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CH 99/HCOMM 522 (equivalent): Health behavior in context: The art and science of health communication

Class meetings: Tuesday 9 – 11:30 a.m. (seminars) Three required meetings with instructor (1 individual, 2 group) Applied Fieldwork hours (arranged, students will complete 4 additional hours over the course of the semester) Location: 11 Talbot Avenue, Room 103 Professor: Carolyn L. Rubin 112 Packard Ave. (second floor) (617) 636-3444 Carolyn.Rubin@tufts.edu Office Hours: Monday, 11 am – 12 noon

Course Description

This course takes an ecological approach to health. The determinants of individual health can range from individual actions to broad social and environmental conditions. While interventions can be directed at the individual, for example helping patients adhere to a low fat dietary regimen, or to the population as a whole, such as mandating seat belt use, an objective of public health practice is often to encourage people to adopt behaviors that will improve their health status. This course provides an overview of the scientific basis for understanding human health behavior and strategies available for changing it. Special focus is put on the role, theory and practice of health communication, as a core element of public health interventions and programs. Students will be introduced to a range of theories, evidence-based strategies, and resources critical to effective public health practice. A series of skill-building sessions and assignments will allow students to practice the skills necessary to design and implement public health interventions in a variety of real-world settings. The course is organized around process. How one analyzes a problem, selects a strategy, and draws on theory and best practices to develop interventions and/or programs to achieve desired outcomes. The course will make use of case study examples during sessions and will mix didactic, lecture/discussion, and focused small group exercises. In addition, students will apply concepts they are learning in the field.

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Learning Objectives At the conclusion of the course students will be able to develop strategies and programs to address health problems. Learning objectives for this course will allow students to:

Describe the determinants of health and health behaviors using a social-ecological model and develop strategies for health interventions that take into account individual and contextual factors, such as:

o Literacy o Culture o Race o Gender

o History o Poverty o Community o Structural factors

Describe and discuss several of the basic health behavior theories and models and

explain how they can be used to understand behavior and inform interventions and communications. Theories may include:

o Health Belief Model o Theory of Reasoned Action/Planned Behavior/ o Transtheoretical Model o Social Learning Theory o Diffusion of Innovation

Develop and describe program planning strategies and methodologies. Demonstrate basic skills required to respond to an RFP, including:

o Problem analysis/literature review o Writing goals and objectives (or specific aims) o Program planning drawing on theory o Logic models o Evaluation (formative, process, outcome) o Budgeting

Course Mechanics The course meets once per week. Sessions will generally be composed of lecture, discussion and small group activities and simulations. It is expected that students will be prepared and will have completed the reading and other course assignments prior to class. The success of the entire group depends on the willingness of each student to attend each class and be fully prepared. The text is Planning Health Promotion Programs: An Intervention Mapping Approach edited by L. Kay Bartholomew, Guy S. Parcel, Gerjo Kok, and Nell H. Gottlieb. (2011), published by Jossey-Bass. Most weeks we will read a chapter or two from this text. Readings that are not found in the course text will be online in some form (either posted on TRUNK or a complete reference provided for accessing them through the library). Readings generally will be available at least a week prior to class.

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Assignments Required assignments are designed to allow students to apply the knowledge and practice skills gained throughout the course. Assignments focus on the competencies necessary to conceptualize, plan, and implement strategies and programs to enhance population health. It is important to take particular care with early assignments as they are designed to build skills needed for the final assignment. The first assignment, The Theory Exercise will involve applying the individual level theories presented in class to explain a discrete behavior and how that behavior might be changed. The second assignment, the Assessment will involve conducting a public health assessment in order to develop an intervention strategy and provide a rationale for that strategy based on a review of the literature. The third assignment, the Strategic Intervention plan provides an opportunity to map out the critical elements of your final proposal and to develop a matrix of change objectives using the tools and skills provided up to that point in the course work. All of these assignments occur within the context of the Group Project which will simulate an "RFP process" such as that used in the public and private sectors to award contracts to potential service vendors. At the beginning of the course small groups will be formed and topics assigned. Groups will be required to analyze the problem they are given, develop and design a strategy to address it, and provide an oral and written presentation. (An outline of the issues to be covered in the presentations will be provided). The group project will provide students with a final opportunity to use the knowledge and skills developed during the course in undertaking the design and development of a communication strategy and present it to the class. The mock grant is due on the second to last class. There can be no exceptions to this deadline. The oral presentations will take place at our last meeting and attendance is required. Details for all assignments will be distributed in class and will include instructions about the required elements. Group assignments In addition to the above assignments, there will be several individual and small group fieldwork activities. This course is designed to be interactive and class participation is expected from everyone through regular attendance, participation in class activities, and dialogue with your classmates and the course instructor.

