Applying Theories and Models

1. Applying Theories and Models …to Community Nutrition Programs and Strategies

2. Theories & Models of Health Behaviour We will explore: • Factors that influences our food choice behaviours • Theories & models of health behaviour • Community & System level change strategies (Community Development, Social Marketing, Policy)

3. Food Choice Behaiours • READ • Raine, K. (2005). Determinants of healthy eating in Canada. An overview and synthesis. Can. J. Public Health, 96, suppl 3, S8-S14.

4. Personal Food Choices • Physiological factors • Food Preferences • Nutritional Knowledge • Perceptions of Healthy Eating • Psychological Factors

5. Personal Food Choices? • Environmental Factors • Interpersonal influences • Physical environment • Economic environment • Social environment • Creating Supportive Environments - Policy

6. Food Choices • Food choices, eating behaviours and resulting nutrional health are influenced by a number of complex and inter-related individual, collective and policy-related determinants. • A growing body of research is supporting the relationship between food preparation and cooking skills and food choices of children and adolescents within the family context. • Health Canada, Improving Cooking and Food Preparation Skills, 2011

7. Food Choices • Diet quality of youth related to frequency of family meals AND involvement in food prep • Taste, nutritional value, cost and time • Main factors behind food choice & prep decisions ACROSS SES groups • Low SES report cooking from ‘scratch’ more often AND use of fewer convenience foods • Health Canada, 2011

8. Best Practices for Interventions • Theoretical basis clear • Or minimally based on set of “defendable community-relevant assumptions” • Experiential/hands-on learning • Promotes self confidence through skill development • Include self-assessment of eating patterns & behaviour change tracking • Health Canada, 2011

9. Best Practices • Tailored for specific population group • Based on measurable, specific goals • Longer vs. shorter duration programs • Provide reinforcement & motivation • Health Canada, 2011

10. What are food skills? • Knowledge • Food safety, label reading, ingredient substitution • Planning • Organizing menu, food prep within budget, teaching children food skills • Conceptualizing food • Creative use of leftovers, adjusting recipes • Mechanical techniques • Following recipe, chopping, mixing, etc. • Food Perception • Using senses, when foods are cooked

11. Options most likely to order if available Broiled or baked meat WW bread Fresh fruit Steamed veg Regular salad dsg on side Options least likely to order if available Low-fat sour cream Low-fat salad dsg Low-fat milk Low-calorie dessert Request to hold high fat ingredients Rural Restaurant Customers Preferences

12. Income & supplement use • Lower income adults less likely to consume vit/min supplements • Higher education linked to greater supplement use • Lower income • Food insecure & poorer diet quality • May need supplements most • Findings suggest need for improved access to supplements for lower income • Whiting, Adolphe, & Vatanparast, Oct 2009, DC Current Issues

13. Food Choice Behaviours • Knowledge  behaviour

14. Food Choice Behaviours • Values • Permeate our lives; define who we are & where we stand; learned from socialization (Vanden Heede, et al., 2006) • conception of what is desirable & undesirable • Beliefs • conceptions of reality & propositions about how the universe works • Norms • principles, rules or standards for behavior - they are people’s conception of what should occur in a given situation • Culture • a guide for behaviour • a mental map

15. Theory • a set of interrelated concepts, definitions, and propositions • presents a systematic view of events or situations • by specifying relationships among variables • in order to explain or predict the events of the situations.

16. Theory • Used as a guide: • WHY people are/are not following health advice • WHAT you need to know before developing or organizing an intervention program • HOW you shape program strategies to reach population and make an impact • WHAT should be monitored, measured, and/or compared in the program evaluation

17. Theory • Helps us understand behavior • Explains dynamics of behavior • Explains process for change of behavior • Identifies target for programs • Identifies methods for accomplishing change • Theories and models EXPLAIN behavior and SUGGEST ways to achieve behavior change

18. Theory • Keep in mind that more than one theory may be used to address an issue • No single theory dominates community nutrition activities

19. Theory • Designing interventions for eating pattern changes can best be done with understanding of relevant theories and of dietary behaviors change and an ability to put them into practice • (Glanz & Eriksen, 1993) • Theories therefore: • Guide program development • Provide foundation for evaluation

20. Model • Vehicle for applying theories • Provides plan for investigating or addressing a phenomenon • Only represents processes; does not attempt to explain them

21. Two models linking theory to practice • Scientific model • Theory defined to deduce hypotheses that are tested with experimental research design • Requires replication by practitioners of exact process to find the ‘truth’ • Humanistic model • Theory define to seek to clarify social values • Practitioners use theory to stimulate dialogue about “eating habits in living the kind of life that community members find most valuable.” Buchanan, 2004, JNEB, 36, 146-154.

