Theory

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Theory
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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)

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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)

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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

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Concepts Constructs

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

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More theory

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

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The Ecological Model

• Emphasizes the links and relationships among
  multiple factors (or determinants) affecting
  health

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Ecological Model
Public Policy
Community
Institutional or Organizational
Interpersonal
Individual
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Individual / Intrapersonal factors

• Knowledge, attitudes, beliefs (KAB)
• Skills
• Motivation
• Self-concept
• Age, gender, genetics

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Interpersonal factors

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

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Institutional or organization factors

• Social institutions with organizational
  characteristics and formal (and informal) rules
  and regulations for operations. (ACHA, 2012)

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Community factors

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

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Public Policy Factors

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

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Ecological Model
Concept Definition
Intrapersonal Factors Individual characteristics that influence behavior, such as knowledge, attitudes, beliefs, and personality traits.
Interpersonal Factors Interpersonal processes, and primary groups including family, friends, peers, that provide social identity, support, and role definition.
Institutional/Organizational Factors Rules, regulations, policies, and informal structures, which may constrain or promote recommended behaviors.
Community Factors Social networks and norms, or standards, which exist as formal or informal among individuals, groups, and organizations.
Public Policy Local, state, federal policies and laws that regulate or support healthy actions and practices for disease prevention, early detection, control, and management.
NIH, Theory at a Glance
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Ecological Model
Public Policy
Community
Institutional or Organizational
Interpersonal
Individual
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Behavior Change Theories

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

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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

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Health Belief Model (HBM)

• Developed in the early 1950s by social
  psychologists in the U.S. Public Health Service.
• Hochbaum Rosenstock
• TB screening

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Constructs of HBM

• Perceived threat
• Perceived susceptibility
• Beliefs about ones chances of getting a
  condition
• Perceived severity
• Beliefs about how serious the condition might be

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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

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Constructs of HBM

• Cues to Action
• Strategies to activate ones readiness
• Self-Efficacy
• Confidence in ones ability to take action

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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
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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
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Health Belief Model
Construct Definition Application
Perceived Susceptibility Ones opinion of chances of getting a condition. Personalize risk based on a persons feature or behavior heighten perceived susceptibility if low.
Perceived Severity Ones opinion of how serious a condition and its effects are. Specify consequences of the risk and the condition.
Perceived Benefits Ones opinion of the efficacy of the advised action to reduce risk / seriousness of impact. Define action to take how, where, when clarify the positive effects to be expected.
Perceived Barriers Ones opinion of the tangible and psychological costs of the advised action. Identify and reduce barriers through reassurance, incentives, assistance.
Cues to Action Strategies to activate readiness Provide how-to information, promote awareness, reminders.
Self-Efficacy Confidence in ones ability to take action. Provide training, guidance in performing action.
NIH, Theory at a Glance
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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

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TRA Cont.

• Beliefs and Subjective Norms help predict
  Intentions
• Your Intentions predict your actual Behavior

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TRA
Attitude toward behavior
Intention
Behavior
Subjective Norm
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Theory of Planned Behavior (TPB)

• Developed by Fishbein Ajzen
• An extension of the Theory of Reasoned Action
  (TRA)

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TPB versus TRA

• Adds the construct
• Perceived Behavioral Control
• Belief about personal control in combination with
  belief about the ones ability to do what needs
  to be done.
• Actual Behavioral Control have the skills and
  resources needed to quit.

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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.

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TPB
Attitude toward the behavior
Intention
Behavior
Subjective Norm
Perceived Behavioral Control
Actual Behavioral Control
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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 farmers market. Lives near park and
walking trails
Not much I can do
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Theory of Planned Behavior
Construct Definition Application / Approach
Behavioral Intention Perceived likelihood of performing behavior Are you likely or unlikely to perform the behavior?
Attitude Personal evaluation of the behavior Do you see the behavior as good, neutral or bad?
Subjective Norm Beliefs about whether key people approve or disapprove of the behavior motivation to behave in a way that gains their approval Do you agree or disagree that most people approve of/disapprove of the behavior?
Perceived Behavioral Control Belief that one has, and can exercise, control over performing the behavior Do you believe performing the behavior is up to you, or not up to you?
NIH, Theory at a Glance
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Transtheoretical Model (TTM)

• AKA Stages of Change
• Developed by Prochaska DiClemente
• Major Constructs
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Decisional Balance
• Self-Efficacy

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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.

