H571 – Week 1 Introductions Review of syllabus Name, program, year, prior experiences with HP and interests for this course Complete sign-in form – indicating your health behaviors of interest and your preferences for week of presentation Review of syllabus Expectations, assignments, questions All communications via email Use only your ONID email address! Activity – Discussion/Brainstorming Review DSC Chapters 1 & 2 and NCI Review TTI

Activity 1: What Is Your Topic/Area of Interest? Think about looking upstream from disease to behavior Understanding the causes and consequences of a particular health-related behavior Promoting a particular desirable behavior or preventing a particular undesirable behavior Amenable to individual-, group- and population-level interventions List your choice of week to present See next slide

H571 syllabus/course outline PART I: Introduction, Intrapersonal Theories, Interpersonal Theories Week 1: Introduction to health promotion and health behavior theory Week 2: Value-Expectancy Theories Week 3: Perceived Threat and Fear Appeals Week 4: Stage Models Week 5: Social Cognitive Theory PART II: Sociocultural Theories Week 6: Behavioral Economics Week 7: Communications theories (HPHB students) Week 8: Diffusion of Innovations and Community Theories Week 10: Ecological approaches and integrative theories (HPHB students)

Discussion: Why is understanding the causes (theories about) and consequences of health behavior important for your topic/area of interest/expertise? Why is understanding how to change health behavior (and theories about behavior change) important for your topic/area of interest/expertise?

Brainstorm: What are the causes of peoples’ behavior? OR Why do people behave the ways the do?

DSC Chapter 1 Health Behavior (HB) in the Context of the "New" Public Health (PH) Three levels of prevention Definition of health promotion (HP) Importance of multiple theories for HP Understand multiple kinds of theories HBs are influenced by multiple environments (physical, social, economic, legal, political) as well as intrapersonal factors Thus, need a broad range of theories

Introduction What is health? Is this definition comprehensive? According to the World Health Organization (WHO): “Health is not merely the absence of disease or infirmity; rather, health should encompass a state of complete physical, mental and social well-being Is this definition comprehensive? Reconceptualized at 1986 Conference Should be defined to encompass the: “extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs; and, on the other hand, to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the object of the living; it is a positive concept emphasizing social and personal resources as well as physical capacities.”

Public Health Issues, 1900 & 1997

Introduction Chronic Diseases: manifest over time, are not always apparent, may be long lasting or recurring Infectious Diseases: diseases transmitted through a specific form of contact How might the role of environment and behavior influence the spread of each disease type?

Key Concepts The United States spends more on health care than any other nation in the world (WHO, 2009) U.S. only ranks 47th in terms of life expectancy See Figure 1-2 (next slide)

Key Concepts

Why Emphasize Prevention? Some estimates suggest that the U.S. government spends $1,390 per person to treat disease, while spending only $1.21 per person on prevention E.g., Type 2 Diabetes Obesity a modifiable risk factor (i.e. can be changed) If obesity and inactivity reduced, should also experience significant decrease in prevalence of Type 2 Diabetes 1 out of every 5 U.S. federal healthcare dollars is spent treating people with diabetes, from a cost-saving perspective should attempt to prevent rather than treat diabetes, unfortunately in 1999, of the total dollars spent on national health care, only 1% went to population-based prevention

Health Behavior is Complex Changing behavior is not as simple as it seems Behavior is complex and influenced by many factors, therefore changing it requires deep understanding of a range of influences Before behavior can be changed, one must understand the determinants of behavior Can include: biological and personality characteristics; family, peers, and community; socio-cultural influences, the built environment, etc. \

Health Promotion is Complex Health promotion involves two aspects: research and practice Health promotion research works to understand underlying individual and environmental factors that influence health behavior Health promotion practice is responsible for designing and implementing interventions to modify factors and ultimately change behavior Both sides (research and practice) must work together and play an integral role in promoting health.

