Download Health Behavior Theories

Introduction to
Health Behavior Theories
Let’s Recap…
Factors That Influence Behavior-Change
Decisions
Self-Monitoring
• Become aware of your behavior pattern
and targets of influence (change)
• Monitor
– Behaviors: drinks, steps, miles, calories,
carbs, etc
– Targets of influence: determine how frequent
they occur, when, where and record
• Start with a clear baseline for later
comparison
Overcoming Obstacles to Behavior Change
Goal of Health Promotion
Health promotion -- process of enabling
people to increase control over their health
behaviors…to improve their health.
Health Promotion Questions
•
Why do people behave in unhealthy (or
healthy) ways?
• What strategies are appropriate to:
– A: discourage risky behaviors?
– B: encourage healthy behaviors?
– C: assure healthy social and physical
environments?
Health Behavior Theories
• Guide the search for "why"
health-related behaviors
occur
• Identify points for possible
change
Introduction to Key Terms
What comes to mind when you hear the
word theory?
Jot down brief thoughts, beliefs, descriptions that
immediately surface to this question…
Theory…?
• The term carries with it, loaded
meanings
– Something abstract
– Assumptions about things
– Empirical generalizations hypotheses
– Causal explanations for certain
phenomena
– A scholarly “school-of-thought”
– Models or conceptual frameworks
There are two faces to theory
• Commonsense theories
• Scientific theories
Commonsense Theories
“Explanations” we invoke (on a daily basis) to make sense of events
we encounter in our lives – sense-making (conspiracy theories)
Case 1: Past couple of weeks, my graduate assistants’ behavior
“seems a little off.” She arrives late for team meetings, and
appears distant and broody when the team interacts. I have
an “explanation” for her behavior:
-She has been under considerable stress, taking her
comprehensive exam, and finalizing a manuscript to submit
for publication.
My explanation is considered a commonsense theory as it
represents a personal attempt to make sense (meaning) of a
situation based on the information at hand.
Scientific Theories
• Are more elaborate
• Contain more clearly outlined
characteristics
• Have a defined purpose
General Scientific Theories
• Definitions…
…A set of universal statements that furnish an
explanation by means of a deductive system
(Norman Denzin, 1970)
…a set of interrelated propositions that allow us to
explain how and why events occur. It is constructed
with several basic building blocks: concepts/
constructs, variables, and statements (Turner, 1986)
Scientific Health Behavior Theories
Behavioral health theories are…
…composed of interrelated propositions, based on
stated assumptions that tie selected constructs
together and create a parsimonious system for
explaining and predicting human behavior
(DiClemente et al. 2002)
... a set of interrelated concepts, definitions, and
propositions that present a systematic view of
situations by specifying relations among
variables, in order to explain and predict the
situations (Glanz et al. 2008)
Let’s break down these definitions
into smaller units. What are some
core elements across all of them?
1.
Description: theories facilitate the description and
understanding of phenomenon being studied so
that others can test (and repeat) such descriptions
with.
2.
Prediction: extends beyond mere description.
Theories allow for the construction of interrelated
propositions (hypotheses) that make predictions
(claims) of why phenomenon (relationships) occur.
3.
Explanation: theories permit the explanation of
observed events in a logical, ordered, and
interconnected manner.
Other Common Components
• Concepts/Constructs
• Variables
• Hypotheses
Concepts & Constructs
• The abstract units that logically build a
theory. Often used interchangeably.
• Ideas or notions (that have been “branded
into a theory with a technical name”) that
are typically “unobservable or latent”
• Examples?
– Self-efficacy, perceived severity, social norms
Variables
• Concepts/constructs are operationalized
(defined) into “measurable” or
“observable” terms called variables
– Referred to as the “proxy” for the
concept/construct and can take on two or
more values.
• Example?
– Self-efficacy– cannot see but can measure it
– perceived ability or skill in certain behavior
Hypotheses
• Helps connect the theoretical dots with
empirical assumptions about phenomenon
we would expect to observe.
– Associations between two or more constructs
• Hypotheses (or assumptions of
associations between two or more
constructs – measured as variables) can
be “tested”…
– Ho: no association
– H1: association
Now that we have definitions under out belt,
how do theories work?
• Need to engage in the “theorizing process…”
…which is more than simply thinking about
descriptions, explanations or predictions…
Theorizing or Theoretical Thinking
• Is a dynamic process of theory building…
Asking and Answering
specific types of questions
Predicting and Analyzing
(testing) specific research questions &
hypotheses
Theory “building” is like Quilting
• Depending on HOW
constructs and
hypotheses are
connected, different
explanations for health
behavior emerge
Quilt Blocks
Question
Why?