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Grading Policy Assignments will be weighted as follows:

Assignments Percent of Grade Assignment 1: Theory exercise 15% Assignment 2: Needs assessment 15% Assignment 3: Strategic intervention plan 15% Group Project/Grant proposal 40% Assignments and participation (in-class group activities, theory presentations)

15%

Attendance and Late Policy It is recommended that should you be absent you contact the Professor at least a week in advance. Absences are less likely to affect your participation grade if you notify the Professor ahead of time. Failure to hand in an assignment on time will almost always result in a grade reduction of at minimum a half letter grade, unless you have clearly asked for and been granted a new due date by the Professor. ATTENDANCE IS REQUIRED AT THE FINAL PRESENTATIONS AND NO EXTENSIONS WILL

BE GIVEN ON THE FINAL PROJECTS. Contacting the Professor Feel free to contact me at any time about any aspect of the course; problems with assignments or group projects, feedback and comments about the course, or ideas about topics to discuss in class. If you do not get a response within 2 working days you might need to resend your email.

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COURSE SCHEDULE

# Date Topic(s) Assignments

1 1/20 Course Introduction and the Determinants of Health

2 1/27 Meet with Professor Rubin

over the next 2-3 weeks

3 2/3 Theories of Health Behavior, part 1 Individual-oriented theories

4 2/10 Visit to Sociedad Latina (1530 Tremont Street, Roxbury, MA 02120)

5 2/17 Theories of Health Behavior: Part II In-class Theory

Presentations Due

6 2/24 Environment-Oriented Theories Fieldwork at Sociedad Latina

Assignment 1 Due

7 3/3 Intervention Mapping Step 1: Conducting Assessments

Groups meet with Professor Rubin

8 3/10

Intervention Mapping Step 2: Preparing Matrices of Change Objectives

3/17 SPRING RECESS

9 3/24 Intervention Mapping Step 3: Selecting Theory Informed Intervention Methods and Applications

Assignment 2 Due

10 3/31 Visit to Boston Chinatown Neighborhood Center (38 Ash Street, Boston, MA 02111)

11 4/7

Intervention Mapping Step 4: Producing Program Components and Materials & Intervention Mapping Step 5: Planning Program Adoption, Implementation, and Sustainability

Assignment 3 Due

12 4/14 Intervention Mapping Step 6: Planning for Evaluation and Grant Writing

Groups meet with Professor Rubin

13 4/21 Health Equity and Public Health Workshop

14 4/28 FINAL PROJECT PRESENTATIONS Group projects due

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Session #1

Introduction & Determinants of Health Learning Objectives:

Describe the levels and components of the ecological model Understand how health is shaped by conditions at multiple levels of the ecological

model Describe ecological and systems approach to intervention development Name key aspects of the ethical practice of health promotion

Reading/Discussion Questions:

What does it mean to take a “social determinants” perspective? What is the relationship between individuals and their environment and what does

this mean for health promotion? Community engagement – what are some of the purposes?

Readings:

1. Text, Chapter 1 (read carefully Box 1.1, Perspectives & Need for Framework pp.8-18, and Important repeating Concepts pp. 35-42, skim 18-33, and skip Navigating the Book & Usefulness of Intervention Mapping)

Session #3

Health Behaviors: What can theory tell us? Learning Objectives:

Define theory Identify behavior-oriented theories and theoretical constructs to explain behavior Describe the specific constructs and their relationship to each other for the Health

Belief Model and Theories of Reasoned Action Reading/Discussion Questions:

What is a theory? For individual theories:

o What are the key premise(s)? o What are the relationships between the component parts? o What would be a necessary component of any intervention using this theory?