Theory is Complex Theory is a tool used in both research and practice Definition: Theory is a set of testable propositions that is used to explain a group of facts of phenomena In health promotion, theory is viewed as a tool for enhancing our understanding of complex situations versus something that offers universal explanations or predictions (Green, 2000)

However… Social scientists have used the term “theory” to mean several different things (there is little consensus): A set of empirical generalizations A unified, systematic causal explanation for various phenomena A theoretical orientation (or “school-of-thought”) A single theory (e.g. Critical Theory) Hypotheses, models, conceptual frameworks

Important to remember Commonsense theories and Scientific theories have a key element in common: They represent efforts at making sense of the world in which humans live; it’s a meaning-attribution activity; an attempt to “tell stories about how things work” HOWEVER, ONE BIG DIFFERENCE: Scientific theories have been tested and found valid across multiple populations and contexts

Definitions from NCI Concepts are the building blocks—the primary elements—of a theory. Constructs are concepts developed or adopted for use in a particular theory. Variables are the operational forms of constructs. They define the way a construct is to be measured in a specific situation. Match variables to constructs when identifying what needs to be assessed during evaluation of a theory-driven program. Models may draw on a number of theories to help understand a particular problem in a certain setting or context. They are not always as specified as theory.

Types of Health Behavior Theories Explanatory theories Help understand the causes/determinants of a behavior Descriptive Change theories Guide the development of interventions Process oriented

Theory to Practice Effective practice depends on using theories and strategies that are appropriate to a situation: The target condition or behavior The target population Units of analysis or change The type of behavior to be addressed

The Public Health Approach Public health seeks to promote health, prevent early mortality and morbidity, and enhance or ensure quality of life Prevention is the basic principle underlying the public health approach Public health focuses on populations (or groups of people); it is not clinical (or focused on individuals)

The Public Health Approach Prevention of disease requires more than just avoiding clinically observable illness Figure 1-3: The wellness/illness continuum If work from right to left (medical to prevention) begins with a diagnosis and is reactive, limits public health approach to changing people one at a time, the prevention to medical orientation lends itself to a population level approach because it is not predicated on an individual medical diagnosis

Primary Prevention Public health predicated on primary prevention Primary prevention: efforts are made to intercept the onset or occurrence of disease, injury or behavior. Ex: vaccination programs, abstinence programs, bicycle helmet laws for children Involves intervening before disease onset

Public Health Approach Universal approach: When an entire population or subgroups of the population are targeted regardless of whether individuals have specific risk factors Selective approach: primary prevention efforts targeted at those in the population who are at heightened risk. Typically targeted based on biological, psychological, social or environmental risk factors Universal approach: If the preventative effort corresponds to a high rate within the population (i.e. diabetes, obesity, alcohol abuse) then the universal approach is very cost-effective. If the rate is infrequent in the population, this may not hold true Selective approach: Ex: Obesity is a risk factor for diabetes so if you want to combat Type 2 diabetes, target individuals whose BMI is above 25, who have not yet developed Type 2 diabetes

Secondary Prevention Secondary prevention occurs when a disease process is diagnosed in an early stage of progression, thereby enhancing the odds of treatment success. Focus is to minimize consequences through early detection and intervention. E.g., Screening programs for STDs, mammography or smoking cessation programs

Tertiary Prevention Tertiary prevention occurs when a disease state is diagnosed in time to apply treatment that may preserve further organic damage or death Involves mitigating the consequences of disease or an injury after the fact Difference between Secondary and Tertiary Prevention can be thought of as the difference between early and late diagnosis

Tertiary Prevention Indicated approach used in tertiary prevention- designed for individuals who have a risk factor that put them at very high risk E.g., Providing mental health counseling for rape victims, providing patients who have Type 2 diabetes with educational pamphlets to help them better manage their disease Tertiary prevention in the public health model is similar to treatment in the medical model

Three Levels of Prevention

Activity Discussion of the most appropriate level of prevention for your chosen topics

