Epi 246 Introduction to Theories of Health Behavior/ Health Behavior Change Focusing on Individual Behavior within Socio-Ecological Perspective Margaret Handley, PhD MPH Associate Professor Dept. Epidemiology and Biostatistics and Center for Vulnerable Populations, DGIM September 22, 2011

Outline of Today’s Lecture Course overview and structure 2. Implementation and dissemination science 3. Behavioral theory in implementation science 4. A few theories to start: Health Belief Model Theory of Planned Behavior Overview – where did this course come from? Next slide go over the range of topics and why- who is coming to present and why Go over HW and two tracks- when is HW due and returned, office hours. Grading- also late items Go over how lectures are set up and when things are put onto course site- the resources and the readings Emphasis to make it practical so please provide feedback on that Emphasis on HOW to use theories and how they have been used to improve evidence, improve interventions, decide which way to go- There are many details to go over, but would like to have this be focus of the reading- excellent book Glanz et al. Would like class to focus on how these are being used, how to create, the frameworks for integrating, how to be critical of theory and lack of it, in different types of IDS research Go over the examples in lecture and as handouts of applications Structure

Epi 246 Learning Objectives Understand key behavioral theories and their components, diverse applications of these components, and behavior change ‘strategies’ or ‘tools’ developed from them. 2. Understand linkages between health behavior theory focused on individuals and implementation and dissemination science in ‘real world’ applications.

Epi 246 Learning Objectives cont. 3. Use ecological perspectives to describe behavior and develop behavior change interventions using multiple theory components. 4. Understand gaps in different approaches to theory and critiques of theories. 5. Apply behavioral theory to planning, developing, implementing and evaluating health-related behavior and behavior change interventions. Notes that this is a long term process as well.

New Ways to Talk About Evidence Gaps “Many evidence-based innovations fail to produce results when transferred to communities in the global south, largely because their implementation is untested, unsuitable or incomplete” “Scientists have been slow to view implementation as a dynamic, adaptive, multi-scale phenomenon that can be addressed through a research agenda” From a public health perspective guidelines for practice cannot address realities of challenges for health faced in community settings And geographically, from a global health perspective, evidence is not implemented at all, implementation is not assessed for efficacy outcomes, and efforts are lacking in providing real integration into low cost effective strategies T. Madon et al .2007

Translational Terms used by Health Research Funders applied health research capacity building diffusion dissemination getting knowledge into practice impact implementation knowledge communication knowledge cycle knowledge exchange knowledge management knowledge translation knowledge mobilization knowledge transfer linkage and exchange popularization of research research into practice research mediation research transfer research translation science communication “third mission” translational research Graham et al. (2006). Lost in knowledge translation: time for a map? Journal of Continuing Education in the Health Professions

What is Translational Research? A bridge between discovery and impact? or maybe a journey? These are my thoughts on this topic – but I dont really think it is a bridge- that is too linear and the t2 terminal at mexico city airport may be closer but Some of the federal initiatives are better at explaining by what translational research does, than a definition of its attributes

The Link Between Translational and Implementation and Dissemination Science “Implementation science is a relatively young branch of health services research that aims to translate biomedical and public health knowledge into changes in the behavior of health care professionals, patients or the general public. IS is concerned with moving from evidence to (changes in) practice and ultimately health outcomes, and in learning how best to do that through research” IDS is ‘young’ in being recognized as an integral component of health services, clinical, epidemiological research. People have been doing it for a long time. Now there is a focus on developing formal training to do IDS, rather than it coming after years of experience and trial and error. It is akin to advances made in clinical epi in last 40 years, that have led to ability to study disease processes and population risk, in entirely new ways. - M Soloman, “The Ethical Urgency of Advancing Implementation Sciences” Am J Bioethics, 2010

What is the Link between Behavior Theory and Improving Evidence-Based Practice? “Increasing evidence suggests that public health and health promotion interventions based in social and behavioral sciences are more effective than those lacking a theoretical base” – Glanz and Bishop “Making research more theory-based will improve evidence-based practice” –Green  the NIH has moved more in this direction as it has seen gaps in evidence and understanding when things do work, which components are important Glanz K and Bishop D. Annu Rev Public Health. 31:3990418. 2010 Green, L.W.  American Journal of Public Health 96(3): 406-409, Mar. 2006 *Eccles M. et al. Changing the behavior of healthcare professionals (2005) *Painter JE et al The use of theory in health behavior research 2000-2005 (2008). 9

