Theories and Planning Models Chapter 4

Chapter Objectives - 1 Define and explain the difference among theory, concept, construct, variable, and model Explain the importance of theory to health education/promotion Explain what is meant by behavior change theories and planning models Describe how the concept of socio-ecological approach applies to using theories

Chapter Objectives - 2 Explain the difference between continuum theories and stage theories Identify and briefly explain the behavior change theories, and their components, used in health education/promotion: Health Belief Model Precaution Adoption Process Model Theory of Planned Behavior Elaboration Likelihood Model of Persuasion Social Cognitive Theory Social Network Theory Information-Motivation-Behavioral Skills Model Social Capital Theory Diffusion Theory Transtheoretical Model of Change Community Readiness Model

Chapter Objectives - 3 Identify and briefly explain the planning models, and their components, used in health education/promotion: PRECEDE-PROCEED Multilevel Approach to Community Health (MATCH) Intervention Mapping CDCynergy Social Marketing Assessment and Response Tool (SMART) Mobilizing for Action through Planning and Partnerships (MAPP) Generalized Model (GM)

Definitions theory – “a set of interrelated concepts, definitions, and propositions that present a systematic view of events or situations by specifying relations among variables in order to explain and predict the events of the situations” (Glanz et al., 2008, p. 26) concept – primary elements of theories (Glanz et al., 2008) construct – a concept developed, created, or adopted for use with a specific theory (Kerlinger, 1986) variable – the operational (practical use) form of a construct; (Rimer & Glanz, 2005, p. 4); how a construct will be measured (Glanz et al., 2008) model – is a composite, a mixture of ideas or concepts taken from any number of theories and used together (Hayden, 2009, p. 1)

Importance of Using Theory in Health Education/Promotion Theories provide direction and organizes knowledge Theories can help in planning, implementing, and evaluating programs Indicates reasons why people are not behaving in healthy ways Identifies information needed for intervention development Provides a conceptual framework Gives insight for delivery Identifies measurements needed for evaluation Help provide focus and infuses ethics and social justice into practice Programs based upon sound theory more likely to succeed

Behavior Change Theories Multiple theories to design interventions Levels of influence are key parts of socio-ecological approach Socio-ecological approach helps to recognize importance of the larger social system of behaviors and social influences Figure 4.1 The socio-ecological model Source: Simons-Morton, B. G., McLeroy, K. R., & Wendel, M. L. (2012). Behavior theory in health promotion practice and research. Burlington, MA: Jones & Bartlett Learning. p. 45.

Intrapersonal (Individual) Theories - 1 Focus on factors within individuals (e.g. knowledge, attitudes, beliefs, self-concept, developmental history, past experiences, motivation, skills, and behaviors) Health Belief Model (HBM), Theory of Planned Behavior (TPB), Elaboration Likelihood Model of Persuasion (ELM), Information-Motivation-Behavior Skills Model (IMB), Transtheoretical Model of Change (TMC), Precaution Adoption, Process Model (PAPM) Continuum theories identify variables that influence action and combine them in a prediction equation

Intrapersonal (Individual) Theories - 2 Stage Theory Comprised of ordered set of categories into which people can be classified Identifies factors that could induce movement from one stage to another Four principle elements Category system to define stages Ordering of stages Barriers to change that are common among people in same stage Different barriers to change, facing people in different stages

Intrapersonal (Individual) Theories - 3 Health Belief Model (Rosenstock) Explains the likelihood of an individual to take action to prevent a disease or injury based upon: Sufficient motivation to make the issue relevant (perceived susceptibility and perceived seriousness) The perceived threat of the health issue The perceived benefits of a given action The perceived barriers to taking the necessary action Cues to actions may also impact on the individual’s likelihood of taking action Self-efficacy – to feel competent to overcome perceived barriers to take action

Intrapersonal (Individual) Theories - 4 Figure 4.2 Health Belief Model as a predictor of preventive health behavior Source: Becker, M. H., et al., from “A new approach to explaining sick-role behavior in low income populations,” American Journal of Public Health 64, March 1974: 205–216, Fig 1. Used by permission of Sheridan Press.

Intrapersonal (Individual) Theories - 5 Theory of Planned Behavior (Fishbein & Ajzen, 1975) Individuals’ intention to perform a given behavior is a function of their attitude toward the behavior, their belief of what others think they should do, and their perception of level of ease or difficulty of the behavior in which they are considering action Attitude toward the behavior Subjective norm Perceived behavioral control Actual behavioral control

Intrapersonal (Individual) Theories - 6 Figure 4.3 Theory of Planned Behavior (TPB) Source: “Theory of Planned Behavior Diagram” (TPB Diagram) by Dr. Icek Ajzen, http://www.people.umass.edu/aizen/tpb.diag.html. Reprinted by permission.