Health Behaviors Behavior- the manner in which something acts, functions, responds, or reacts. Health behavior- the actions, responses or reactions of an individual, group or system that prevent illness, promote health and maintain quality of life E.g., individual health behavior: using a condom, getting vaccinated, buckling your seatbelt E.g., group health behavior: improving public parks, instituting a citywide smoking ban

Three Categories of Health Behaviors Preventive behavior: Health-related behaviors of people who are healthy and try to maintain their health Illness behavior: behavior undertaken by individuals who perceive themselves to be ill and who seek relief or definition of illness Sick-role behavior: the treatment plan once an individual is diagnosed with a disease

Health Behaviors

“New” Public Health Increased emphasis on the significant role of environmental influences in shaping individual behavior and affective health (i.e. culture, policy, technology, urbanization, built environment) Health promotion: the art and science of motivating people to enhance their lifestyle to achieve complete health, not just the absence of disease

Figure 1-6: Health Promotion Strategies Each strategy can be applied to a range of settings, risk factors, population groups, diseases or negative health outcomes. Strategies not applied in isolation, overlap and are integral to achieving health promotion objectives

Health Promotion What is missing from the last image? Health promotion researchers, policy makers and practitioners use theory to guide many of their health promotion strategies. Health promotion is a process; therefore, defines itself in terms of its goals and strategies. Relies on theoretical contributions from many other disciplines (social psychology, sociology, child development, education, etc.)

DSC – Chapter 2 Understand: That health behaviors are diverse Proximal and distal influences And ultimate/fundamental causes How Theory Informs Health Promotion and Public Health Practice Use of theory in multilevel approaches to prevention/HP

Introduction Theory has become an indispensable tool for the development, implementation and evaluation of public health initiatives It enables researchers to better understand and change health behavior

Role of Theory Theory can be used to: Define the specific objectives/strategies Related to a targeted behavior Meant to alter hypothesized mediators Or causes of the targeted behavior To lead to effective behavior change Note the emphasis on effective – not all HP is effective For a large number of people the objective of public health (in contrast to clinical services)

Health Behaviors are Diverse Three dimensions of health behavior Complexity, frequency, volitionality Complexity: involving higher levels of knowledge, skill or resources to perform than simple behaviors E.g., Correct use of the male condom involves at least 10 steps; the more complicated the behavior, the lower the likelihood it will be performed correctly

Health Behaviors are Diverse Complexity not always inherent in the behavior, can be a function of the environment E.g., Getting a flu vaccine may not be complex for a middle class American with health insurance; however, the same behavior may be high in complexity for a person living in isolated, rural poverty

Health Behaviors are Diverse Frequency: Health behaviors can be frequent and repetitive (diet and exercise), one time only (screening for radon), or periodic (obtaining a mammogram) Behaviors may be highly complex but only require infrequent repetition (colorectal cancer screening) or complex and require daily repetition (consuming a low-fat diet)

Health Behaviors are Diverse Volitionality: the degree of personal control over the behavior Highly volitional behavior is one over which the person has complete control; performing the behavior does not require external resources, assistance or support (i.e. flossing) Behaviors low in volitionality require reliance on external resources (i.e. consuming fresh produce, may not be affordable or available)

Theory at Multiple Levels Much like health behaviors, theories are also diverse Theories can be applied at several “levels” within the environment See Figure 2-2 (next slide)

Figure 2-2: Socioecological Model

Ecological Framework Outer levels influence inner levels all the way down to the individual (“I” in the inner-most circle) The individual is often the “target” of the intervention; however, making changes at any of the levels can influence individual health behavior Ecological approaches are now widely believed to be more effective than single-level approaches Example: When assessing whether older adults in Denmark received an influenza vaccine, individual factors such as barriers/benefits to vaccination where cited, however, factors such as type of housing and living arrangements were also found to be associated with vaccination rates

Proximal vs. Distal Influences Proximal Influences: inner-level factors that are close in proximity to the individual (“I”) Distal Influences: factors located in the outer levels, that do not always directly or immediately affect the individual due to their location in the model See Box 2-1 (next slide) Ex: Taxes on cigarettes and tobacco smoking regulations, distal influences on tobacco use. May have broad impact and eventually influence individual-level behavior

Box 2-1: Proximal vs. Distal Influences Ex: Taxes on cigarettes and tobacco smoking regulations, distal influences on tobacco use. May have broad impact and eventually influence individual-level behavior

However ….. We see a slightly different formulation in the TTI (and in Week 10)

Role of Theory Theory helps us to develop an organized, systematic and efficient approach to investigating health behaviors (so we are not just guessing at distal and proximal influences!)

