H671 – Advanced Theories of Health Behavior

1. H671 – Advanced Theories of Health Behavior • Introductions • Review syllabus and requirements • Including weekly writing assignments • How to think about theory – Darcie • Class activity and discussion • Break • Advanced thinking about theory – Flay • Discussion • The TTI – Flay • Discussion

2. WHY LEARN THEORY? • In order to have an impact on health behavior, it is necessary to understand it. • In the current research and program environment, it is increasingly important to demonstrate systematic connectionsbetween: • an assessment of a health problem (how you define the problem, including applicable theory); • what you say you are going to do about it (program components); and • how you know whether or not your program had an impact (evaluation). • Because theory is a tool for explaining behavior, it is a key part of making such connections.

3. Theory & Practice • Traditionally a duality • Dewey: “experimental knowing” as the ground between theory and practice • Bidirectional Continuum • Fundamental Research • Intervention Research • Surveillance Research • Application and Program Delivery

4. Theory • A systematic view of phenomena created to explain and predict them • Theory must provide a logical explanation for a phenomenon that takes all known information into account • Example: Newtonian physics • A theory must have these qualities: • Generality, Testability, Abstraction • “A set of interrelated constructs (concepts), definitions, and propositions that present a systematic view of phenomena by specifying relations among variables, with the purpose of explaining and predicting the phenomena.” • Kerlinger, 1986

5. Components of Theories • Concepts • Major components of a theory • Building blocks • May or may not have meaning outside the context of the theory • Constructs • A concept that has been developed or adopted for use in a particular theory • A construct can only be understood in the context of its parent theory • Example: Self-Efficacy • Variables • The empirical counterparts of constructs • Operational form of a construct • They specify how a construct is to be measured in a specific situation • Example: Creating a questionnaire to measure depression so you can assign a score to an individual

6. Specifying Relations: How dovariables affect or relate to each other? • Correlative • Depression and Cancer • Causative • Smoking and Heart Disease • Coincident • Being left-handed and developing Diabetes Type I • Mediating • A process that intervenes between input and output in a system • Example: Social Support mediates between stress & disease • Moderating • A variable that affects the direction or strength of the relation between an independent and dependent variable • Example: Lifestyle factors moderate the effects of race on hypertension

7. Types of Theory • Explanatory Theories • Describe problems • Identify sources of problems • Search for modifiable factors • Examples • Health Belief Model • Theory of Planned Behavior

8. Types of Theory (Cont.) • Change Theories • Of behavior change • Intervention design • Evaluation strategies • Provide explicit assumptions for why a program will work • Help determine why a program didn’t work • Examples • Community Organization • Diffusion of Innovations

9. ROOTS OF CURRENT HEALTH BEHAVIOR THEORY • Theories about something are explanatory statements or models. • The term theory, as it is commonly used, derives its meaning from a context of Western philosophy and science. • There are many other explanatory traditions as well. • Primary fields from which most current health behavior theory come – psychology and social psychology. • And…Important contributions from ecology, sociology, anthropology, organizational and community theory, communications theory, and others.

10. BASIC ASSUMPTIONS IN THE WESTERN TRADITION OF THEORY • Order and regularity – that the universe is ordered and regular, which has practical applications for technology, etc. • Predictability – if there is order and regularity, the rules or “laws” can be learned, and used to predict. • Primacy of empirical data – the positivist epistemology associated with the Western tradition holds that what we know comes from our senses -- observable, tangible evidence • Progress and perfectability – that there is an inexorable movement towards more knowledge, better understanding, higher complexity etc.

11. COGNITIVE PSYCHOLOGY • Focus on the THINKING PROCESS. • THINKING PROCESSES include perception, memory, decision-making, interpretation, reasoning, judgment, etc. • Some cognitive psychologists (e.g. Piaget) focus on the development of the thinking process. • See the influence of cognitive psychology in many of the individual-level theories (e.g., Health Belief Model) that are discussed in the course.

12. BEHAVIORIST PSYCHOLOGY • ASSUMPTION: Behavior is learned through a process of stimulus and response. “Thinking” not a major part of this process. • Early focus on classical conditioning (Pavlov’s dog), then on operant conditioning (Skinner) -- the conditioning of behavior by positive and negative reinforcements. Idea of shaping behavior, behavior modification. • Behavior modification still used in smoking cessation, addiction treatment and other programs. • The basic assumptions about learning behavior through positive and negative reinforcements appear in a number of health behavior theories.

13. HUMANISTIC PSYCHOLOGY • Focus on individual capacity, on human capability of choice. • ASSUMPTION: That human beings desire to grow and attain their full potential – role of psychology is to help. • Before attaining higher level needs, humans have to satisfy basic to “mid-level” needs, from basic physiological to emotional to social (Maslow). • Humanistic psychology influenced the public health emphasis on quality of life, and the lifestyle concept.

14. SOCIAL PSYCHOLOGY • Most of psychology focuses on the individual experience; social psychology focuses on the interaction between individuals and the group – groups, relationships, social units. • This may include: group dynamics, authority and legitimacy, emotion and its expression, aggression, self-identity, motivation, gender roles, norms, attitudes, group prejudices. • Social psychology has had a considerable influence on such health behavior theories as Social Cognitive Theory, Theory of Planned Behavior, Social Network Theory, and others.