Intrapersonal (Individual) Theories - 7 Elaboration Likelihood Model of Persuasion Developed to explain inconsistencies in research results from the study of attitudes (Petty, Barden, & Wheeler, 2009) Attitudes form via two routes The two routes usually leads to attitudes with different consequences The model specifies how variables have an impact on persuasion elaboration – refers to the amount of cognitive processing (i.e., thought) that a person puts into receiving messages

Intrapersonal (Individual) Theories - 8 Figure 4.5 The Elaboration Likelihood Model of Persuasion (ELM) Source: From Petty, R. E., Barden J., & Wheeler, S. C., “The Elaboration Likelihood Model of Persuasion: Developing health promotions for sustained behavioural change” in Emerging theories in health promotion practice and research, 2nd ed.; DiClemente, R. J., Crosby, R. A., & Kegler, M. (Eds.), p. 196. Copyright © 2009 John Wiley & Sons, Inc. Reproduced with permission of John Wiley & Sons, Inc.

Intrapersonal (Individual) Theories - 9 Information-Motivation-Behavioral Skills Model Created to address the critical need for a strong theoretical basis for HIV/AIDS prevention efforts Information Motivation Behavioral skills Preventive behaviors Figure 4.6 The Information-Motivation-Behavioral Skills Model of HIV Prevention Health Behavior Source: From Fisher, J. D., & Fisher, W. A., “Changing AIDS risk behavior,” Psychological Bulletin 111 (3), 455–474, 1992. Published by American Psychological Association (APA). Reprinted by permission.

Intrapersonal (Individual) Theories - 10 Transtheoretical Model of Change (TMC) (Prochaska, 1979) People make behavior change through a series of different stages related to the behavior Stages of change Precontemplation—stage people are in before they are ready to change and are not intending to change Contemplation—stage when individuals are considering making a behavior change within the next 6 months Preparation—stage where the individual is actively planning change Action—the effort to make the change in behavior Maintenance—sustaining the change and resisting relapse Termination

Intrapersonal (Individual) Theories - 11 Precaution Adoption Process Model (PAPM) (Weinstein & Sandman, 2002) Explains how a person comes to the decision to take action, and how the decision is translated into action Figure 4.7 Stages of the Precaution Adoption Process Model (PAPM) Source: From Weinstein, N. D., Sandman, P. M., & Blalock, S. J., “The Precaution Adoption Process Model” in Health behavior and health education: Theory, research, and practice, 4th ed., K. Glanz, B. K. Rimer, and K. Viswanath, (Eds.), p. 127. Copyright © 2008 John Wiley & Sons, Inc. Reproduced with permission of John Wiley & Sons, Inc.

Interpersonal Theories - 1 Theories that “assume individuals exist within, and are influenced by, a social environment. The opinions, thoughts, behavior, advice, and support of people surrounding an individual influence his or her feelings and behavior, and the individual has a reciprocal effect on those people” (Rimer & Glanz, 2005, p. 19) These theories help to explain Social norms Social learning Social power Social integration Social networks Social support Social capital Interpersonal communication

Interpersonal Theories - 2 Social Cognitive Theory (Bandura, 1986) Learning is a reciprocal interaction between the individual’s environment, cognitive process, and behavior Behavioral capability Expectations Expectancies Locus of control Reciprocal determinism Observational learning Reinforcement Self-control Self-efficacy Emotional coping response

Interpersonal Theories - 3 Social Network Theory Explains the web of social relationships that surround people Key component – relationship between and among individuals and how those relationships influences beliefs and behaviors When assessing a network’s role, considers – Centrality vs. Marginality Reciprocity of relationships Complexity or intensity of relationships in the network Homogeneity or diversity of people in the network Subgroups, cliques, and linkages Communication patterns in the network

Interpersonal Theories - 4 Social Capital Theory Does not provide theories of change Does not guarantee empirical outcomes Does have an impact on health Type of network resources Bonding Bridging Linking Trust and reciprocity Norms and expectations Figure 4.9 Social capital Source: From Hayden, J., Introduction to Health Behavior Theory, 1st ed., Fig 9-3, p. 125. Copyright © 2009, Jones and Bartlett Publishers, Sudbury, MA. http://www.jblearning.com. Reprinted by permission.

