1. H671 – Advanced Theories of Health Behavior n Introductions n Review syllabus and requirements –Including weekly writing assignments n How to think about theory – Darcie –Class activity and discussion n Break n Advanced thinking about theory – Flay –Discussion n The TTI – Flay –Discussion

2. WHY LEARN THEORY? n In order to have an impact on health behavior, it is necessary to understand it. n In the current research and program environment, it is increasingly important to demonstrate systematic connections between: –an assessment of a health problem (how you define the problem, including applicable theory); – what you say you are going to do about it (program components); and –how you know whether or not your program had an impact (evaluation). n Because theory is a tool for explaining behavior, it is a key part of making such connections.

3. Theory & Practice n Traditionally a duality n Dewey: “experimental knowing” as the ground between theory and practice n Bidirectional Continuum –Fundamental Research –Intervention Research –Surveillance Research –Application and Program Delivery

4. Theory n A systematic view of phenomena created to explain and predict them n Theory must provide a logical explanation for a phenomenon that takes all known information into account –Example: Newtonian physics n A theory must have these qualities: –Generality, Testability, Abstraction n “A set of interrelated constructs (concepts), definitions, and propositions that present a systematic view of phenomena by specifying relations among variables, with the purpose of explaining and predicting the phenomena.” –Kerlinger, 1986

5. Components of Theories n Concepts –Major components of a theory –Building blocks –May or may not have meaning outside the context of the theory n Constructs –A concept that has been developed or adopted for use in a particular theory –A construct can only be understood in the context of its parent theory Example: Self-Efficacy n Variables –The empirical counterparts of constructs –Operational form of a construct –They specify how a construct is to be measured in a specific situation Example: Creating a questionnaire to measure depression so you can assign a score to an individual

6. Specifying Relations: How do variables affect or relate to each other? n Correlative –Depression and Cancer n Causative –Smoking and Heart Disease n Coincident –Being left-handed and developing Diabetes Type I n Mediating –A process that intervenes between input and output in a system –Example: Social Support mediates between stress & disease n Moderating –A variable that affects the direction or strength of the relation between an independent and dependent variable –Example: Lifestyle factors moderate the effects of race on hypertension

7. Types of Theory n Explanatory Theories –Describe problems –Identify sources of problems –Search for modifiable factors –Examples Health Belief Model Theory of Planned Behavior

8. Types of Theory (Cont.) n Change Theories –Of behavior change –Intervention design –Evaluation strategies –Provide explicit assumptions for why a program will work –Help determine why a program didn’t work –Examples Community Organization Diffusion of Innovations

9. ROOTS OF CURRENT HEALTH BEHAVIOR THEORY n Theories about something are explanatory statements or models. n The term theory, as it is commonly used, derives its meaning from a context of Western philosophy and science. n There are many other explanatory traditions as well. n Primary fields from which most current health behavior theory come – psychology and social psychology. n And…Important contributions from ecology, sociology, anthropology, organizational and community theory, communications theory, and others.

10. BASIC ASSUMPTIONS IN THE WESTERN TRADITION OF THEORY n Order and regularity – that the universe is ordered and regular, which has practical applications for technology, etc. n Predictability – if there is order and regularity, the rules or “laws” can be learned, and used to predict. n Primacy of empirical data – the positivist epistemology associated with the Western tradition holds that what we know comes from our senses -- observable, tangible evidence n Progress and perfectability – that there is an inexorable movement towards more knowledge, better understanding, higher complexity etc.

11. COGNITIVE PSYCHOLOGY n Focus on the THINKING PROCESS. n THINKING PROCESSES include perception, memory, decision-making, interpretation, reasoning, judgment, etc. n Some cognitive psychologists (e.g. Piaget) focus on the development of the thinking process. n See the influence of cognitive psychology in many of the individual-level theories (e.g., Health Belief Model) that are discussed in the course.

12. BEHAVIORIST PSYCHOLOGY n ASSUMPTION: Behavior is learned through a process of stimulus and response. “Thinking” not a major part of this process. n Early focus on classical conditioning (Pavlov’s dog), then on operant conditioning (Skinner) -- the conditioning of behavior by positive and negative reinforcements. Idea of shaping behavior, behavior modification. n Behavior modification still used in smoking cessation, addiction treatment and other programs. n The basic assumptions about learning behavior through positive and negative reinforcements appear in a number of health behavior theories.

13. HUMANISTIC PSYCHOLOGY n Focus on individual capacity, on human capability of choice. n ASSUMPTION: That human beings desire to grow and attain their full potential – role of psychology is to help. n Before attaining higher level needs, humans have to satisfy basic to “mid-level” needs, from basic physiological to emotional to social (Maslow). n Humanistic psychology influenced the public health emphasis on quality of life, and the lifestyle concept.

14. SOCIAL PSYCHOLOGY n Most of psychology focuses on the individual experience; social psychology focuses on the interaction between individuals and the group – groups, relationships, social units. n This may include: group dynamics, authority and legitimacy, emotion and its expression, aggression, self-identity, motivation, gender roles, norms, attitudes, group prejudices. n Social psychology has had a considerable influence on such health behavior theories as Social Cognitive Theory, Theory of Planned Behavior, Social Network Theory, and others.

15. SOCIOLOGY n Sociology includes the study of society and its phenomena – social groups, social hierarchies, social structures, the nature of social interaction and organization, the interaction between social and economic systems. n There is overlap between sociology, psychology and anthropology in explaining behavior. n Influence on health behavior theory: concepts of class and hierarchy, group norms and conformity, role of social capital, social organization and its impact on behavior.

16. CULTURAL ANTHROPOLOGY n Focus on the role of culture in human behavior, the ways in which life-patterns are organized, together with systems of knowledge and belief, language and symbol. n This may include: cultural beliefs, attitudes, social-cultural roles, gender, language, symbolic expression, social authority and legitimacy, health knowledge systems, healing practices, healers, etc. n Influence on health behavior theory: holistic (ecological) approaches, cultural influence on treatment and care, values and meanings as connected to behavior, cultural constructions of disease and illness.

17. ECOLOGY AND BIOLOGICAL SYSTEMS n The study of how living organisms function within interdependent systems – human ecology refers to the same idea applied to human systems. n This may include: relationships between the life patterns of organisms and their environment; ecological niches, symbiotic and other relationships. n Influence on health behavior theory: ecological approach, focus on multiple determinants of health, role of the environment in behavior.

18. Meta Information n No one theory is adequate n Every theory and model has a specific goal –What does it try to explain? Is it about how people learn? Is it about how people change? Is it about how people relate to others? n Every theory/model is somehow connected to what came before –Evolution of understanding –Increasing complexity and sophistication n Every theory/model has a better/best fit: –For particular problems –For particular populations –For particular interventions n Every theory/model was developed in a cultural and social milieu that may be different from present day

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

20. Reason # 1: Ethics and social justice n 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).

21. Reason # 1 cont. n 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

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

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

24. Reason # 2 cont. n Theorizing: responsibility embedded in 6 of the 7 areas of professional responsibility for health educators, defined by NCHEC (National Commission for Health Education Credentialing). n 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)

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

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

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

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

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

30. Reason # 6: Builds scientific knowledge n The body of knowledge in a given field needs two types of research: 1.Descriptive 2.Analytical n Public Health: too much descriptive research? Not enough analytical? n “Chaos in the Brickyard” letter by Bernard K. Forscher (Science, 1963) –Too many scattered bricks (data) –No buildings (bricks connected in a planned manner)

31. Reason # 7: Provide roadmaps for research n 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