1. Epi 246 Individual-Focused Theories of Health Behavior/ Health Behavior Change Using a Socio-Ecological Perspective Margaret Handley, PhD MPH Dept. Epidemiology and Biostatistics and Center for Vulnerable Populations, DGIM January 6, 2011

2. Outline of Today’s Lecture I.Implementation and dissemination sciences II. Link between IDS and behavior change theories III. Course overview and structure IV. Ecological models and individual-focused theory V. A few explanatory theories to start and applications within IDS-related work Health Belief Model Theory of Planned Behavior Trans-theoretical Model-Stages of Change

3. I. The Need for Implementation and Dissemination Sciences “The uptake of research findings into routine practice is a haphazard and unpredictable process” “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.” “Implementation science represents a philosophical commitment to bringing the same scientific rigor to health care delivery systems as we bring to biomedical discoveries.” Eccles et al, 2005; Madon T, et al. 2007 M. Soloman et al.; https://www.aamc.org/newsroom/reporter/dec10

4. Defining Translational Research and Implementation and Dissemination Sciences Translational Research: “translation of results from clinical studies into everyday clinical practice and health decision making” -- Institute of Medicine Implementation and dissemination sciences (IDS): are“T3” activities, with goals to ensure that the knowledge and materials produced by health research actually lead to improved population health by: 1)reaching the people for whom they are intended; 1)are relevant to the people for whom they are intended; 3) are implemented effectively, safely, efficiently, equitably in a patient- and community-centered manner.

5. IDS Training at UCSF “Implementation and dissemination sciences is research aimed at enhancing the adoption and appropriate adaptation (e.g. translation) of best evidence-based practices and policies in clinical care and public health; and the development of best evidence through community engagement.” -UCSF TICR Program in Implementation and Dissemination Sciences

6. US Historical Perspective on IDS Research  IDS research is not new, but new terminology.  IDS research is more developed in the UK and Canada, but after IOM report, ‘Crossing the Quality Chasm’ more US recognition of its importance in reducing disparities  IDS research viewed as a natural progression of biomedical and public health advances-- and thus needs a more coherent research approach. -- this includes more involvement of theory and socio-ecological context

7. II. Behavioral Theory and IDS  Reviews of IDS-related research indicate majority of interventions achieve modest effects, yet no empirical basis for selection of appropriate interventions for diverse settings  Interventions with theoretical basis found to be more successful that those without  As behavior change relates to multiple levels, theories at multiple levels need consideration>> relevance of socio-ecological frameworks Glanz K and Bishop D. 2010;Eccles et al, 2006, Shortell et al, 2001

8. Research Design Analogy - Evidence Continuum – Begin with Theory Eccles, M e al, 2005. J Clin Epi 107-112. Medical Research Council, 2000

9. III. Epi 246 Learning Objectives 1.Understand key individual-focused health behavior change theories, including components and HOW they are used. 2. Understand linkages between health behavior theory focused on individuals and implementation and dissemination sciences interventions in ‘real world’ applications.

10. Epi 246 Learning Objectives cont. 3. Use ecological frameworks/planning models/structural determinants perspectives, to describe behavior and develop behavior change interventions. 4. Understand limitations of the different individual-focused approaches to theory. 5. Apply different behavioral theory components to planning, implementing and evaluating health-related behavior and behavior change interventions in your specific area of interest.

11. Epi 246 Requirements 1.Homework most weeks --Discussed first 20 minutes of following week --Turned in at end of the day following week 2. Participation 3. Final Project

12. Which Health Behavior/Change Theories? Those most relevant to behavior change in clinical and community health contexts: 1.Psychological theories 2. Health communication theories 3. Dissemination of information theories 4. Theories from behavioral economics 5. Theories of community building/empowerment

13. Learning Objectives – Today’s lecture 1. Understand why health behavior change theories focused at individuals are helpful for IDS research and real world application of interventions 2. Understand components of Health Belief Model, Theory of Planned Behavior, Trans- theoretical Model 3. Become familiar with how to explore components of specific theories and explore across multiple levels related to individual and contextual factors

14. IV. Individual ‘vs’ Structural/Ecological Perspective?

15. Individual and Structural Perspectives “The use of collective action to support personal responsibility is central to public health” -Brownell et al, Health Affairs 2010 “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.”