15. SOCIOLOGY • Sociology includes the study of society and its phenomena – social groups, social hierarchies, social structures, the nature of social interaction and organization, the interaction between social and economic systems. • There is overlap between sociology, psychology and anthropology in explaining behavior. • Influence on health behavior theory: concepts of class and hierarchy, group norms and conformity, role of social capital, social organization and its impact on behavior.

16. CULTURAL ANTHROPOLOGY • Focus on the role of culture in human behavior, the ways in which life-patterns are organized, together with systems of knowledge and belief, language and symbol. • This may include: cultural beliefs, attitudes, social-cultural roles, gender, language, symbolic expression, social authority and legitimacy, health knowledge systems, healing practices, healers, etc. • Influence on health behavior theory: holistic (ecological) approaches, cultural influence on treatment and care, values and meanings as connected to behavior, cultural constructions of disease and illness.

17. ECOLOGY AND BIOLOGICAL SYSTEMS • The study of how living organisms function within interdependent systems – human ecology refers to the same idea applied to human systems. • This may include: relationships between the life patterns of organisms and their environment; ecological niches, symbiotic and other relationships. • Influence on health behavior theory: ecological approach, focus on multiple determinants of health, role of the environment in behavior.

18. Meta Information • No one theory is adequate • Every theory and model has a specific goal • What does it try to explain? • Is it about how people learn? • Is it about how people change? • Is it about how people relate to others? • Every theory/model is somehow connected to what came before • Evolution of understanding • Increasing complexity and sophistication • Every theory/model has a better/best fit: • For particular problems • For particular populations • For particular interventions • Every theory/model was developed in a cultural and social milieu that may be different from present day

19. Reasons for Thinking Theoretically about Health Promotion • # 1 - Infuses Ethics and Social Justice into Public Health Practice • # 2 - Represents A Moral Duty and A Professional Responsibility • # 3 - Guides the Profession • # 4 - Prevents Ideological Take-Over, or Hegemony • # 5 - Guides and Perfects Practice • # 6 - Builds Scientific Knowledge • # 7 - Provides Roadmaps for Research

20. Reason # 1: Ethics and social justice • The Tuskegee Study • Breech of ethical principles in conducting research. • One of the reasons for ethical mis-conduct: • According to James Jones (author of the book Bad Blood) – medicine, at the time, was a profession “almost wholly composed of people uninterested in theorizing” (Jones, 1993, p. 96).

21. Reason # 1 cont. • Tuskegee happened because… • The medical (and public health) profession trained physicians to become • Healing technicians • Health methodologists • Health strategists • Not trained to • Reflect • Inquire • Question the status quo • OR: not trained to think theoretically

22. Reason # 2:Moral duty and Professional responsibility • Professions have defined tasks and values. • Professional tasks and values = professional responsibilities • Most professions  CODE OF ETHICS and PROFESSIONAL COMPETENCIES

23. Reason # 2 cont. Our professional responsibilities include: • Develop our professional tools • Become more effective and efficient • Reflect continually on our practice • Question our methods • Reform our views, when needed • Build narratives that provide meaning for people’s health promotion efforts • Witness / Listen to our clients’ narratives

24. Reason # 2 cont. • Theorizing: responsibility embedded in 6 of the 7 areas of professional responsibility for health educators, defined by NCHEC (National Commission for Health Education Credentialing). • Examples: • “Identify factors that influence health behaviors” (Area I – sub-competency C) • “Identify factors that foster or hinder the process of health education” (Area I – sub-competency E)

25. Reason # 3:Guides the Profession • Few scholars are thinking theoretically about the direction health promotion/public health is taking. • Those who have thought theoretically, have contributed: • New theories • New models and perspectives • New approaches • Helpful critiques

26. Reason # 3 cont. • Few scholars engage in theoretical thinking about public health because: • It is disquieting • Can be disturbing • Can “rattle the status quo cage” • Yet: THIS is what theory does…

27. Reason # 4: Prevent ideological take-over, or hegemony • Ideology = the integrated assertions, theories and aims that form the collection of plans societies have for governing themselves. • Hegemony = happens when one social group’s ideology dominates another group and becomes the predominant influence over this group (OR: an ideology take-over).

28. Reason # 4 cont. • If public health professionals do not build and shape public health’s ideology, professionals outside public health will. • Consider the influence of other fields of knowledge on public health, historically. • Public health cannot exist without an ideology (or set of theories). • Someone has to build these theories and assertions. • If not public health professionals, who?

29. Reason # 5: Guides and perfects practice • Practice = set of activities used to promote health and prevent illness. • “Practice makes perfect” “Theory makes perfect” (Willinsky, 1998, p.245). • Prevention interventions: more effective when based on theory • Many theories suggest strategies for changing specific factors/variables/elements. • Practitioners may not have to re-invent the wheel, when using these theories.

30. Reason # 6: Builds scientific knowledge • The body of knowledge in a given field needs two types of research: • Descriptive • Analytical • Public Health: too much descriptive research? Not enough analytical? • “Chaos in the Brickyard” letter by Bernard K. Forscher (Science, 1963) • Too many scattered bricks (data) • No buildings (bricks connected in a planned manner)

31. Reason # 7: Provide roadmaps for research • Most fields: asking for more theory-based research • Provides data that can be generalized more broadly (applied to a larger number of contexts/contingencies). • Facilitates conducting and implementing research projects. • Provides blueprint for selecting which variables to measure. • Provides parameters for analyzing (and interpreting) what was measured. • Avoids: Re-inventing the wheel, going around in circles