Community Theories - 1 Group of theories includes three of the ecological perspective levels Institutional (e.g., rules & regulations) Community (e.g., social norms) Public policy (e.g., legislation)

Community Theories - 2 Diffusion Theory (Rogers, 1983) Explains diffusion of innovations in a population Categorizes individuals based upon when they adopt a new behavior, idea, or program Innovators – first to adopt. Early adopters – influential and open to trying innovations, but are more grounded than innovators Early majority individuals – wary and watchful about their involvement in new ideas Late majority – get involved through peers or mentors programs and more skeptical and adopt after most people Laggards – last to be involved and interested in change Health educators will need to modify marketing strategies to attract individuals from each of the different categories

Community Theories - 3 Figure 4.10 Bar chart depicting percentages of persons adopting an innovation over time

Community Theories - 4 Community Readiness Model (Edwards et al., 2000) Stage model to explain the nine stages of community readiness to change No awareness Denial Vague awareness Preplanning Preparation Initiation Stabilization Confirmation/expansion Professionalism

Community Theories - 5 Table 4.3 Community readiness stages and goals

Planning Models - 1 Sound health promotion programs are organized around a well-thought-out and well-conceived model Models serve as frames from which to build; structure & organization for the planning process Many models Many have common elements but may have different labels No perfect model

Planning Models - 2 PRECEDE-PROCEED (Green & Kreuter, 1991) Best known & often used model Developers: Larry W. Green & Marshall W. Kreuter PRECEDE—predisposing, reinforcing, and enabling constructs in educational / ecological diagnosis & evaluation PROCEED—policy, regulatory, and organizational constructs in educational & environmental development

Planning Models - 3 PRECEDE PROCEED Social assessment Epidemiological assessment Educational and ecological assessment Intervention alignment and administrative and policy assessment PROCEED Implementation Process evaluation Impact evaluation Outcome evaluation

Planning Models - 4 Figure 4.14 PREDEDE-PROCEED model for health program planning Source: From Green, L. W., & Kreuter, M. W., Health program planning: An educational and ecological approach, 4th ed., p. 17, Fig 1.5. Copyright © 2005 The McGraw-Hill Companies, Inc. Reprinted by permission.

Planning Models - 5 Multilevel Approach to Community Health (MATCH) (Simons-Morton et al., 1995) Ecological planning perspective Recognizes that intervention activities should be aimed at a variety of objectives and individuals Phases Phase 1: health goal selection Phase 2: intervention planning Phase 3: program development Phase 4: implementation Phase 5: evaluation

Planning Models - 6 Intervention Mapping (Bartholomew et al.,1998) Based upon the importance of theory and evidence in the development of health promotion programs Step 1: needs assessment Step 2: matrices of change objectives Step 3: theory-based methods and practical strategies Step 4: program development Step 5: adoption and implementation Step 6: evaluation planning

Planning Models - 7 CDCynergy (CDC, 1998) Developed for public health professionals at the Centers for Disease Control and Prevention Used by professionals who have responsibilities for health communication Six phases Phase 1: describe problem Phase 2: analyze problem Phase 3: plan intervention Phase 4: develop intervention Phase 5: plan evaluation Phase 6: implement plan Content specific editions of the software are available

Planning Models - 8 Social Marketing Assessment and Response Tool (SMART) (Neiger, 1998) Central focus is the consumer Composed of seven phases: Phase 1: preliminary planning Phase 2: consumer analysis Phase 3: market analysis Phase 4: channel analysis Phase 5: develop intervention, materials, and pretest Phase 6: implementation Phase 7: evaluation

Planning Models - 9 Mobilizing for Action through Planning and Partnerships (MAPP) (NACCHO, 2001) Blends the strengths of other planning models Six phases Phase 1: organizing for success and partnership development Phase 2: visioning Phase 3: conducting the four MAPP assessments Phase 4: identify strategic issues Phase 5: formulate goals and strategies Phase 6: the action cycle

Planning Models - 10 Figure 4.13 Mobilizing for Action through Planning and Partnerships (MAPP) model Source: National Association of Country and City Health Officials, “Mobilizing for Action through Planning and Partnerships (MAPP) Model” from http://www.naccho. org/topics/infrastructure/mapp/upload/ MAPP_Handbook_fnl.pdf. Reprinted by permission.

Planning Models - 11 Generalized Model for Program Planning (GMPP) (McKenzie et al., 2009). Five tasks: Assessing needs Setting goals and objectives Developing interventions Implementing interventions Evaluating results

Planning Models - 12 Figure 4.14 Generalized model Source: From McKenzie, J. F., Neiger, B. L., & Thackery, R., Planning, implementing and evaluating health promotion programs: A primer, 6th ed., p. 45, Fig. 3.1. Copyright © 2013. Reproduced by permission of Pearson, Boston, MA.

Summary Health education/promotion is a multidisciplinary profession & has evolved from the theory & practice of other disciplines Many of the theories & models used in health education/promotion also have evolved from these other disciplines Key terms: theory, concept, construct, variable, & model There are many behavior change theories that can be categorized using the five levels (intrapersonal, interpersonal, institutional, community, & public policy) of the socio-ecological approach There is a distinction between continuum theories & stage theories Planning models provide a framework on which to build programs

Theories and Planning Models Chapter 4: The End