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

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 -- Glanz and Bishop, Ann Rev Public Health 2010

18. V. How Individual-Based Theories Are Useful 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? 2.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 underlying effective interventions – to tailor/scale up NIH Science of Behavior Change, Meeting Summary, June 15-16, 2009

19. 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 4. Building/creating theory – Developing new or revised theory using constructs specified, measured, and analyzed Painter, et al, 2008

20. Practical uses of theories Targeted Behavior or Situation Explanatory Theory: Why? What can be changed? Underlying dynamics? Change Theory: Which strategies? Which messages? Underlying assumptions?

21. 1.Risk appraisal 2.Self perception 3.Emotions 4.Relationships & social influences 5. Environment, community, cultural & structural influences e.g. SOCIAL NORMS e.g. SELF-EFFICACY e.g. PERCEIVED Susceptibility and Perceived CONSEQUENCES e.g. FOOD POLICIES, AVAILABILITY of CONDOMS, DIRECT APPT. SCHEDULING, TRANSPORTATION

22. 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) Strong Health Beliefs translates into MOTIVATION and ACTION to prevent, get screened for or control illness

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

24. HBM Examples Concept/ Application Explanatory Screening or Testing Educational Interventions fotonovelas, clinician training 1. Perceived Susceptibility Could I be exposed to TB?Focus on belief that they could get lead poisoning? 2. Perceived Severity How significant are consequences of TB? Focus on belief that lead poisoning is bad for you? 3. Perceived Benefits Is getting tested better than not getting tested? Focus on belief that not getting lead poisoning will improve health? 4. Perceived Barriers What barriers are in the way and what might mitigate these? Focus on belief that identified barriers can be overcome, such as limiting eating high risk foods? 5. Cues to Action What could help me? (Reminder cues for action *Often person-specific) Focus on reminders/ cues for action? 6. Self-Efficacy What would enable me to follow through? Guidance/ training (practice in making an appointment) Focus on self-efficacy building/confidence in avoiding high risk foods in all circumstances?

25. HBM Explanatory Example: TB Treatment Adherence Munro et al, 2007. BMC Public Health; Munro et al, 2007. PlosMedicine

26. Action 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 INCREASE MOTIVATION Cues to action: Increase awareness, media/marketing, prompts, reminders HBM: APPLICATIONS FOR CHANGING INDIVIDUAL BELIEFS

27. 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 Strong Planned Behavior translates into INTENTION to ACT to prevent, screen for or control illness

28. Action 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 INTENTION Theory of Planned Behavior

29. Action 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 INCREASE INTENTION Theory of Planned Behavior

30. TPB: Explanatory Example Example- Factors influencing compliance with guidelines for induced abortion  Measured behavioral intention, attitudes, subjective norm, perceived behavioral control, open-ended barriers  Perceived behavioral control was low, perceptions that organizational barriers were important too  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. TPB: Explanatory Example Predicting Safer Sex Mauschbaum et al 2009

32. Use of components of different levels within Socio-Ecological model to understand where to target condom-based intervention efforts, and differences by location for such interventions:  Individual interviews to capture these constructs for:  Institutional level factors (work env., availability of condoms on site, policies to encourage)  Inter-personal factors (financial arrangements)  Personal factors (condom self efficacy, substance use) Example Socio-Ecological Model and HIV Risk Larios et al, 2009

33. http://www.engenderhealth.org/res/onc/hiv/preventing/hiv6p3.html

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

35. Homework For students applying theory to an active project For one of the behaviors relevant to your outcome, complete a table or diagram relating variables relevant to your behavior to theories presented in class. Describe which theory they relate to and your rationale for choosing. How can you expand on these individual factors, to include factors at multiple levels? For students not applying theory to an active project Select a specific behavior of interest to your work. Which levels do you think have the most significant roles? Who would you engage to develop a formative project to understand more about this behavior and how could you include elements of the theories from class? Using examples from theories or frameworks presented in class, create a table or diagram to organize related concepts. Which theory do they relate to and how would you measure them