theory
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THEORY
What is theory?
Theory
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:
Major ideas
Constructs: Concepts that have been developed and
defined for use in a particular theory
More theory
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
Individual
Interpersonal
Institutional orOrganizational
Community
Public Policy
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
Strategies to activate one’s “readiness”
Self-Efficacy Confidence in one’s ability to take action
Health Belief Model
Perceived Susceptibility & Perceived Seriousness
Perceived Threat
Likelihood of taking recommended action
Cues to Action
Modifying Factors: age, race, ethnicity, SES, personality
Outcome Expectations: Perceived Benefits vs.
Perceived Risks/Barriers
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
TRA
Attitude toward behavior
Subjective Norm
Intention Behavior
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.
TPB
Attitude toward the behavior
Subjective Norm
Intention Behavior
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)
Precontemplation
Contemplation
Preparation
Action
Maintenance
Decisional Balance
Decisional Balance
Self-Efficacy
Self-Efficacy
Transtheoretical Model (TTM)
Between every stage, the client needs to have decisional balance and self-efficacy
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 TTMDo you exercise regularly?
No Yes
Do you intend to in the next 30 days?
Have you been doing so for more than 6 months?
No Yes No Yes
Do you intend to in the next six months?
No Yes
Precontemplation
Contemplation
Preparation Action Maintenance
(Pearson Ed, 2012)
Adapted from:Autobiography in Five Short Chapters
by Portia Nelson
II walk down the street.
There is a deep hole in the sidewalk.I fall in
I am lost … I am helplessIt takes forever to find a way out.
III 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.
IIII 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.
IVI walk down the same street.
There is a deep hole in the sidewalk.I walk around it.
VI 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.
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
Framework:Social Determinants of Health
Community
Social Networks Interpersonal
Individual
Organizational/Institutional
PoliticalPopulation Level
Ecological ModelEcological 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.
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 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
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
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