Informal Steps to the Inductive Approach Your own hunch about the nature of the health behavior and underlying causes Think about the health behavior from a theoretical perspective Conduct an empirical evaluation (relying on published literature) that suggests underlying causes of risk and protective behaviors

Inductive Approach These steps serve to identify the determinants of a specific health behavior Determinants: factors that influence the health behavior (levels of influence in the Ecological and TTI Models) Determinants may range from individual characteristics such as knowledge, attitudes and beliefs, to social factors such as family, friends and community, to environmental (or sociocultural) factors such as laws, economics, politics, religion, culture

Inductive Approach It is determinants/mediators that we target to affect behavior change By changing multiple determinants, we may be able to induce lasting behavioral change Theory helps researchers and practitioners highlight determinants/mediators more quickly and effectively

Program Planning

Multi-level Intervention The ecological approach uses theory to create intervention points across several levels Multi-level: implies at least two of the following ecological levels have been examined: individual, familial, relational, peer, community, societal or policy/legal When interactions between levels are examined, we gain a greater understanding of health behaviors

Hypothesized Mediators Mediator: represents the determinant targeted by the intervention and its association with the health behavior When the determinant is theory-derived, referred to as a hypothesized mediator Hypothesized mediator “comes between” intervention and behavioral outcome Ex: Identify cost as a barrier to vaccination, eliminate the hypothesized mediator (offer vaccines for free), expect an increase in vaccination uptake

Objectives An objective is a quantifiable action that (when achieved) will contribute to achieving behavior change E.g., Breastfeeding. Suppose social support is a hypothesized mediator of breastfeeding among first time mothers. If the goal of the intervention is to increase breastfeeding, the objective to enhance social support networks has a chance of being effective.

Objectives Theory guides the identification of objectives that (if achieved) will lead to changes in the behavior Figure 2-4:

Ecological Approach May be most appropriate to health behaviors that are complex, require frequent repetition and require external resources (i.e. changing lifestyle behaviors that lead to obesity and diabetes) Some of the most powerful approaches may be too expensive for use by local public health professionals – require access to changing policies/regulations/laws (or poverty!)

Conclusion Theory is a vital tool in health promotion practice and research Theory selection and use is one essential part of program planning that guides intervention development One theory does not fit all needs, program objectives are diverse and, thus, integrated theories or a selection of theories may be useful

The Theory of Triadic Influence Snyder & Flay, 2012: Brief introduction to the Theory of Triadic Influence (TTI)

Proximal Correlates of Behavior Social skills Self management Self-efficacy Social Norms theories Conformity theories Expectancy theories Attitude theories BEHAVIOR Intentions/Decision Attitudes Toward Behavior Social Normative Beliefs Self-Efficacy Theory of Planned Behavior Theory of Reasoned Action

Distal Causes of Behavior Person-Situation-Environment (Lewin, 1951) Biological theories Psychoanalytic theories Resilience (Garmazey) Personality theories Self-Control (Gottfredson & Hirschi) Social Control (Elliott) Family Systems (Brooks) Peer Clustering (Oetting)   Class Conflict Low SES, Anomie Social Disorganization Strain Theory (Merton) Radical Theories GENETICS ENVIRONMENT BEHAVIOR Intentions/Decision IntraPersonal Environment Social Situation

THE THEORY OF TRIADIC INFLUENCE GENETICS ENVIRONMENT IntraPersonal Environment Social Situation Attitudes Toward Behavior Self-Efficacy Social Normative Beliefs Intentions/Decision BEHAVIOR 64

