1. Theory

2. What is theory?
“… a set of interrelated concepts, definitions, and propositions that presents a systematic view of events or situations by specifying relationships among variables in order to explain and predict the events or the situations.”
(Glanz, Rimer, and Lewis, p. 25)

3. Theory
“Effective health promotion and education depends on practitioners’ marshaling the most appropriate theory and practice strategies for a given situation.”
“The gift of theory is that it provides conceptual underpinnings for well-crafted research and practice.”
(Glanz, Rimer, & Lewis, pp )

4. Theory Generality Testability
Shape and boundaries, but not specific topic or content
Variables

5. Theories are used to …
Guide the search for why people behave in certain ways
Help pinpoint information needed before developing and organizing an intervention program
Provide insight as to how to shape strategies to reach people
Help identify what should be monitored, measured, and compared

6. Concepts & Constructs Concepts: Constructs: Major ideas
Concepts that have been developed and defined for use in a particular theory

7. Models
“… draw upon a number of theories to help understand a specific problem in a particular setting or context.”
(Glanz, Rimer, & Lewis, pp. 27)

8. More theory
“Habit is habit, and not to be flung out of the window, but coaxed downstairs a step at a time.”
Mark Twain

9. Planning Models Like a road map
Present all possible routes you might take to develop, implement, and evaluate a program.

10. Planning Models
PRECEDE/PROCEED
MATCH
CDCynergy

11. PRECEDE/PROCEED Model

12. MATCH (Multilevel Approach To Community Health)
Developed in late 1980s
Used by U.S. Government
Applied when behavioral & environmental risk & protective factors for disease / injury are known & general priorities determined
Includes ecological planning – levels of influence

13. MATCH Figure 4.16: MATCH: Multilevel Approach To Community Health
(Pearson Ed, 2012)

14. CDCynergy Developed by the Office of Communication at the CDC in 1997
First issued in 1998
Developed initially for public health professionals at CDC with responsibilities for health communication
Developed for health communication but can be used with all health promotion planning
Available on CD-ROM; many versions
(Pearson Ed, 2012)

15. CDCynergy P 6: Implement Plan
P 3: Plan Intervention (Is communication dominant or supportive?)
P 6: Implement Plan
P 5: Plan Evaluation
P 4: Develop Intervention
P 2: Analyze Problem (causes, goals, intervention strategies
P 1: Describe Problem (identify & define)
(Pearson Ed, 2012)

16. Generalized Model for Program Planning (GMPP)
Figure 4.18: Generalized Model for Program Planning
(Pearson Ed, 2012)

17. Theories and Levels of Influence
Behavior is very complex
Influenced and supported in multiple ways

18. The Ecological Model
Emphasizes the links and relationships among multiple factors (or determinants) affecting health

19. Ecological Model Public Policy Community Institutional or
Organizational
Interpersonal
Individual

20. Individual / Intrapersonal factors
Knowledge, attitudes, beliefs (KAB)
Skills
Motivation
Self-concept
Age, gender, genetics

21. Interpersonal factors
Social support / social networks
Social norms, cultural environment
Religious affiliation
Access to social and health services

22. Institutional or organization factors
Educational system
Access to health care
Social Interactions

23. Community factors Living and working conditions Public safety
Local public health
Housing
Economic development
Environment

24. Public Policy Factors Federal, State & Local Policy and Law
Zoning
Taxes
Public Health System
Educational System

25. Behavior Change Theories
The specific route(s) you will take to reach your destination – they suggest a road to follow.

26. Behavior change theories with individual focus
The Health Belief Model (HBM) **
The Transtheoretical Model (TTM) **
Theory of Planned Behavior (TPB) **
Other Theories:
Elaboration Likelihood Model of Persausion
Information – Motivation – Behavioral Skills Model
Health Action Process Approach

27. Health Belief Model (HBM)
Developed in the early 1950’s by social psychologists in the U.S. Public Health Service.
Hochbaum & Rosenstock
TB screening

28. Constructs of HBM Perceived threat Perceived susceptibility
Beliefs about one’s chances of getting a condition
Perceived severity
Beliefs about how serious the condition might be

29. Constructs of HBM Outcome Expectations Perceived Benefits
Beliefs that the advised action will reduce risk or seriousness of the condition.
Perceived risks/barriers
Beliefs about the “costs” of taking the advised action

30. Constructs of HBM Cues to Action Self-Efficacy
Strategies to activate one’s “readiness”
Self-Efficacy
Confidence in one’s ability to take action