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Contemplation

• Shoe shopping
• Seriously thinking about making a behavior
  change, but have not yet made a commitment to
  action

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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

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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

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Maintenance

• Shoes go on every day.
• Sustaining the behavior change for over 6 months.

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Decisional Balance

• The costs and benefits of changing.

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Self-Efficacy

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

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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)

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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
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Stages of Change (TTM)
Construct Definition Application
Pre-contemplation Unaware of problem, hasnt thought about change. Increase awareness of need for change, personalize information on risks and benefits.
Contemplation Thinking about change in the near future. Motivate, encourage to make specific plans.
Preparation Making a plan to change. Assist in developing concrete action plans, setting gradual goals.
Action Implementation of specific action plan. Assist with feedback, problem solving, social support, reinforcement.
Maintenance Continuation of desirable actions, or repeating periodic recommended step(s) Assist in coping, reminders, finding alternatives, avoiding relapses
NIH, Theory at a Glance
Groups with this theory dont forget a relapse
plan!
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Pros 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

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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)
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Adapted fromAutobiography 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.

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• II
• I walk down the same street.
• There is a deep hole in the sidewalk.
• I pretend I dont see it.
• I fall in again.
• I cant believe I am in the same place.
• It still takes a long time to get out.

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• III
• I walk down the same street.
• There is a deep hole in the sidewalk.
• I see it is there.
• I still fall in its a habit.
• My eyes are open.
• I know where I am.
• I get out immediately.

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• 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.

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Behavior change theories with interpersonal focus

• Social Cognitive Theory (SCT)
• Social Network Theory (SNT)
• Social Capital Theory

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Social Cognitive Theory (SCT)

• A behavior change theory with an Interpersonal /
  Social network focus.

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Reciprocal Determinism
Characteristics of the Person
Environment in which the behavior is performed
Behavior of the person
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More constructs of SCT

• Behavior Capacity
• Expectations
• Expectancies
• Self-Control / Self-Regulation

• Self-Efficacy
• Reinforcement
• Observational Learning
• Emotional Coping Responses

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Reinforcement

• Any action or event that increases the desired
  behavior
• Present something positive
• Money
• New clothes
• Remove something negative
• Nagging
• Teasing

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Punishment

• Any action or event that decreases the likelihood
  that the desired behavior will occur.
• Present something negative
• Criticize
• Policies or laws
• Remove something positive
• Praise
• Privilege

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Social Cognitive Theory
Construct Definition Application
Reciprocal Determinism Behavior changes result from interaction between person and environment Involve the individual and relevant others work to change the environment, if warranted.
Behavioral Capacity Knowledge and skills to influence behavior Provide information and training about action.
Expectations Beliefs about likely results of action Incorporate information about likely results of action in advice.
Self-Efficacy Confidence in ability to take action and persist in the action Point out strengths use persuasion and encouragement approach behavior change in small steps.
Observational Learning Beliefs based on observing others like self and/or visible physical results Point out others experience, physical changes identify role models to emulate.
Reinforcement Responses to a persons behavior that increase or decrease the chances of recurrence Provide incentives, rewards, praise encourage self-reward decrease possibility of negative responses that deter positive changes.
NIH, Theory at a Glance
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Behavior theories with community focus

• Diffusion of Innovation Theory (DF)
• AKA Diffusion Theory
• Community Readiness Model (CRM)

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Diffusion of Innovations Theory

• Rogers, 1983
• A behavior change theory with a community focus

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Diffusion of Innovations

• The progressive adoption by members of a
  community or society of an idea or practice over
  time.

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Adoption Curve
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Categories of Adopters

• Innovators (lt3)
• Independent, risk-takers, eager to try new ideas
• Not necessarily the most respected members of the
  community
• Seek info on their own, rely on their own
  judgment in making decisions about adoption
• Try out new ideas and provide the first tests of
  the utility of the innovation

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Categories of Adopters

• Early Adopters (14)
• Respected members of the community
• Opinion leaders
• Powerful influence on other potential adopters
• Trendy like to be up on what is good and new
• Seen as opinion leaders

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Categories of Adopters

• Early Majority (34)
• Greatly influenced by mass media and opinion
  leaders
• By virtue of their numbers, they begin to form a
  new norm
• Lots of contact with peers, but dont hold
  leadership positions.

