Theory

1. Theory

2. What is theory? • “… a set of interrelated concepts, definitions, and propositions that presents a systematic view of events or situations by specifying relationships among variables in order to explain and predict the events or the situations.” • (Glanz, Rimer, and Lewis, p. 25)

3. Theory • “Effective health promotion and education depends on practitioners’ marshaling the most appropriate theory and practice strategies for a given situation.” • “The gift of theory is that it provides conceptual underpinnings for well-crafted research and practice.” (Glanz, Rimer, & Lewis, pp. 30-31)

4. 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

5. Concepts & Constructs • Concepts: • Major ideas • Constructs: • Concepts that have been developed and defined for use in a particular theory

6. More theory • “Habit is habit, and not to be flung out of the window, but coaxed downstairs a step at a time.” • Mark Twain

7. The Ecological Model • Emphasizes the links and relationships among multiple factors (or determinants) affecting health

8. Ecological Model Public Policy Community Institutional or Organizational Interpersonal Individual

9. Individual / Intrapersonal factors • Knowledge, attitudes, beliefs (KAB) • Skills • Motivation • Self-concept • Age, gender, genetics

10. Interpersonal factors • Social support / social networks • Formal and informal • Family, friends, peers • Social norms, cultural environment

11. Institutional or organization factors • Social institutions with organizational characteristics and formal (and informal) rules and regulations for operations. (ACHA, 2012)

12. Community factors • The geographic, cultural or social community. • May include: • Community organizations • Local laws • Physical characteristics/attributes of location • Available (or unavailable) services

13. Public Policy Factors • Local, state, national and global laws and policies. (ACHA, 2012) • May promote or restrict behavior

14. Ecological Model NIH, Theory at a Glance

15. Ecological Model Public Policy Community Institutional or Organizational Interpersonal Individual

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

17. 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

18. Health Belief Model (HBM) • Developed in the early 1950’s by social psychologists in the U.S. Public Health Service. • Hochbaum & Rosenstock • TB screening

19. 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

20. 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

21. Constructs of HBM • Cues to Action • Strategies to activate one’s “readiness” • Self-Efficacy • Confidence in one’s ability to take action

22. Health Belief Model Modifying Factors: age, race, ethnicity, SES, personality Outcome Expectations: Perceived Benefits vs. Perceived Risks/Barriers Perceived Susceptibility & Perceived Seriousness Perceived Threat Likelihood of taking recommended action Cues to Action Self-efficacy

23. Health Belief Model Outcome Expectations: Perceived benefits: no HTN medication, delay or prevent heart disease/stroke, live longer, better quality life. Perceived barriers/risks: time, money, injury? 45 y/o Caucasian male, married, 2 children, works full-time, desk job, does not seek health information Strong family history of heart disease / strokes; feels it could “happen to him” and ultimately lead to serious disability/death Perceived Threat Likelihood of taking recommended action Doctor diagnosed him as hypertensive, started on medication Self-efficacy: moderate

24. Health Belief Model NIH, Theory at a Glance

25. 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

26. TRA Cont. • Beliefs and Subjective Norms help predict Intentions • Your Intentions predict your actual Behavior

27. TRA Attitude toward behavior Intention Behavior Subjective Norm

28. Theory of Planned Behavior (TPB) • Developed by Fishbein & Ajzen • An extension of the Theory of Reasoned Action (TRA)

29. 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.

30. 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.

31. TPB Attitude toward the behavior Intention Behavior Subjective Norm Perceived Behavioral Control Actual Behavioral Control

32. TPB Healthy eating takes time, extra money and a lot of energy Friends / family do not exercise and junk food is always abundant Intention Eating healthier/exericse Nearby grocery stores often have good sales, lives near farmer’s market. Lives near park and walking trails “Not much I can do”

33. Theory of Planned Behavior NIH, Theory at a Glance

34. Transtheoretical Model (TTM) • AKA: Stages of Change • Developed by Prochaska & DiClemente • Major Constructs: • Precontemplation • Contemplation • Preparation • Action • Maintenance • Decisional Balance • Self-Efficacy

35. 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.”

36. Contemplation • “Shoe shopping” • Seriously thinking about making a behavior change, but have not yet made a commitment to action

37. 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

38. 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

39. Maintenance • “Shoes go on every day.” • Sustaining the behavior change for over 6 months.

40. Decisional Balance • The costs and benefits of changing.

41. Self-Efficacy • Confidence that one can be successful in the new behavior across different challenging situations.

42. 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)

43. Transtheoretical Model (TTM) Precontemplation Decisional Balance Contemplation Self-Efficacy Between every stage, the client needs to have decisional balance and self-efficacy Preparation Decisional Balance Action Self-Efficacy Maintenance

44. Stages of Change (TTM) NIH, Theory at a Glance Groups with this theory: don’t forget a relapse plan!

45. 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

46. How to stage a person using TTM Do you exercise regularly? No Yes Do you intend to in the next 30 days? Have you been doing so for more than 6 months? Yes No Yes No Do you intend to in the next six months? Preparation Action Maintenance Yes No Precontemplation Contemplation (Pearson Ed, 2012)

47. Adapted from:Autobiography in Five Short Chaptersby Portia Nelson I I walk down the street. There is a deep hole in the sidewalk. I fall in I am lost … I am helpless It takes forever to find a way out.

48. II I 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.

49. III I 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.

50. IV I walk down the same street. There is a deep hole in the sidewalk. I walk around it. V I walk down another street.