31. Likelihood of taking recommended action
Health Belief Model
Modifying Factors: age, race, ethnicity, SES, personality
Outcome Expectations: Perceived Benefits vs. Perceived Risks/Barriers
Perceived Susceptibility & Perceived Seriousness
Perceived Threat
Likelihood of taking recommended action
Cues to Action
Self-efficacy

32. Theory of Reasoned Action (TRA)
Constructs:
Attitude toward the behavior
Beliefs about the behavior
Evaluation of behavioral outcomes
Subjective norms
What others think about your behavior
How motivated you are to comply with the expectations of others

33. TRA Cont. Beliefs and Subjective Norms help predict Intentions
Your Intentions predict your actual Behavior

34. Attitude toward behavior
TRA
Attitude toward behavior
Intention
Behavior
Subjective Norm

35. Theory of Planned Behavior (TPB)
Developed by Fishbein & Ajzen
An extension of the Theory of Reasoned Action (TRA)

36. TPB versus TRA Adds the construct: Perceived Behavioral Control
Belief about personal control in combination with belief about the one’s ability to do what needs to be done.
Actual Behavioral Control: have the skills and resources needed to quit.

37. TPB Cont. People will perform a behavior if:
They believe the advantages of success outweigh the disadvantages of failure.
They believe that other people with whom they are motivated to comply, think they should perform the behavior.
They have sufficient control over the factors that influence success or ability to perform the behavior.

38. Attitude toward the behavior Perceived Behavioral Control
TPB
Attitude toward the behavior
Intention
Behavior
Subjective Norm
Perceived Behavioral Control
Actual Behavioral Control

39. Transtheoretical Model (TTM)
AKA: Stages of Change
Developed by Prochaska & DiClemente
Major Constructs:
Precontemplation
Contemplation
Preparation
Action
Maintenance
Decisional Balance
Self-Efficacy

40. Precontemplation “The shoes are still at the store”
Not thinking about changing behavior in the next six months.
May be unaware of risks or problems.
Needs some work “under the hood.”

41. Contemplation “Shoe shopping”
Seriously thinking about making a behavior change, but have not yet made a commitment to action

42. Preparation “You bought the shoes”
Ready to take action in the very near future (next 30 days)
Have a plan of action
Experimenting with new behaviors

43. Action “Wearing your shoes on a regular basis”
Actively engaged in new behavior(s) for less than six months.
Efforts are sufficient to reduce risk of disease

44. Maintenance “Shoes go on every day.”
Sustaining the behavior change for over 6 months.

45. Decisional Balance
The costs and benefits of changing.

46. Self-Efficacy
Confidence that one can be successful in the new behavior across different challenging situations.

47. Relapse
More likely when you are stressed, anxious, or feeling depressed.
More likely if you lack social support or are experiencing interpersonal conflicts
More likely if you return to a setting (environment) that “cues” your old behavior(s)

48. Transtheoretical Model (TTM)
Precontemplation
Decisional Balance
Contemplation
Decisional Balance
Preparation
Self-Efficacy
Action
Self-Efficacy
Maintenance

49. Pro’s of TTM Encourages less “labeling” terms.
(Precontemplation rather than “loser” or “lost cause”)
Must accept people “where they are”
Behavior change is not viewed as linear
It is easy to stage clients
It is not based on an instant gratification mentality
Allows for stage-matched interventions

50. How to stage a person using TTM
Do you exercise regularly? No
Yes
Do you intend to in the next 30 days?
Have you been doing so for more than 6 months?
Yes No
Yes No
Do you intend to in the next six months?
Preparation
Action
Maintenance
Yes No
Precontemplation
Contemplation
(Pearson Ed, 2012)

51. Adapted from: Autobiography in Five Short Chapters by Portia Nelson
I I walk down the street. There is a deep hole in the sidewalk. I fall in I am lost … I am helpless It takes forever to find a way out.

52. II I walk down the same street. There is a deep hole in the sidewalk
II I walk down the same street. There is a deep hole in the sidewalk. I pretend I don’t see it. I fall in again. I can’t believe I am in the same place. It still takes a long time to get out.

53. III I walk down the same street. There is a deep hole in the sidewalk
III I walk down the same street. There is a deep hole in the sidewalk. I see it is there. I still fall in … it’s a habit. My eyes are open. I know where I am. I get out immediately.

