Understanding Theory: Concepts, Variables, and Models for Effective Health Promotion

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. Theory • Generality • Testability • Shape and boundaries, but not specific topic or content

5. 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

6. Concepts & Constructs • Concepts: • Major components of theory • Constructs: • Concepts that have been developed and defined for use in a particular theory

7. Variables • Variables • The measurable forms of constructs • Variables are a measure of a specific construct in a specific situation.

8. Models • “… draw upon a number of theories to help understand a specific problem in a particular setting or context.” • (Glanz, Rimer, & Lewis, pp. 27)

9. Putting it together • A personal belief is a CONCEPT that has been shown to relate to various health behaviors. • Using a THEORY that includes the concept of personal beliefs helps explain why young men don’t think they will ever get testicular cancer.

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

11. Planning Models • Like a road map • Present all possible routes you might take to develop, implement, and evaluate a program.

12. Planning Models • PRECEDE/PROCEED • MATCH • CDCynergy

13. PRECEDE/PROCEEDModel

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

15. Theories and Levels of Influence • Behavior is very complex • Influenced and supported in multiple ways

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

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

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

19. Interpersonal factors • Social support / social networks • Social norms, cultural environment • Religious affiliation • Access to social and health services

20. Institutional or organization factors • Educational system • Access to health care • Social Interactions

21. Community factors • Living and working conditions • Public safety • Local public health • Housing • Economic development • Environment

22. Public Policy Factors • Federal, State & Local Policy and Law • Zoning • Taxes • Public Health System • Educational System

23. Behavior change theories with individual focus • The Health Belief Model (HBM) • The Transtheoretical Model (TTM) • Theory of Planned Behavior (TPB)

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

25. 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

26. 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

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

28. 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

29. 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

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

31. TRA Attitude toward behavior Intention Behavior Subjective Norm

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

33. 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.

34. 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.

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

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

37. Precontemplation • “The care is still in the garage!” • Not thinking about changing behavior in the next six months. • May be unaware of risks or problems. • Needs some work “under the hood.”

38. Contemplation • “The engine is started, but we’re not quite in gear!” • Seriously thinking about making a behavior change, but have not yet made a commitment to action

39. Preparation • “We’re in gear and ready for short trips.” • Ready to take action in the very near future (next 30 days) • Have a plan of action • Experimenting with new behaviors

40. Action • “We’re on the road on a regular basis.” • Actively engaged in new behavior(s) for less than six months. • Efforts are sufficient to reduce risk of disease

41. Maintenance • “We’re on cruise control.” • Sustaining the behavior change for over 6 months.

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

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

44. 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)

45. Strategies/process to get from one stage to the next. • Precontemplation to Contemplation • Awareness • New information • Persuasive communications • Experiences

46. Strategies • Contemplation to Preparation • Knowledge acquisition • Information • Persuasive communications • Experiences

47. Strategies • Preparation to Action • Deciding • How-to information • Skill development • Attitude change

48. Strategies • Action to Maintenance • Skills • Reinforcement • Support • Self-Management • Attitude and attribution change

49. Strategies • Maintenance • Continuation • Relapse prevention skills • Self-Management • Social and environmental support

50. Transtheoretical Model (TTM) Precontemplation Decisional Balance Contemplation Decisional Balance Preparation Self-Efficacy Action Self-Efficacy Maintenance