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Categories of Adopters

• Late Majority (34)
• Skeptical of change
• Tend to wait until an innovation is established
  as a norm before adopting
• Motivation is greatly influenced by peers
• Dont like risk and uncertainty

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Categories of Adopters

• Laggards (16)
• Very traditional and conservative
• Tend to have less education and lower SES
• Socially and geographically mobile
• Narrow and restricted communication networks
• Suspicious of innovations and adverse to risk

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Determinants of Diffusions Speed and Extent

• Is the innovation better than what it will
  replace?
• Does the innovation fit with the intended
  audience?
• Is the innovation easy to use?
• Can the innovation be tried out before adopting?
• Are the results of the innovation observable and
  easily measured?

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Diffusion of Innovations Theory
Concept Definition Application
Relative advantage The degree to which an innovation is seen as better than the idea, practice, program, or product it replaces. Point out unique benefits monetary value convenience, time saving, prestige, etc.
Compatibility How consistent the innovation is with values, habits, experience, and needs of potential adopters. Tailor innovation for the intended audiences values, norms, or situation.
Complexity How difficult the innovation is to understand and/or use. Create program/idea/product to be uncomplicated, easy to use and understand.
Trialability Extent to which the innovation can be experimented with before a commitment to adopt is required. Provide opportunities to try on a limited basis, e.g., free samples, introductory sessions, money-back guarantee.
Observability Extent to which the innovation provides tangible or visible results. Assure visibility of results feedback or publicity.
NIH, Theory at a Glance
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Summary of Theories
Theory Focus Key Concepts
Health Belief Model Individuals perceptions of the threat posed by a health problem, the benefits of avoiding the threat, and factors influencing the decision to act. Perceived susceptibility Perceived severity Perceived benefits/barriers Cues to action Self-Efficacy
Transtheoretical Model Individuals motivation and readiness to change a problem behavior. Pre-contemplation Contemplation Preparation Action Maintenance
Theory of Planned Behavior Individuals attitudes toward a behavior, perceptions of norms, and beliefs about the ease or difficulty of changing. Behavioral intention Attitude Subjective norm Perceived behavioral control
NIH, Theory at a Glance
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Summary of Theories continued
Theory Focus Key Concepts
Social Cognitive Theory Personal factors, environmental factors, and human behavior exert influence on each other. Reciprocal determinism Behavioral capacity Expectations Self-efficacy Observational learning Reinforcements
Diffusion of Innovations Theory How new ideas, products, and practices spread within a society or form one society to another. Relative advantage Compatibility Complexity Trialability Observability
NIH, Theory at a Glance
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A few more pieces

• Predisposing, Reinforcing, and Enabling Factors
• Barriers to change
• PRECEDE/PROCEED behavioral diagnosis phase

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Predisposing Factors

• Provide the rationale or motivation for a person
  or group to act
• KAB (knowledge, attitudes, beliefs)
• Personal preferences
• Existing skills
• Self-efficacy beliefs
• Individual level theories
• Intrapersonal are most appropriate for addressing
  these factors.

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Reinforcing Factors

• Factors that provide reinforcement and reward for
  actions and encourage repetition of the action
• Social support
• Peer influence
• Significant others (family, spouse, partner)
• Employers, teachers, health providers, community
  leaders, decision-makers

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Enabling Factors

• Factors that provide the means or make the action
  possible.
• Availability of programs or services or skills
  training
• Accessibility of programs or services or skills
  training

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Writing Objectives

• Objectives start with the word to followed by
  an action verb.
• Specify a single, key action to be accomplished
• The What / how much
• Specifies a target date
• The When
• Avoids the How and Why
• Realistic and attainable

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Objectives

• S specific
• M measurable
• A attainable
• R realistic
• T timely

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Examples of objectives

• To decrease soda intake by one soda a week and be
  soda free by December 1st, 2012.
• To increase running distance 1 mile every week in
  order to run a marathon on March 10th, 2013.
• To cook a new vegetable recipe once a week
  through December 5th, 2012.