Evidence Continuum – Begin with Theory This article in the reading gives a nice summary of how theory on behavior is critical to the uptake of research findings into practice- this framework shows how theory-informed approach to research is akin to pre-clinical stages of trials development This big first block ‘theory’ includes theories to understand behavior as well as those to change behavior- some are suited to both, others help more in one or another domain more fully Eccles, M e al, 2005. J Clin Epi 107-112. Medical Research Council, 2000 10

Which Health Behavior/Change Theories? Psychological theories 2. Inter-personal theories 3. Health communication theories 4. Dissemination of information theories 5. Theories from behavioral economics Participatory, community building, empowerment theories 7. All of the above

Learning Objectives – Lecture 1 1. Understand why health behavior change theories focused at individuals are is helpful for implementation and dissemination science research and real world applications 2. Understand components of the Health Belief Model and Theory of Planned Behavior 3. Conceptualize applying components of these theories to health-related behaviors – including both understanding behavior and intervention planning/evaluation

An Individual or a Structural/Ecological Perspective? Glanz terms ecological perspective as view that public health/HP/interventions should target individual, interpersonal, organizational and environmental level factors Some history- beginnings of health promotion and public health more ecological, then very individual, and now returning to ecological models Clearly it is not a dichotomy, in every situation there is some of each- in this class we are starting with the individual, and moving outside of their isolated psychological state to include more and more influences, but the premise is that individuals’ actions matter in behavior change and sometimes it is not the individuals we first think of as the change agents, who are the most effective – what we will also do in this class, is present alternatative views on behavior change agents- that contradicts the’ empowered individual’ or ‘empowerable individual’ assumptions, that are often at the heart of many of these theories 13

Ecological and Individual Perspectives “The use of collective action to support personal responsibility is central to public health” -Brownell et al, Health Affairs 2010 Glanz terms ecological perspective as view that public health/HP/interventions should target individual, interpersonal, organizational and environmental level factors Some history- beginnings of health promotion and public health more ecological, then very individual, and now returning to ecological models Clearly it is not a dichotomy, in every situation there is some of each- in this class we are starting with the individual, and moving outside of their isolated psychological state to include more and more influences, but the premise is that individuals’ actions matter in behavior change and sometimes it is not the individuals we first think of as the change agents, who are the most effective – what we will also do in this class, is present alternatative views on behavior change agents- that contradicts the’ empowered individual’ or ‘empowerable individual’ assumptions, that are often at the heart of many of these theories “There is a confluence of structural forces that shape and determine poverty and it is important to probe beneath the superficial determinants of and presumptions about poverty.” 14

A Generalized Ecological Perspective K Glanz and B Rimmer. Theory at a Glance. NCI, 2005

How Individual-Based Behavior Theories Are Used 1. Provide a road map for answering difficult questions on which behaviors to target and for whom e.g. Do you target the providers’ behavior re guidelines or focus on structural or policy barriers? Or both? Help understand environmental factors that reinforce or undermine individual behaviors e.g. Neighborhood ‘walkability’, access to condoms, ease of appointment scheduling 3. Help understand the mechanisms (ingredients) underlying effective interventions – to tailor/scale up Also see the article in the reading – the 5 roles of theory in design and testing of behavior change interventions NIH Science of Behavior Change, Meeting Summary, June 15-16, 2009 http://commonfund.nih.gov/pdf/SOBC_Meeting_Summary_2009.pdf

Behavioral Sciences Theory Theory – a set of inter-related concepts, definitions, and propositions that explain or predict events or situations (can also specify relationships among these variables) Behavioral Sciences Theory an amalgamation of approaches, methods, and strategies/tools from social and health sciences that is accessible to both researchers and practitioners Now we are moving into discussion of theory- As defined in this course- Includes- psychology, sociology, anthropology, economics, nursing, communications, media, Some emphasized here re community building, social learning/diffusion of innovations and social marketing are often valued by practitioners -- Glanz and Bishop, Ann Rev Public Health 2010

