Theories of behavior change: Application to sexual and domestic violence prevention programming

1. Theories of behavior change:Application to sexual and domestic violence prevention programming Emily F. Rothman, ScD Boston University School of Public Health

2. Agenda • What are theories of behavior change (ToBC) and why do they matter? • Examples of ToBC success from other topics • Four leading ToBC theories • How to generate a program from a ToBC • Your questions/comments

3. The Dangers of Relying on Intuitive Thinking and Common sense

4. What is the rationale?

5. “It makes sense” • “It sounds good” • “It would have straightened me out” • “They will be so scared that they’ll realize the error of their ways” • From the Web site: “Apart from becoming more disciplined, the fear of coming back to the boot camp will prevent teens from misbehaving again.”

7. Putting Resources Behind Boot Camps: • Wastes money • Doesn’t address the problem • May make the problem worse • Harms young people

8. Putting Resources Behind Boot Camps: • Wastes money • Doesn’t address the problem • May make the problem worse • Harms young people BEFORE WE THROW STONES… HOW DO WE KNOW THAT WE AREN’T DOING THE SAME THING?

9. An analysis of 18 different studies found that school programs that promote physical activity for kids DO NOT reduce their body mass index

13. What’s the message?

14. What’s the message?

15. What’s the message?

16. What’s the message?

17. What’s so great about ToBC? • They explain human behavior • Theory-based health behavior change programs are thought to be more effective than those that do not use theory

18. The Beer Experiment proves we’re crazy! • Blind test: 59 percent of the participants actually preferred the beer with vinegar to an unadulterated glass of Sam Adams. • In another test, however, in which participants were told ahead of time which glass of beer had vinegar in it, the proportion preferring the vinegar beer dropped to 30 percent. • give the same ice cream two different labels, "low fat" and "regular fat," and people will say the high-fat product tastes better. And they'll eat more of it.

19. Lingo • Sometimes we use the word “model” instead of theory • Very minor differences between those things • There are other kinds of theory in the world: • Economic theory • Physics theory (theory of relativity?) • Social theory (Feminist theory, Marxist theory) Today we are just talking about a handful of theories that can be used to describe how and why people change their behavior.

20. Commonly Used Theories in Health Behavior Research & Health Promotion Practice • Health Belief Model • Social Cognitive Theory • Construct of Self-Efficacy • Theory of Reasoned Action • Theory of Planned Behavior • Stages of Change/ Transtheoretical Model • Precaution Adoption Process Model

21. Example of ToBC success Problem:Lack of condom use among sex workers Individual factors: Workers low perceived susceptibility and low knowledge about HIV Environmental constraint: Perceived pimps attitudes’ towards condoms use Morisky DE, Pena M, Tiglao TV, et al. The impact of the work environment on condom use among female bar workers in the Philippines. Health EducBehav2002; 29:461-472

22. Example of ToBC success Theory:Diffusion of Innovation How: Selected sex workers educate peers about HIV How: Educate bar managers about importance of condoms

23. Example of ToBC in practice Problem: Middle school youth overweight and inactive Individual factors: Didn’t prioritize exercise; wasn’t on their radar screen Environmental constraint: Bad gym facilities Grim, ML & Pazmino-Cevallos, M. (2007). Using social cognitive theory in physical education: an example of the translation of research into practice. The Journal of the Virginia Association for Health, Physical Education, Recreation and Dance.

24. Example of ToBC in practice Theory: Social cognitive theory How: • Short education sessions (5-10 min) • Self-monitoring with activity logs • Goal-setting and rewarding yourself • Newsletters to parents • Fitness buddy • Scavenger hunt for facilities • Reflection on time spent per day • Practice taking heart rate • Tailoring for enjoyment

25. Social cognitive theory • Behavior • Environment • Person

26. Social cognitive theory • Behavior • Opportunities and social support • Person

27. Social cognitive theory • Behavior • Emotional coping • Self-efficacy • Problem solving skills • Expectations • Expectancies • Environment

28. Social cognitive theory • Reinforcements • Observational learning • Environment • Person

29. Health Belief Model http://ww2.fhi.org/en/aids/aidscap/aidspubs/behres/bcr4theo.html • Background • (education, age, sex, race/ethnicity) • Expectations • Perceived benefit of actions • Perceived barriers to action • Perceived self-efficacy to perform action • Threat • Perceived susceptibility to problem • Perceived severity of problem • Behavior change • Cues to action • Media • Personal influence • reminders

30. SUSCEPTIBILITY: A person thinks a bad outcome (e.g., get sick or a disease) is likely to occur in the absence of behavior change • SEVERITY: The consequence of the recommended action is perceived to be severe as opposed to mild. • BELIEFS: He or she believes that the recommended action will reduce the likelihood of the negative consequences (e.g., disease) • BARRIERS: There are not significant psychological, financial, or other costs or barriers to engaging in the behavior. • CUES TO ACTION: There are internal or external reminders to perform the recommended action • SELF-EFFICACY: The person feels strongly that he or she is capable of taking the recommended action

31. SUSCEPTIBILITY: A person thinks a bad outcome (e.g., get sick or a disease) is likely to occur in the absence of behavior change • SEVERITY: The consequence of the recommended action is perceived to be severe as opposed to mild. • BELIEFS: He or she believes that the recommended action will reduce the likelihood of the negative consequences (e.g., disease) • BARRIERS: There are not significant psychological, financial, or other costs or barriers to engaging in the behavior. • CUES TO ACTION: There are internal or external reminders to perform the recommended action • SELF-EFFICACY: The person feels strongly that he or she is capable of taking the recommended action