What constructs keep reoccurring across the behavior-oriented theories? What constructs are less often included?

Readings:

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1. Text, Chapter 2 (read carefully Health Belief Model pp.67-68, Theories of Reasoned Action pp.71-79, Transtheoretical Model pp.86-90, & Social Cognitive Theory pp.102-105, skim the rest)

2. Visit and explore NCI’s website “Health Behavior Constructs.” Click on and read through the pages about a construct that look interesting to you http://dccps.cancer.gov/brp/constructs/

Optional Reading- HBM, TPB, TTM & SCT discussed by their developers:

1. James O. Prochaska, Colleen A. Redding, Lisa L. Harlow, Joseph S. Rossi and Wayne F. Velicier, The Transtheoretical Model of Change and HIV Prevention: A Review, Health Educ Behav 1994 21: 471

2. Icek Ajzen, The theory of planned behavior, Organizational Behavior and Human Decision Processes, Volume 50, Issue 2, December 1991, Pages 179-211

3. Irwin M. Rosenstock, Why People Use Health Services, The Milbank Memorial Fund Quarterly, Vol. 44, No. 3, Part 2: Health Services Research I. A Series of Papers Commissioned by the Health Services Research Study Section of the United States Public Health Service. Discussed at a Conference Held in Chicago, October 15-16, 1965 (Jul., 1966), pp. 94-127

4. Albert Bandura, Health Promotion by Social Cognitive Means, Health Educ Behav April 2004 vol. 31 no. 2 143-164

Session #4

Behavior change in action: Site visit to Sociedad Latina Learning Objectives:

Link behavior change theory with an example of a real-world intervention Describe what community-based interventions look like.

Reading/Discussion Questions: Think about questions you’d like to ask the staff at Sociedad Latina about their

experience with identify needs of the community, changing youth behaviors, and implementing interventions

How does community engagement happen? What are some of the different forms participation can take (or not)?

How does power impact participatory processes and the development of program goals and interventions?

Readings: 1. Wilson et al. Using formative research to develop environmental and ecological

interventions to address overweight and obesity Obesity. 15 Suppl 1:37S-47S, 2007 Nov.

2. Freeman, et al. Challenges of Conducting Community-Based Participatory Research in Boston’s Neighborhoods to Reduce Disparities in Asthma Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 83, No. 6

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Session #5

Behavior –Oriented Theory Applications Learning Objectives:

Select behavior-oriented theories and constructs to inform methods to change behaviors

Understand how theory can be applied to understand behaviors and develop strategies to change behaviors

Reading/Discussion Questions:

What is the link between the theory and the definition of the problem to be addressed?

What is the link between theory and the focus of interventions/programs? What is the link between theory and intervention/program activities? What is the link between theory and evaluation? Is it possible to take an a-theoretical stance?

Readings (1 & 2 are examples of using theory to understand behavior, 3 & 4 of using it to inform interventions):

1. Champion et al. Measuring Mammography and Breast Cancer Beliefs in African American Women J Health Psychol 2008 13: 827

2. Vissman et al. Applying the theory of planned behavior to explore HAART adherence among HIV-positive immigrant Latinos: Elicitation interview results Patient Education & Counseling. 85(3):454-60, 2011 Dec.

3. McEachan et al. Testing a workplace physical activity intervention: a cluster randomized controlled trial International Journal of Behavioral Nutrition and Physical Activity 2011, 8:29

4. Champion et al. Comparison of tailored interventions to increase mammography screening in non-adherent older women Preventive Medicine. 36(2):150-8, 2003 Feb.