Behavioral Theory Use on a Continuum 1. Informed by theory – Framework or constructs identified, but not specifically applied 2. Applied theory - Framework or constructs identified--at least one construct specifically applied 3. Testing theory - Framework or constructs identified and tested against one another This class is aimed to give you examples and tools for all of these different ways 4. Building/creating theory – Developing new or revised theory using constructs specified, measured, and analyzed Painter, et al, 2008 18

“Theoretical Domains” – These occur in some form, with some related terminology, with some degree of emphasis, in just about every change theory dealing with individuals. e.g. PERCEIVED Susceptibility and Perceived CONSEQUENCES Risk appraisal Self perception Emotions Relationships & social influences Environment, community, cultural & structural influences e.g. SELF-EFFICACY e.g. SOCIAL NORMS PEER LEARNING e.g. FOOD POLICIES, POVERTY, DIRECT APPT. SCHEDULING, TRANSPORTATION 19 19

History of Cognitive Theories- Health Belief Model Origins of cognitive theories came from some US work on preventive behaviors in 50s and 60s- we did not understand why preventive behaviors were hard to influence?

Health Belief Model Focus: Key Concepts Individuals’ perceptions of the threat posed by a health problem, The benefits of avoiding the threat, and factors influencing the decision to act. Usually related to patients and health behavior within community settings - Perceived susceptibility - Perceived severity - Perceived benefits - Perceived barriers - Cues to action - (Self-efficacy) Explain- why do some people do this and others don’t? Cues to action=Activation factors for change readiness SE=confidence in ones ability to act Origins story- TB screening What is encouraging some and discouraging others? Cues to action in lead research and screening- Views about susceptibility seemed likely to play a part, barriers to costs and benefits re avoiding or doing screening, how ready to act about it Past work on needle exchange- uptake- asked views of susceptibility to HIV, ….. Strong Health Beliefs translates into MOTIVATION and ACTION to prevent, get screened for or control illness

Health Belief Model Action FOCUS ON INDIVIDUAL BELIEFS THAT AFFECT MOTIVATION Perceived susceptibility, perceived severity (combined = perceived THREAT) Perceived benefits Perceived barriers Perceived self-efficacy Action Motivation MODIFYING FACTORS AND ENVIRONMENT Age, gender, socioeconomics, knowledge personality Cues to action

Example- Understanding Behavior with HBM Concept Motivations BEFORE/ AFTER Prevention Education Visit Screening or Testing Perceived Susceptibility ASSESS: Belief that they could get lead poisoning Belief that may have been exposed to TB 2. Perceived Severity ASSESS: Belief that lead poisoning is bad for you, even if you cannot see its effects Belief that consequences of TB without knowledge or treatment are significant enough to try to avoid 3. Perceived Benefits ASSESS: Belief that not getting lead poisoning will improve health, be good for child’s future Belief that the recommended action of getting tested would benefit them 4. Perceived Barriers ASSESS: Belief that there was some truth to the lead problem, and that not just a negative ‘Mexican’ stereotype Identify their personal barriers to getting tested and explore ways to eliminate or reduce these barriers 5. Cues to Action Reminder, cues for action – *Best person-town-specific Reminder cues for action *Often person-specific 6. Self-Efficacy Confident in avoiding high risk foods in social circumstances Guidance/ training (practice in making an appointment)

Health Belief Model Example: TB Treatment Adherence Two Reviews of literature found some support for health belief model for understanding adherence behaviors but harder to see benefits in promoting adherence (This review ignores cures to action and self efficacy) 44 articles on qualitative data re to TB adherence- 8 themes and two are HB-based re disease and treatment. Adherence, treatment efficacy, patients views on DOTS and DOTS workers Positive impact of providers on adherence Munro et al, 2007. BMC Public Health; Munro et al, 2007. PlosMedicine