32. SUSCEPTIBILITY: A person thinks a bad outcome (e.g., get sick or a disease) is likely to occur in the absence of behavior change • SEVERITY: The consequence of the recommended action is perceived to be severe as opposed to mild. • BELIEFS: He or she believes that the recommended action will reduce the likelihood of the negative consequences (e.g., disease) • BARRIERS: There are not significant psychological, financial, or other costs or barriers to engaging in the behavior. • CUES TO ACTION: There are internal or external reminders to perform the recommended action • SELF-EFFICACY: The person feels strongly that he or she is capable of taking the recommended action

33. SUSCEPTIBILITY: A person thinks a bad outcome (e.g., get sick or a disease) is likely to occur in the absence of behavior change • SEVERITY: The consequence of the recommended action is perceived to be severe as opposed to mild. • BELIEFS: He or she believes that the recommended action will reduce the likelihood of the negative consequences (e.g., disease) • BARRIERS: There are not significant psychological, financial, or other costs or barriers to engaging in the behavior. • CUES TO ACTION: There are internal or external reminders to perform the recommended action • SELF-EFFICACY: The person feels strongly that he or she is capable of taking the recommended action

34. SUSCEPTIBILITY: A person thinks a bad outcome (e.g., get sick or a disease) is likely to occur in the absence of behavior change • SEVERITY: The consequence of the recommended action is perceived to be severe as opposed to mild. • BELIEFS: He or she believes that the recommended action will reduce the likelihood of the negative consequences (e.g., disease) • BARRIERS: There are not significant psychological, financial, or other costs or barriers to engaging in the behavior. • CUES TO ACTION: There are internal or external reminders to perform the recommended action • SELF-EFFICACY: The person feels strongly that he or she is capable of taking the recommended action

35. SUSCEPTIBILITY: A person thinks a bad outcome (e.g., get sick or a disease) is likely to occur in the absence of behavior change • SEVERITY: The consequence of the recommended action is perceived to be severe as opposed to mild. • BELIEFS: He or she believes that the recommended action will reduce the likelihood of the negative consequences (e.g., disease) • BARRIERS: There are not significant psychological, financial, or other costs or barriers to engaging in the behavior. • CUES TO ACTION: There are internal or external reminders to perform the recommended action • SELF-EFFICACY: The person feels strongly that he or she is capable of taking the recommended action

36. Jane is likely to quit smoking because… • She thinks that she might get lung cancer if she continues to smoke (high susceptibility). • She believes that dying from lung cancer is terrible (high severity). • She would feel happier if her hair and clothes didn’t always smell like smoke, and it would save her money too (multiple benefits to quitting). • Her friends are supportive of her quitting, and her company has a free cessation program (few barriers to quitting). CREDIT: gim.med.ucla.edu/FacultyPages/.../Theory%20and%20Behavior.ppt

37. Jon is not likely to quit smoking because… • He agrees with the tobacco industry--smoking doesn’t cause lung cancer (lowsusceptibility). • He believes that dying from lung cancer is not any worse than any other way of dying (neutral severity). • Jon feels that smoking relaxes him (few benefits to quitting). • He’s a musician and everyone in his band smokes, he also feels that smoking makes his voice sound better (multiple barriers to quitting) CREDIT: gim.med.ucla.edu/FacultyPages/.../Theory%20and%20Behavior.ppt

38. Using the Health Belief Model

39. Stages of change (Transtheoretical model) Consciousness raising Dramatic relief Environmental reevaluation Self re-evaluation Self liberation Reinforcement management Helping relationships Counter-conditioning Stimulus control

40. Stages of change (Transtheoretical model) http://info.k4health.org/pr/j56/4.shtml

41. Precaution Adoption Process Model • Stage 1: Unaware Media messages get you to the next stage Personal experiences or significant others move you forward • Stage 2: Unengaged • Stage 3: Deciding about acting • Stage 4: Decided not to act • Stage 5: Decided to act • Stage 6: Acting • Stage 7: Maintenance

42. Precaution Adoption Process Model • Do you know what “dating violence” means? • No = {stage 1} = teach about what counts as dating abuse • Yes= go to next stage • Do you currently intervene with friends when you observe unhealthy relationship behavior? • No= stage 2= teach about how to intervene • Yes = go to next stage • Which of the following best describes you? • I’ve never thought about intervening. {Stage 2} • I’m undecided about it. {Stage 3} • I’ve decided I don’t want to. {Stage 4} • I’ve decided I do want to. {Stage 5}

43. Theory of Reasoned Action (the original) • Belief that the behavior leads to desired outcomes • Valuing the outcomes • =Attitude towards the behavior • Intention • Behavior • Beliefs about whether other people you to do the behavior • Valuing the opinions of those people • =Subjective norm

44. Theory of Planned Behavior (the Part 2) • Belief that the behavior leads to desired outcomes • Valuing the outcomes • =Attitude towards the behavior USED IN ADVERTISING! • Intention • Beliefs about whether other people you to do the behavior • Valuing the opinions of those people • Behavior • =Subjective norm • Perceived power to make behavior change • Control over own behavior

45. Theory of Planned Behavior (the Part 2) • Belief that the behavior leads to desired outcomes • Valuing the outcomes • =Attitude towards the behavior • Intention • Beliefs about whether other people you to do the behavior • Valuing the opinions of those people • Behavior • =Subjective norm • Perceived power to make behavior change • Control over own behavior

46. Summing up: 8 lessons learnedthe person must…

47. Summing up: 8 lessons learnedthe person must…

48. How to generate a program from a ToBC • Read the theory; all about the theory • Read examples of other programs born from that theory • Start jotting down ideas • Use a translation grid

49. Example translation grid

50. Example translation grid: dating abuse using Health Belief Model