THE THEORY OF TRIADIC INFLUENCE Distal Influences Proximal Predictors Levels of Causation Ultimate Causes Social/ Personal Nexus Expectancies & Evaluations Affect and Cognitions Decisions Experiences Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream Biological/Nature Nurture/Cultural BIOLOGY/ PERSONALITY SOCIAL SITUATION CULTURAL ENVIRONMENT 1 2 3 4 5 6 Sense of Social Interpersonal Others’ Interactions w/ Social Instit’s Information/ Self/Control Competence Bonding Beh & Atts Opportunities 7 8 9 10 11 12 Self Skills: Motivation Perceived Values/ Knowledge/ Determination Social+General to Comply Norms Evaluations Expectancies 13 14 15 16 17 18 SELF-EFFICACY BEHAVIORAL CONTROL SOCIAL NORMATIVE BELIEFS ATTITUDES TOWARD THE BEHAVIOR 19 20 21 22 23 DECISIONS/INTENTIONS Trial Behavior EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological

THE THEORY OF TRIADIC INFLUENCE Reciprocal Feedback: Once a behavior occurs, the resulting reactions and/or experiences (thoughts and feelings) feed back to change the original causes Reciprocal feedback occurs through all streams and levels Engaging in a behavior changes one’s attitudes, normative beliefs and self efficacy It also changes one’s knowledge, relationships with parents and peers, and sense of self

THE THEORY OF TRIADIC INFLUENCE Distal Influences Proximal Predictors Levels of Causation Ultimate Causes Social/ Personal Nexus Expectancies & Evaluations Affect and Cognitions Decisions Experiences Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream Biological/Nature Nurture/Cultural BIOLOGY/ PERSONALITY SOCIAL SITUATION CULTURAL ENVIRONMENT Values/ Evaluations Knowledge/ Expectancies Perceived Norms Information/ Opportunities Interpersonal Bonding Social Competence Interactions w/ Social Instit’s Others’ Beh & Atts Motivation to Comply Skills: Social+General Sense of Self/Control Will: Self- Determination 1 2 3 7 8 9 10 11 12 13 14 15 16 17 18 l 4 5 6 a b c d e f C F I B E H A D G g h i j k m n o p q r s t u v w x SELF-EFFICACY BEHAVIORAL CONTROL SOCIAL NORMATIVE BELIEFS ATTITUDES TOWARD THE BEHAVIOR 19 20 21 22 23 DECISIONS/INTENTIONS Trial Behavior EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological Related Behaviors J K 67

THE THEORY OF TRIADIC INFLUENCE Continuous Cycle of Causation: Feedback changes the likelihood of engaging in the same or a similar behavior in the future Thus, causes and effects are in a continuous cycle: With each behavior changing the causes, and The changed causes leading to the same or similar behavior over time Mutually influential individual  contextual relations Developmental regulation

Feedback Also Shown This Way Att SNB P SE S B I E Att SNB P SE S B I E Att SNB P SE S DEVELOPMENT & TIME

THE THEORY OF TRIADIC INFLUENCE Role of Related Behavior: The reactions to certain behaviors feed back to influence the causes of RELATED BEHAVIORS e.g., smoking and other drug use - Related behaviors have similar causes, with the more distal causes being the most similar - Less related behaviors (e.g., smoking and skiing) have fewer causes in common - Even related behaviors have some differences in proximal causes

Closely and less related behaviors: Ultimate causes may be the same, distal predictors less so. E S P E S P E S P E S P E S P E S P E S P A single behavior Eg, smoking Two closely related behaviors. Eg, smoking and drinking Less and less related behaviors. Eg, smoking, drug abuse, sex, exercise.

