THEORY

What is theory?

Theory

Theory

Generality

Testability

Shape and boundaries, but not specific topic or content

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 components of theory

Constructs: Concepts that have been developed and

defined for use in a particular theory

Variables

Variables The measurable forms of constructs

Variables are a measure of a specific construct in a specific situation.

Models

Putting it together

A personal belief is a CONCEPT that has been shown to relate to various health behaviors.

Using a THEORY that includes the concept of personal beliefs helps explain why young men don’t think they will ever get testicular cancer.

More theory

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

Behavior Change Theories

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

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 with individual focus

The Health Belief Model (HBM)

The Transtheoretical Model (TTM)

Theory of Planned Behavior (TPB)

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.

TPBAttitude

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 care is still in the garage!”

Not thinking about changing behavior in the next six months.

May be unaware of risks or problems. Needs some work “under the hood.”

Contemplation

“The engine is started, but we’re not quite in gear!”

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

Preparation

“We’re in gear and ready for short trips.”

Ready to take action in the very near future (next 30 days)

Have a plan of action Experimenting with new behaviors

Action

“We’re on the road on a regular basis.”

Actively engaged in new behavior(s) for less than six months.

Efforts are sufficient to reduce risk of disease

Maintenance

“We’re on cruise control.”

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)

Strategies/process to get from one stage to the next. Precontemplation to Contemplation

Awareness New information Persuasive communications Experiences

Strategies

Contemplation to Preparation Knowledge acquisition

Information Persuasive communications Experiences

Strategies

Preparation to Action Deciding

How-to information Skill development Attitude change

Strategies

Action to Maintenance Skills Reinforcement Support Self-Management Attitude and attribution change

Strategies

Maintenance Continuation

Relapse prevention skills Self-Management Social and environmental support

Precontemplation

Contemplation

Preparation

Action

Maintenance

Decisional Balance

Decisional Balance

Self-Effic

acy

Self-Effic

acy

Transtheoretical Model (TTM)

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

Adapted from:

Autobiography in Five Short Chaptersby 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.

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

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 Wednesday’s class.