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