Health Belief Model Action APPLICATIONS FOR CHANGING INDIVIDUAL BELIEFS Perceived THREAT: personalize risk, educate on risk Perceived benefits: operationalize specific actions and benefits Perceived barriers: reduce perceptions, problem-solve, incentives Perceived self-efficacy: support and training, goal setting Very cognitive focused and focused on individual exclusively, with some attention to modifying effects, but these assumed to act through motivation, not independent of it Evidence- strong for many types of preventive and treatment behaviors- strongest construct seems to be barriers and susceptibility, least is severity- you must feel at risk, able to overcome barriers, and confident you will be able to complete the behavior Varies in measures to local conditions and problems such that you often need to develop the constructs for each project, through qualitative work- eg barriers to different types of behaviors will vary- eg barriers to breast cancer screening different than those for colon cancer screening- then validate these measures in the sample you are working with- eg focus groups to identify the barriers, then construct survey items and measure content validity eg factor analysis etc Book gives good detailed examples of these strategies in health care and community settings, with various degrees of tailoring for breast cancer screening to help women overcome barriers. Also are examples re risk sexual behavior interventions that target self-efficacy, as this makes sense to develop skills that can be used more than one time (eg condom use) Action INCREASE MOTIVATION Cues to action: Increase awareness, media/marketing, prompts, reminders

HBM and Re-Framing Public Health Information 26

HBM Case Study: Asking Mom: Formative Research for an HPV Campaign Targeting Mothers of Adolescent Girls Shafer et al 2011 Context: Targeted health communication campaigns that promote HPV vaccination have potential to reduce racial and geographic disparities in cervical cancer incidence in rural S. USA. What should messages include? Behavior targeted: HPV vaccine Initiation/mother is target Focus Groups for Pre-production Message Concepts: HBM constructs- eg. Perceived susceptibility/ Severity 2. Prospect theory – decision making and ‘gain’ frame 3. Emotional truths to influence decision making Two Reviews of literature found some support for health belief model for understanding adherence behaviors but harder to see benefits in promoting adherence (This review ignores cures to action and self efficacy) 44 articles on qualitative data re to TB adherence- 8 themes and two are HB-based re disease and treatment. Adherence, treatment efficacy, patients views on DOTS and DOTS workers Positive impact of providers on adherence

Theory of Planned Behavior Focus: Key Concepts: Individual’s attitude towards a behavior, perceptions of norms, and beliefs about ease of difficulty of changes Often used in clinician as well as patient and community behavior Behavioral intention: - Attitude - Subjective norm - Perceived control and Self-efficacy Define- Subjective norms – influence of SIGNIFICANT others in the form of pressure or persuasion Jane Austen’s ‘persuasion’ addresses subjective norm as the main thesis Behavioral control- barriers and facilitators to the behavior Strong Planned Behavior translates into INTENTION to ACT to prevent, screen for or control illness

Theory of Planned Behavior FOCUS ON BELEIFS THAT AFFECT INTENTION Beliefs, Evaluation of Behavioral Outcomes (combined=ATTITUDES), normative beliefs, Motivation (combined=SUBJECTIVE NORM) Control beliefs, perceived power (self-efficacy) (combined=PERCEIVED CONTROL) MODIFYING FACTORS AND ENVIRONMENT Demographic Attitudes to target Behavior Personality More interpersonal factors recognized here Action INTENTION

Theory of Planned Behavior Case Study: Factors influencing compliance with guidelines for induced abortion- Foy 2005 Measured behavioral intention, attitudes, subjective norm, perceived behavioral control, open-ended barriers Perceived behavioral control was low, perceptions that organizational barriers were important Interventions were recommended to target: Professional control over appointments, staff social marketing re 5 day window, training staff in family planning, more contraceptive choices available Foy R et al Intl J Qual in Healthcare 2005

Theory of Planned Behavior APPLICATIONS TO CHANGE FACTORS THAT AFFECT INTENTION ATTITUDES: Increase exposure to pro-behavior attitudes SUBJECTIVE: Social marketing to ‘naturalize’ desired behavior NORM PERCEIVED CONTROL: Identify behaviors within control, then train and guide, goal setting, reinforce, demonstrate skills Action INCREASE INTENTION

Behavior Change and Rationality How am I supposed to think about the consequences before they happen?