How?
When?
What for?
Answer
Explanations structured
logically
“Because….”
“Given X, then Y…”
“For…”
The Theorizing Process
You may be asking yourself…
• Why should we think theoretically about health
promotion?
– Isn’t observing and collecting data related to
public health issues and delivering health
education practice, enough?
– Because our field is “applied,” why do we need to
consider theory in our practice?
Reason 1
Because theoretical thinking…
…infuses ethics and social justice into
health education practice
The Tuskegee Study
• Study Timeframe: 1932-1972
• Study Goal: to determine the long-term course of syphilis
in the absence of treatment and to note the peculiarities
of the disease in black men in particular (as there was
widespread belief among MDs that blacks responded
differently to disease than did whites).
• Study Sample: conducted among a group of 600 black
men (399 syphilis cases, 201 controls)
• Study Site: Men from Macon County, Alabama - which
exhibited the highest syphilis rates in the U.S. at the
time. Hence was seen as a “natural lab” by Tuskegee
Institute (worked with govt to obtain needed resources).
What Happened…
• To lure into study, men were told they
were sick b/c they suffered from “bad
blood.” NONE told that they had syphilis.
• Later when tx for syphilis (penicillin)
became available 10 yrs later (in 1943), it
was withheld from those who had it.
• Initially imagined as a 6-month study, it
lasted until 1972 - for 40 years
Aftermath of Tuskegee Study
• Characterized as one of the most infamous manmade tragedies in the history of American Science
that “breeched ethical principles in conducting
research”
• 65 yrs later, on May 16, 1997, Pres Bill Clinton
apologized in the name of the US Govt to the handful
of survivors & their families gathered at the white
house for the event. He stated…
– …“the people who ran the study at Tuskegee diminished
the stature of man by abandoning the most basic ethical
precepts – they forgot their pledge to health and repair”
You may ask…how on earth?
• This was a time when a “code of ethics” outlining the
protection of human subjects in research were
virtually non-existent…
• Rather, research & practice was based on the
medical way:
– A process of “peer-review” with emphasis on “preserving
professional autonomy” (not with ensuring ethical research or
defining good practice) and
– Medicine, at the time, was a profession (MDs and techs)
“almost wholly composed of people uninterested in
theorizing”
Jones, 1993
Relevance to Health Education Practice?
• Ethical misconduct occurred b/c medical
professionals ignored theory (as they were
trained to practice, collect data, and adhere
to methods).
• Because theorizing facilitates the groundwork
for ethics and promotion of social justice
within any profession…it’s very relevant to
health promotion given that ethics and
social justice are major goals promoted
within the practice.
Reason 2
Because theoretical thinking…
…represents a moral duty and professional
responsibility for health promotion
practice
Notion of Professional Responsibility
• Health promotion professionals are held
accountable for adhering to “codes of ethical
conduct” and professional competencies (AKA:
professional standards).
• Seven core competencies have been defined by the
National Commission for Health Education
Credentialing (NCHEC).
• Theorizing is a professional standard embedded
within 6 of the 7 areas of responsibility (as tasks).
Examples:
• “Identify diverse factors that influence health behaviors, i.e.,
theorizing about cause and effect relationships” (Area I, SubCompetency C)
• “Identify factors that foster or hinder the process of health
education” (Area I, Sub-competency E)
Reason 3
Because theoretical thinking…
…guides the practice of health promotion
For you as a public health professional
“in-training”
• The “theorizing process” is a valuable tool
needed for the work you are setting out to
do…
Assessi
ng
Needs
Setting
Goals
and
Objectiv
es
Developin
g an
Interventio
n
Implementi
ng the
Interventio
n
Evaluating
the
Results
Importance of Theory-Practice Link
• Theory is a tool for making
systematic connections
between:
– assessment of a health
problem;
– program components; and
– program evaluation
Why, in the current public health
environment, is it increasingly
important to demonstrate these
connections?
Health Behavior (and change) is Complex
• Health behavior change interventions are not end-all
be-all cures…
…record of success in behavioral change for HP
2010 objectives are not 100% successful.
• Illustration: prevalence of adolescent obesity tripled in
the past 30 years. Most childhood interventions are
rooted in theories of health behavior change. In a
review of recent programs, only 3 interventions
significantly impacted weight. Given the limited success
of most childhood obesity interventions, alternative
approaches need to be explored (Chehab et al., 2007).
Reason 4
Because theoretical thinking…
…prevents ideological takeover in health
promotion practice
Roots of Health Behavior Theories
• Primary fields from which most current health
behavior theories come:
–
–
–
–
–
Psychology
Sociology
Anthropology
Communications
Others…
• There is much overlap between these disciplines in
explaining behavior
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 via behavior modification.
