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

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

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

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

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

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

11. PRECEDE/PROCEEDModel

12. MATCH (Multilevel Approach To Community Health) • Developed in late 1980s • Used by U.S. Government • Applied when behavioral & environmental risk & protective factors for disease / injury are known & general priorities determined • Includes ecological planning – levels of influence

13. MATCH Figure 4.16: MATCH: Multilevel Approach To Community Health (Pearson Ed, 2012)

14. CDCynergy • Developed by the Office of Communication at the CDC in 1997 • First issued in 1998 • Developed initially for public health professionals at CDC with responsibilities for health communication • Developed for health communication but can be used with all health promotion planning • Available on CD-ROM; many versions (Pearson Ed, 2012)

15. CDCynergy P 6: Implement Plan P 3: Plan Intervention (Is communication dominant or supportive?) P 5: Plan Evaluation P 4: Develop Intervention P 2: Analyze Problem (causes, goals, intervention strategies P 1: Describe Problem (identify & define) (Pearson Ed, 2012)

16. Generalized Model for Program Planning (GMPP) Figure 4.18: Generalized Model for Program Planning (Pearson Ed, 2012)

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

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

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

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

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

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

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

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

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

26. 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

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

28. 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

29. 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

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

31. 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

32. 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

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

34. TRA Attitude toward behavior Intention Behavior Subjective Norm

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

36. 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.

37. 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.

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

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

40. 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.”

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

42. 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

43. 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

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

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

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

47. 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)

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

49. 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

50. 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)