22. Theories and models • Intrapersonal level (Individual) • Stages of Change (TTM) • The Health Belief Model • Theory of Reasoned Action • Interpersonal level • Social Cognitive Theory • Community and group level • Diffusion of innovations

23. Transtheoretical Model (TTM) – Intrapersonal • Developed by Prochaska & Diclemente • Stages of Change Model

24. Transtheoretical Model (TTM) • Focus • Person’s readiness to change or attempt to change toward healthy behaviour

25. Transtheoretical Model (TTM) • Assumptions • Behaviour change involves series of stages or steps • Common stages across variety of health behaviours • Tailor interventions to be most effective • Encourages us to think about client’s readiness to change

26. Transtheoretical Model (TTM) • Precontemplation – unaware or not interested in making change • Contemplation – thinking about taking action - next 6 mths • Preparation – active decision to change and planning • Action – trying to make change for <6mths • Maintenance -has sustained change for >6mths • Termination – no temptation and 100% self-efficacy

27. TTM • Self Efficacy • confidence in ability to change behaviour & to withstand temptations to relapse • Decisional Balance • pros and cons of change • how an individual perceives these

28. Decisional Balance Pros of Change Cons of Change Pros of No Change Cons of No Change

29. TTM Applications • Intervention strategies should be matched with processes commonly used in particular stage of change • cognitive processes used in pre-action stages • Seeking information • behavioral processes used in Prep, Action and Maintenance • Seeking ways to strengthen behaviour

30. TTM Applications • TTM originated with addictive behaviours research • e.g., smoking cessation • Dietary change involves complex combination of removal of one set of behaviours & acquisition of new set of behaviours • Measurement of definite stage of change is more difficult

31. TTM – use to increase V/F intake in preschool children • Low-income parents & primary caregivers (N=238) • Incorporates staging algorithm for increasing V/F accessibility to PS children, decisional balance, self-efficacy Hildebrand, & Betts, 2009; JNEB,41(2), 110-119

32. TTM – use to increase V/F intake in preschool children • Precontemplation/Contemplation (43%) • Best to use methods to share ideas for planning meals and snacks to include V/F • Preparation (29%) • Aim to build skills in making quick & economical V/F • Stress parent role-modeling • Encourage goal setting • Action/Maintenance • To prevent relapse, build in social support in all learning formats Hildebrand, & Betts, 2009; JNEB,41(2), 110-119

33. TTM with low income parents & caregivers • Caregivers assessed for stage of change for increasing V/F access for PS children • 43% precontemplation/contemplation • 29% preparation • Those in action & maintenance • Showed higher self efficacy u • Used more behavioral processes • Interventions should be tailored to stage of change • Cognitive vs. behavioural • Hildebrand, & Betts, 2009

34. Health Belief Model - Intrapersonal • Hochbaum, Rosenstock and Kegel - 1950s • to explain why people would/would not use health services

35. Health Belief Model - Intrapersonal • Focus • Person’s perception of a health problem & appraisal of recommended behaviour to manage or prevent the problem

36. Health Belief Model – Three Components 1. Perception of threat to health • personal threat to health • concerned that ‘disease’ carries serious personal consequences 2. Outcome expectations • perceived benefits and barriers to taking specific action 3. Self-efficacy • belief that one can make a behaviour change • Other factors affect perceived threat, outcome expectations & efficacy expectations • Thus, factors influence health behaviour indirectly

37. Using Health Belief Model • Include skill-building components • increase self-efficacy • Be aware of times of increased threat perception • ↑ likelihood of change • Identify barriers to action • develop strategies for helping clients overcome barriers

38. Ajzen and Fishbein Behaviour determined directly by intention to perform the behaviour Theory of Reasoned Action – Intrapersonal

39. Theory of Reasoned Action • Intention • Instructions given to self to behave in certain way • Consider behaviour outcomes & opinion of significant others when forming opinions • Intentions influenced by attitudes and social pressures to perform (subjective norms) • Perceived social pressure to perform or not perform a behaviour

40. Developed by Bagozzi Modified Theory of Reasoned Action Theory of Trying - Intrapersonal

41. Theory of Trying • Added components that influence intention to try behaviour: • past experience (success or failure) with behaviour • mechanisms for coping with behaviour outcome • emotional responses to process

42. Application of Theories to Practice • Self-assurance seems linked to successful behaviour change • self-esteem • self-efficacy

43. Application of Theories to Practice • Could screen clients upon program entry • degree of readiness to change • degree of past success • degree of confidence in ability to change • level of commitment to program

44. Developed by Bandura to explain how people acquire & maintain behaviours SLT = Social Learning Theory Social Cognitive Theory

45. Interpersonal Model – Social Cognitive Theory Internal/Personal Factors Environmental Factors Behavior (Bandura, 1972)

46. Social Cognitive Theory • Strength • focus on target behaviours rather than attitudes & knowledge • Key concepts and their implications • Table 15-3, page 487

47. Interpersonal level applications • Small Groups • Supplement or substitute individual counseling • Social Support • Interacting with positive role models and problem solving through discussions with people with shared problems • Peer Education • Effective at enhancing observational learning through role models • Youth and cultural minority groups

48. Interpersonal level applications • Point-of-purchase nutrition information • Guide food selections in food establishments, i.e., supermarkets, cafeterias, restaurants • Information during decision making increase awareness and serve as reminder

49. Rogers and Shoemaker, 1970s to explain how product/idea becomes accepted by majority of consumers Community & Group – Diffusion of Innovation

50. Diffusion of Innovation • Focus • Addresses how new ideas, products & social practices spread within a society or from one society to another