• Behavior modification technique still used (smoking
cessation, addiction, eating disorders, gambling, etc)
• Basic assumptions about learning behavior through
positive and negative reinforcements appear in a number
of health behavior theories.
COGNITIVE PSYCHOLOGY
• Focus on the THINKING PROCESSES
• THINKING PROCESSES include beliefs,
perception, memory, decision-making,
interpretation, reasoning, judgment, etc.
• Some cognitive psychologists focused
solely on the development of the thinking
process (piaget)
• See influence of cognitive psychology focus
in many of health behavior theories
SOCIAL PSYCHOLOGY
• Social psychology focuses on the
interaction between individuals and the
group (relationships, social units)
• See this influence on health behavior
theories.
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.
• Much of this study is also present in many health
behavior theories in terms of the relationship
between (social class/hierarchy, group norms, social
organization and its impact on behavior).
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, socialcultural roles, gender, language, symbolic
expression, social authority and legitimacy, health
knowledge systems, healing practices, healers, etc.
• Cultural anthropology has much influence on health
behavior theories  cultural influence on health
behaviors, values and meanings as connected to
behavior, cultural constructions of disease and
illness.
Health Promotion Ideologies
• Even though public health is an “applied field” that borrows
much from these other disciplines, it is vital that health
promotion professionals remain critically reflective about
the processes by which health behavior theories are
translated into PH mainstream
• If health promotion ideology in terms of health behavior
theories is not being construed and shaped by the health
promotion workforce itself, then other ideologiesdeveloped by others outside the field will fill the void.
• In other words, if we don’t theorize in our practice, we will
fall prey to “being practiced & theorized” by other
disciplines in the social science field.
Reason 5
Because theoretical thinking…
…builds scientific knowledge in health
promotion practice
Where’s the scientific structure?
• In the absence of theory, the
knowledge base in health promotion
developed via research is not
critically grounded and merely a
collection of loosely derived nuggets
of information (without logical or
ordered meaning).
• Need to move beyond mere
descriptions of events (which is the
role of epidemiology data/inquiries)
Reason 6
Because theoretical thinking…
…provides roadmaps for research in
health promotion practice
A blue print for Health Promotion
Practice
• Theories are set up to inform associations we
look at or test – the why and how of people’s
behaviors and behavior changes rather than
“fishing” for variables or brainstorming a list of
factors that are not grounded in theory
• Using theory-informed research provides a blue
print of what to look for (or measure), and also
allows for further testing of associations in other
settings, with diverse populations for
generalizability factor.
How theory informs practice
• Many theories suggest strategies for changing
specific variables
• SCT: concepts of self-regulation and self-efficacy
• Intervention Goal: increase sedentary lifestyle (daily
levels of physical activity)
– Think about self-regulation and how to build in self-rewards into
the program (direct participants to chose self rewards that they
value to reinforce new physical activity behs)
– Think about self-efficacy and if in fact an individual can engage
in a specific behavior (walk for 30 mins a day). If people are not
confident to perform beh it doesn’t matter that they have put in
pleasurable self-rewards as the beh will not occur.
Reason # 6
• Theory-based evaluation
– Provides evaluation blueprint for analyzing the
effectiveness of a program
• Parameters for analyzing (and interpreting) what
was measured.
Study of Health Behavior
• Given that many factors shape and
motivate health behavior:
– individual’s biology,
family/community environment, &
the larger societal landscape
For each of these “factors,” there are corresponding theories
related to health behavior
INFLUENCES OF SMOKING BEHAVIOR…
Income
Leisure facilities
Religion
Nicotine addiction
Self-image
Stress
Locus of control
Peer group
SMOKING
Education
Environment
Gender
Age
Housing
Family
Ethnic group
Employment/unemployment
Taxation level on tobacco
Advertising
Culture of society
…Has a Corresponding Health
Behavior Theory
Public Policy
Institutional
Organizations- Institutions-Social networks
Community
(Work, School, Hospital)
Interpersonal
(Social networks)
Intrapersonal
(KABS)
Theories of Health Behavior
• Health Beliefs
• Theory of Planned
Behavior
• Stages of Change
• Precaution Adoption
Process
•
•
•
•
Social Cognitive Theory
Social Networks/Support
Diffusion of Innovations
Communication Theory
Individual Level
Theory
Stages of
Change
Model
Focus
Individuals' readiness to
change or attempt to change
toward healthy behaviors
Key concepts
Precontemplation
Contemplation
Decision/determination
Action
Maintenance
Health
Persons' perception of the
Belief Model threat of a health problem and
the appraisal of recommended
behavior(s) for preventing or
managing the problem
Perceived susceptibility
Perceived severity
Perceived benefits of action
Perceived barriers to action
Cues to action
Self-efficacy
The Theory
of Planned
Behavior
/Theory of
Reasoned
Action
Behavioral Intention
Attitude
Subjective Norm
Perceived Behavioral
Control
Behavioral intention is key,
intention is driven by attitude
and beliefs about what others
who are important think
Health Belief Model
Modifying factors
Beliefs
Age
Perceived
Gender
Susceptibility,
Ethnicity
Severity,
Personality
Benefits,
Socioeconomic status
and Barriers
Knowledge
Self-Efficacy
Behavior
Cues to
Action
-Edu/Advice
-Symptoms
-Media
Theory of Planned Behavior
Do you exercise regularly?