54. IV I walk down the same street. There is a deep hole in the sidewalk
IV I walk down the same street. There is a deep hole in the sidewalk. I walk around it. V I walk down another street.

55. Behavior change theories with interpersonal focus
Social Cognitive Theory (SCT) **
Social Network Theory (SNT)
Social Capital Theory

56. Social Cognitive Theory (SCT)
A behavior change theory with an Interpersonal / Social network focus.

57. Characteristics of the Person
Reciprocal Determinism
Characteristics of the Person
Environment in which the behavior is performed
Behavior of the person

58. Constructs of SCT Behavior Capacity Expectations Expectancies
Self-Control / Self- Regulation
Self-Efficacy
Reinforcement
Observational Learning
Emotional Coping Responses

59. Principles of Modeling
Attention
Remembering
Repetition
Motivation
Model Similarity
Age
Gender
Status
Competence

60. Reinforcement Any action or event that increases the desired behavior
Present something positive
Money
New clothes
Remove something negative
Nagging
Teasing

61. Punishment
Any action or event that decreases the likelihood that the desired behavior will occur.
Present something negative
Criticize
Policies or laws
Remove something positive
Praise
Privilege

62. Organizational/Institutional Social Networks Interpersonal
Framework:
Social Determinants of Health
Political
Population Level
Community
Organizational/Institutional
Social Networks Interpersonal
Individual
Ecological Model

63. Behavior theories with community focus
Diffusion of Innovation Theory (DF) **
AKA: Diffusion Theory
Community Readiness Model (CRM)

64. Diffusion of Innovations Theory
Rogers, 1983
A behavior change theory with a community focus

65. Diffusion of Innovations
The progressive adoption by members of a community or society of an idea or practice over time.

66. Categories of Adopters
Innovators (<3%)
Independent, risk-takers, eager to try new ideas
Not necessarily the most respected members of the community
Seek info on their own, rely on their own judgment in making decisions about adoption
Try out new ideas and provide the first tests of the utility of the innovation

67. Categories of Adopters
Early Adopters (14%)
Respected members of the community
Opinion leaders
Powerful influence on other potential adopters
Trendy … like to be up on what is good and new
Seen as opinion leaders

68. Categories of Adopters
Early Majority (34%)
Greatly influenced by mass media and opinion leaders
By virtue of their numbers, they begin to form a new norm
Lots of contact with peers, but don’t hold leadership positions.

69. Categories of Adopters
Late Majority (34%)
Skeptical of change
Tend to wait until an innovation is established as a norm before adopting
Motivation is greatly influenced by peers
Don’t like risk and uncertainty

70. Categories of Adopters
Laggards (16%)
Very traditional and conservative
Tend to have less education and lower SES
Socially and geographically mobile
Narrow and restricted communication networks
Suspicious of innovations and adverse to risk

71. Adoption Curve

72. Determinants of Diffusion’s Speed and Extent
Is the innovation better than what it will replace?
Does the innovation fit with the intended audience?
Is the innovation easy to use?
Can the innovation be tried out before adopting?
Are the results of the innovation observable and easily measured?

73. A few more pieces Predisposing, Reinforcing, and Enabling Factors
Barriers to change
PRECEDE/PROCEED behavioral diagnosis phase

74. Predisposing Factors
Provide the rationale or motivation for a person or group to act
KAB (knowledge, attitudes, beliefs)
Personal preferences
Existing skills
Self-efficacy beliefs
Individual level theories
Intrapersonal are most appropriate for addressing these factors.

75. Reinforcing Factors
Factors that provide reinforcement and reward for actions and encourage repetition of the action
Social support
Peer influence
Significant others (family, spouse, partner)
Employers, teachers, health providers, community leaders, decision-makers

76. Reinforcing Factors Continued
Interpersonal level theories are most appropriate in addressing these factors
Interpersonal level theories suggest communication channels (e.g. significant others or social networks) and methods (e.g. incentives or social supports).

77. Enabling Factors
Factors that provide the means or make the action possible.
Availability of programs or services or skills training
Accessibility of programs or services or skills training

78. Activity
Pick a theory (Health Belief Model, Theory of Planned Behavior, Transtheoretical Model, Social Cognitive Theory OR Diffusion of Innovation Theory)
Map out the constructs of the theory
Where do these constructs fit into the Ecological Model?
Give a brief (at least one sentence) explanation of each construct
Provide examples for each construct that relates to your topic
List as many predisposing, reinforcing, and enabling factors as you can think of for the topic.
Keep this model for the next class.