you, or not up to you?
Transtheoretical Model (TTM)
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AKA: Stages of Change
Developed by Prochaska & DiClemente
Major Constructs:
Precontemplation
 Contemplation
 Preparation
 Action
 Maintenance
 Decisional Balance
 Self-Efficacy
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Precontemplation
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“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
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“Shoe shopping”
Seriously thinking about making a behavior change,
but have not yet made a commitment to action
Preparation
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“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
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“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
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“Shoes go on every day.”
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Sustaining the behavior change for over 6 months.
Decisional Balance
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The costs and benefits of changing.
Self-Efficacy
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Confidence that one can be successful in the new
behavior across different challenging situations.
Relapse
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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)
Precontemplation
Transtheoretical
Model (TTM)
Decisional Balance
Contemplation
Preparation
Between every stage,
the client needs to have
decisional balance and
self-efficacy
Decisional Balance
Action
Maintenance
Stages of Change (TTM)
Construct
Definition
Application
Pre-contemplation
Unaware of problem, hasn’t thought
about change.
Increase awareness of need for
change, personalize information
on risks and benefits.
Contemplation
Thinking about change in the near
future.
Motivate, encourage to make
specific plans.
Preparation
Making a plan to change.
Assist in developing concrete
action plans, setting gradual
goals.
Action
Implementation of specific action
plan.
Assist with feedback, problem
solving, social support,
reinforcement.
Maintenance
Continuation of desirable actions, or
repeating periodic recommended
step(s)
Assist in coping, reminders,
finding alternatives, avoiding
relapses
NIH, Theory at a Glance
Groups with this theory: don’t forget a relapse plan!
Pro’s of TTM
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Encourages less “labeling” terms.
 (Precontemplation
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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?
Yes
No
Do you intend to in
the next six months?
No
Preparation
Have you been doing so
for more than 6 months?
No
Yes
Action
Maintenance
Yes
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.
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.
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.
I walk around it.
V
I walk down another street.
Behavior change theories with
interpersonal focus
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Social Cognitive Theory (SCT) **
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Social Network Theory (SNT)
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Social Capital Theory
Social Cognitive Theory (SCT)

A behavior change theory with an Interpersonal /
Social network focus.
Reciprocal Determinism
Characteristics
of the Person
Environment in
which the behavior is
performed
Behavior of
the person
More constructs of SCT

Behavior Capacity
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Self-Efficacy
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Expectations
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Reinforcement
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Expectancies
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Self-Control / SelfRegulation
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Observational
Learning
Emotional Coping
Responses
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
 Remove
or laws
something positive
 Praise
 Privilege
Social Cognitive Theory
Construct
Definition
Application
Reciprocal
Determinism
Behavior changes result from
interaction between person
and environment
Involve the individual and relevant
others; work to change the environment,
if warranted.
Behavioral
Capacity
Knowledge and skills to
influence behavior
Provide information and training about
action.
Expectations
Beliefs about likely results of
action
Incorporate information about likely
results of action in advice.
Self-Efficacy
Confidence in ability to take
action and persist in the action
Point out strengths; use persuasion and
encouragement; approach behavior
change in small steps.
Observational
Learning
Beliefs based on observing
others like self and/or visible
physical results
Point out others’ experience, physical
changes; identify role models to
emulate.
Reinforcement
Responses to a person’s
behavior that increase or
decrease the chances of
recurrence
Provide incentives, rewards, praise;
encourage self-reward; decrease
possibility of negative responses that
deter positive changes.
NIH, Theory at a Glance
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.
Adoption Curve
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
 Don’t
is greatly influenced by peers
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
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?
Diffusion of Innovations Theory
Concept
Definition
Application
Relative advantage
The degree to which an innovation is
seen as better than the idea, practice,
program, or product it replaces.
Point out unique benefits;
monetary value convenience,
time saving, prestige, etc.
Compatibility
How consistent the innovation is with
Tailor innovation for the
values, habits, experience, and needs of intended audience’s values,
potential adopters.
norms, or situation.
Complexity
How difficult the innovation is to
understand and/or use.
Create
program/idea/product to be
uncomplicated, easy to use
and understand.
Trialability
Extent to which the innovation can be
experimented with before a
commitment to adopt is required.
Provide opportunities to try on
a limited basis, e.g., free
samples, introductory sessions,
money-back guarantee.
Observability
Extent to which the innovation provides
tangible or visible results.
Assure visibility of results:
feedback or publicity.
NIH, Theory at a Glance
Summary of Theories
Theory
Focus
Key Concepts
Health Belief
Model
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/barriers
Cues to action
Self-Efficacy
Transtheoretical
Model
Individuals’ motivation and
readiness to change a problem
behavior.
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Theory of
Planned
Behavior
Individuals’ attitudes toward a
behavior, perceptions of norms,
and beliefs about the ease or
difficulty of changing.
Behavioral intention
Attitude
Subjective norm
Perceived behavioral control
NIH, Theory at a Glance
Summary of Theories continued
Theory
Focus
Key Concepts
Social Cognitive Theory
Personal factors,
environmental factors, and
human behavior exert
influence on each other.
Reciprocal determinism
Behavioral capacity
Expectations
Self-efficacy
Observational learning
Reinforcements
Diffusion of Innovations
Theory
How new ideas, products, and
practices spread within a
society or form one society to
another.
Relative advantage
Compatibility
Complexity
Trialability
Observability
NIH, Theory at a Glance
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
these factors.
are most appropriate for addressing
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
Enabling Factors

Factors that provide the means or make the action
possible.
 Availability
 Accessibility
of programs or services or skills training
of programs or services or skills training
Writing Objectives


Objectives start with the word “to” followed by an
action verb.
Specify a single, key action to be accomplished
 The

Specifies a target date
 The


What / how much
When
Avoids the How and Why
Realistic and attainable
Objectives

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S: specific
M: measurable
A: attainable
R: realistic
T: timely
Examples of objectives



To decrease soda intake by one soda a week and
be soda free by December 1st, 2012.
To increase running distance 1 mile every week in
order to run a marathon on March 10th, 2013.
To cook a new vegetable recipe once a week
through December 5th, 2012.