No
Yes
Do you intend to in the
next 30 day?
Yes
No
Do you intend to in
the next six
months?
No
Preparation
Yes
Precontemplation
Contemplation
How to
stage a
person
Have you been doing so
for more than 6 months?
No
Yes
Action
Maintenance
Precaution Adoption Process
Model
• Neil Weinstein’s precaution adoption
process model assumes that when
people begin new and relatively
complex behaviors aimed at protecting
themselves from harm, they move
through as many as seven stages of
belief about their personal
susceptibility
Stages of the PAPM
Unaware
Of hazard
Unengaged
(optimistic bias)
Undecided
about acting
(action is not nec)
Decide not to act
(precaution would be
effective)
Decide to act
Acting
Maintaining
Interpersonal Level
Theory
Focus
Key Concepts
Social
Cognitive
Theory
Behavior is explained via a 3way, dynamic reciprocal theory
in which personal factors,
environmental influences and
behavior continually interact
Behavioral capability
Reciprocal determinism
Expectations
Self-efficacy
Observational learning
Reinforcement
Social Cognitive Theory
Cognitions
Behaviors
Outcomes
Self Efficacy
Outcome
Environmental support Expectations
Social Network Theories
• Balance theory: a balance is maintained
between formal and informal support
systems
– Formal support: large organizations
(hospitals, etc)
– Informal support: family, friends, neighbors
– Individuals with strong informal support
networks live longer than those without that
type of support.
Community Level
Theory
Focus
Key Concepts
Community
Emphasizes active
Organization participation and
Theories
development of communities
that can better evaluate and
solve health and social
problems
OrganizaConcerns processes and
tional
strategies for increasing the
Change
chances that healthy policies
Theory
and programs will be adopted
and maintained in formal
organizations
Empowerment
Community competence
Participation and relevance
Issue selection
Critical consciousness
Diffusion of
Innovations
Relative advantage
Compatibility
Complexity
Trialability
Observability
Addresses how new ideas,
products, and social
practices spread within a
society or from one society to
another
Problem definition
(awareness stage)
Initiation of action
(adoption stage)
Implementation of change
Institutionalization of change
Diffusion of Innovations
• A process by which an
innovation (practice) is
communicated through certain
channels over time among the
members of a social system.
• Characteristics of the
innovation (practice) itself, the
diffusion process, persons who
adopt it, and the social system
will all influence how much and
how quickly innovation
(practice) is adopted, if at all.
• Attributes of innovations can help to
explain the different rates of adoption of
innovations by individuals:
1) Relative advantage
2) Compatibility
3) Complexity
4) Trialability or Flexibility
5) Observability
The communications process
MESSAGE -CHANNEL
SOURCES
RECEIVER
FEEDBACK
STIMULUS
RESPONSE
McGuire’s Communication Persuasion
Matrix
Output
Input
Source/Message/ Channel/Receiver/Destination
Attention
Comprehension
Acceptance
Retention
Action
Continuation
Principles that Cross Theories
• Acquiring behaviors is a process where
people are at different stages
• Knowledge is sufficient for beh change
• Importance of knowledge-attitudesintention-behavior sequence
• Individual motivation important
• Beliefs and values matter
• Rewarding experiences foster behavior
change
• Social relationships/norms important
• Behavior not independent of context
Planning Framework
Goal of this lecture:
• Enable each of you to understand what is
meant by the infamous saying in terms of
the work you do as PH professionals:
There is nothing so practical than a good
theory.
Kurt Lewin, 1951
A Good Fit Theory
• Is logical
• Is consistent with observations
• Is similar to those used in previous
successful interventions for a similar
situation
Throughout the Course…
• Take a stab at theorizing to know you can
become more than just a “theory
consumer” or a “theory applicator” in a
group