1. Epi 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

2. 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

3. 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.

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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:
Green, L.W.  American Journal of Public Health 96(3): , 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 (2008). 9

10. 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, J Clin Epi Medical Research Council, 2000 10

11. 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

12. 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

13. 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

14. 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

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

16. 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

17. 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

18. 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

19. “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

20. 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?

21. 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

22. 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

23. 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)

24. 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, BMC Public Health; Munro et al, PlosMedicine

25. 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

26. HBM and Re-Framing Public Health Information26

27. 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

28. 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

29. 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

30. 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

31. 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

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