THEORY

What is theory?

Theory

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

Concepts & Constructs

Concepts: Major ideas

Constructs: Concepts that have been developed and

defined for use in a particular theory

More theory

The Ecological Model

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

Ecological Model

Individual

Interpersonal

Institutional orOrganizational

Community

Public Policy

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

Interpersonal factors

Social support / social networks Formal and informal

Family, friends, peers Social norms, cultural environment

Institutional or organization factors Social institutions with organizational

characteristics and formal (and informal) rules and regulations for operations. (ACHA,

2012)

Community factors

The geographic, cultural or social community. May include:

Community organizations Local laws Physical characteristics/attributes of location Available (or unavailable) services

Public Policy Factors

Local, state, national and global laws and policies. (ACHA, 2012)

May promote or restrict behavior

Ecological Model

Individual

Interpersonal

Institutional orOrganizational

Community

Public Policy

Behavior Change Theories

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

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

Health Belief Model (HBM)

Developed in the early 1950’s by social psychologists in the U.S. Public Health Service.

Hochbaum & Rosenstock

TB screening

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

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

Constructs of HBM

Cues to Action Strategies to activate one’s “readiness”

Self-Efficacy Confidence in one’s ability to take action

Health Belief Model

Perceived Susceptibility & Perceived Seriousness

Perceived Threat

Likelihood of taking recommended action

Cues to Action

Modifying Factors: age, race, ethnicity, SES, personality

Outcome Expectations: Perceived Benefits vs.

Perceived Risks/Barriers

Self-efficacy

Health Belief Model

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

45 y/o Caucasian male, married, 2 children, works full-time, desk job, does not seek health information

Outcome Expectations: Perceived benefits: no

HTN medication, delay or prevent heart

disease/stroke, live longer, better quality life.

Perceived barriers/risks: time, money, injury?

Self-efficacy: moderate

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

TRA Cont.

Beliefs and Subjective Norms help predict Intentions

Your Intentions predict your actual Behavior

TRA

Attitude toward behavior

Subjective Norm

Intention Behavior

Theory of Planned Behavior (TPB) Developed by Fishbein & Ajzen

An extension of the Theory of Reasoned Action (TRA)

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.

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.

TPB

Attitude toward the behavior

Subjective Norm

Intention Behavior

Perceived Behavioral

Control

Actual Behavioral

Control

TPBHealthy eating

takes time, extra money and a lot of

energy

Friends / family do not exercise

and junk food is always

abundant

Eating healthier / exercising

Behavior

“Not much I can do”

Nearby grocery stores often have good sales,

lives near farmer’s market. Lives near park and

walking trails

Transtheoretical Model (TTM) AKA: Stages of Change Developed by Prochaska & DiClemente Major Constructs:

Precontemplation Contemplation Preparation Action Maintenance Decisional Balance Self-Efficacy

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.”

Contemplation

“Shoe shopping”

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

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

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

Maintenance

“Shoes go on every day.”

Sustaining the behavior change for over 6 months.

Decisional Balance

The costs and benefits of changing.

Self-Efficacy

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

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)

Precontemplation

Contemplation

Preparation

Action

Maintenance

Decisional Balance

Decisional Balance

Self-Effic

acy

Self-Effic

acy

Transtheoretical Model (TTM)

Between every stage, the client needs to have decisional balance and self-efficacy

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

How to stage a person using TTMDo you exercise regularly?

No Yes

Do you intend to in the next 30 days?

Have you been doing so for more than 6 months?

No Yes No Yes

Do you intend to in the next six months?

No Yes

Precontemplation

Contemplation

Preparation Action Maintenance

(Pearson Ed, 2012)

Adapted from:

Autobiography in Five Short Chaptersby Portia Nelson

II walk down the street.

There is a deep hole in the sidewalk.I fall in

I am lost … I am helplessIt takes forever to find a way out.

III walk down the same street.

There is a deep hole in the sidewalk.I pretend I don’t see it.

I fall in again.I can’t believe I am in the same place.

It still takes a long time to get out.

IIII walk down the same street.

There is a deep hole in the sidewalk.I see it is there.

I still fall in … it’s a habit.My eyes are open.I know where I am.

I get out immediately.

IVI walk down the same street.

There is a deep hole in the sidewalk.I walk around it.

VI walk down another street.

Behavior change theories with interpersonal focus

Social Cognitive Theory (SCT) **

Social Network Theory (SNT)

Social Capital Theory

Social Cognitive Theory (SCT) A behavior change theory with an

Interpersonal / Social network focus.

Reciprocal Determinism

Characteristics

of the Person

Environment in which the behavior is performed Behavior of

the person

More constructs of SCT

Behavior Capacity

Expectations

Expectancies

Self-Control / Self-Regulation

Self-Efficacy

Reinforcement

Observational Learning

Emotional Coping Responses

Reinforcement

Any action or event that increases the desired behavior

Present something positive Money New clothes

Remove something negative Nagging Teasing

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

Behavior theories with community focus

Diffusion of Innovation Theory (DF) ** AKA: Diffusion Theory

Community Readiness Model (CRM)

Diffusion of Innovations Theory Rogers, 1983

A behavior change theory with a community focus

Diffusion of Innovations

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

Adoption Curve

Categories of Adopters

Innovators (<3%) 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

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

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 don’t hold leadership positions.

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

Don’t like risk and uncertainty

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

Determinants of Diffusion’s 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?

A few more pieces

Predisposing, Reinforcing, and Enabling Factors

Barriers to change PRECEDE/PROCEED behavioral diagnosis

phase

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.

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

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

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

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.