The TTI Developmental-Ecological System Levels of P P S E P Eval Behavior SNB Self Efficacy Att Intentions Will + Skill Exp Mc NB Know Value Social Bonds Role Models Self- Control Com- petence Values Environment Knowledge ENVIRONMENT Situation Person Affective/Control Substreams Cognitive/Competence Substreams Causation Ultimate Underlying Causes Distal Predisposing Influences Proximal Immediate Predictors DEVELOPMENT & TIME 72

Supplementary Slides Reasons for thinking theoretically: Material from Goodson, Patricia (2010). Theory in Health Promotion Research and Practice: Thinking Outside the Box. Boston: Jones and Bartlett Publishers.

Reasons for Thinking Theoretically about Health Promotion # 1 - Infuses Ethics and Social Justice into Public Health Practice # 2 - Represents A Moral Duty and A Professional Responsibility # 3 - Guides the Profession # 4 - Prevents Ideological Take-Over, or Hegemony # 5 - Guides and Perfects Practice # 6 - Builds Scientific Knowledge # 7 - Provides Roadmaps for Research

Reason # 1: Ethics and social justice The Tuskegee Study Breech of ethical principles in conducting research. One of the reasons for ethical mis-conduct: According to James Jones (author of the book Bad Blood) – medicine, at the time, was a profession “almost wholly composed of people uninterested in theorizing” (Jones, 1993, p. 96).

Reason # 1 Tuskegee happened because… The medical (and public health) profession trained physicians to become Healing technicians Health methodologists Health strategists Not trained to Reflect Inquire Question the status quo OR: not trained to think theoretically

Reason # 2:Moral duty and Professional responsibility Professions have defined tasks and values. Professional tasks and values = professional responsibilities Most professions  CODE OF ETHICS and PROFESSIONAL COMPETENCIES

Reason # 2 Our professional responsibilities include: Develop our professional tools Become more effective and efficient Reflect continually on our practice Question our methods Reform our views, when needed Build narratives that provide meaning for people’s health promotion efforts Witness / Listen to our clients’ narratives

Reason # 2 Theorizing: responsibility embedded in 6 of the 7 areas of professional responsibility for health educators, defined by NCHEC (National Commission for Health Education Credentialing). Examples: “Identify factors that influence health behaviors” (Area I – sub-competency C) “Identify factors that foster or hinder the process of health education” (Area I – sub-competency E)

Reason # 3: Guides the Profession Few scholars are thinking theoretically about the direction health promotion/public health is taking. Those who have thought theoretically, have contributed: New theories New models and perspectives New approaches Helpful critiques

Reason # 3 Few scholars engage in theoretical thinking about public health because: It is disquieting Can be disturbing Can “rattle the status quo cage” Yet: THIS is what theory does…

Reason # 4: Prevent ideological take-over, or hegemony Ideology = the integrated assertions, theories and aims that form the collection of plans societies have for governing themselves. Hegemony = happens when one social group’s ideology dominates another group and becomes the predominant influence over this group (OR: an ideology take-over).

Reason # 4 If public health professionals do not build and shape public health’s ideology, professionals outside public health will. Consider the influence of other fields of knowledge on public health, historically. Public health cannot exist without an ideology (or set of theories). Someone has to build these theories and assertions. If not public health professionals, who?

Reason # 5: Guides and perfects practice Practice = set of activities used to promote health and prevent illness. “Practice makes perfect”  “Theory makes perfect” (Willinsky, 1998, p.245). Prevention interventions: more effective when based on theory Many theories suggest strategies for changing specific factors/variables/elements. Practitioners may not have to re-invent the wheel, when using these theories.

Reason # 6: Builds scientific knowledge The body of knowledge in a given field needs two types of research: Descriptive Analytical Public Health: too much descriptive research? Not enough analytical? “Chaos in the Brickyard” letter by Bernard K. Forscher (Science, 1963) Too many scattered bricks (data) No buildings (bricks connected in a planned manner)

Reason # 7: Provide roadmaps for research Most fields: asking for more theory-based research Provides data that can be generalized more broadly (applied to a larger number of contexts/contingencies). Facilitates conducting and implementing research projects. Provides blueprint for selecting which variables to measure. Provides parameters for analyzing (and interpreting) what was measured. Avoids: Re-inventing the wheel, going around in circles