Session #6

Environment-Oriented Theories and Practice Learning Objectives:

Identify theories to describe environmental conditions that influence behavior and health

Identify potential environmental agents whose role behavior influences the

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environmental conditions Explain the differences in intervention methods due to role and power at higher

ecological levels of the environment Understand the range of perspectives and world-views that stakeholders may bring

to a coalition Develop conflict resolution skills for use in community coalition building

Reading/Discussion Questions:

How do you define community? Community engagement – what barriers do the environment-oriented theories

suggest? And what strategies to overcome some of the barriers? Why is power in society an important consideration in planning health promotion

programs? “Program” – a set of activities undertaken by individuals or organizations – what

assumptions are inherent in that definition? Readings: 1. Text, Chapter 2: pp. 108-111, Diffusion of Innovations Theory (DIT)

2. Text, Chapter 3 (read carefully Community-Level Theories pp.136-155, skim the rest)

3. Text, Chapter 4 (pp. 171-189)

Session #7

Assessment: Overview Learning Objectives:

Describe the components of a needs assessment using the PRECEDE model (Green & Kreuter, 2005)

Describe the key elements of a participatory planning group that includes program participants and implementers

Reading/Discussion Questions:

How are the following terms used in the readings: intervention mapping, planning process, logic model, needs, core processes, triangulation?

How are needs assessments framed and what sorts of data/information is used? How does community engagement happen? What are some of the different forms

participation can take? How useful and logical are logic models?

Readings:

1. Levy SR, et al. Using Multilevel, multisource needs assessment data for

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planning community interventions. Health Promotion Practice 2004; Vol. 5 2. Text, Chapter 4, Step 1

Session #8

Making change: Preparing Objectives Learning Objectives:

State expected program outcomes for health-related behavior and environmental conditions

Subdivide behavioral and environmental outcomes into performance objectives Select important and changeable determinants of behavioral and environmental

outcomes Create change objectives on each level of the ecological model that address

determinants and are tied to the performance objectives Describe how the concepts entailed in the terms program outcomes, performance

objectives, and change objectives are related to SMART objectives, goals and objectives, and specific aims.

Reading/Discussion Questions:

Why is it important to be very specific when stating behavioral and environmental outcomes?

How do you determine whether you could/should seek to change environmental conditions?

What are factors to consider in differentiating priority populations? When do you need to differentiate into subgroups?

Readings:

1. Text, Chapter 5, Step 2 2. Sorensen G, Emmons K, Hunt, M et. Al. Model for incorporating social context in

health behavior interventions: applications for cancer prevention for working-class, multiethnic populations Preventive Medicine Volume 37, Issue 3, September 2003, Pages 188-197

3. Huhman M et al. The VERB campaign’s strategy for reaching African American, Hispanic, Asian and American Indian Children and Parents. American Journal of Preventive Medicine, Vol 34, Issue 6, SUppl 1, June 2008. 194-209

4. Evaluation Guide: Writing SMART Objectives (CDC/ Heart Disease and Stroke Prevention)

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Session #9

Making Change: Selecting Intervention Methods Learning Objectives:

Identify theoretical methods that can influence change in health determinants Identify the conditions under which a given method is most likely to be effective Select of design practical applications for applying the methods in an intervention

program Ensure that the final applications address identified change objectives

Reading/Discussion Questions:

To what extent does theory determine strategy? Is there room for creativity? For community input? Are there times when assumptions about the target population can lead to

ineffective methods? How do you decide if a “proven” theory-based method will work in your

intervention? What characteristics of the environment/conditions do you need to take into account?

How does one draw from multiple theories to design a program? Consider the data needed for programs designed to focus on:

o Structural change o Community/institutional change o Individual and small group behavior change o Normative change

Readings: Text, Chapter 6, Step 3

Session #10

Developing programs and interventions: Site visit to Boston Chinatown Neighborhood Center Reading/Discussion Questions:

1. Brainstorm questions you’d like to ask the staff about their process of determining the needs of the community and how they develop interventions.

2. What concerns do community-based agencies have about partnering with academic researchers?

Readings: 1. Text, Chapter 7, Step 4 (to page 408)

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2. Bogart LM, Uyeda K. Community-based participatory research: partnering with communities for effective and sustainable health interventions. Health Psychology 2009; 28(4): 389-90. ONLINE.

3. Wallerstein, N., Duran, B., Minkler, M., Foley, K. Developing and maintaining partnerships with communities. In, Israel, B.A., Eng, E., Schulz, A.J., Parker, E.A. (eds.) Methods in community-based participatory research for health. San Francisco CA: Jossey-Bass, 2005; chapter 2, pages 27-51.

Session #11

Program Message Considerations: Health Literacy Learning Objectives:

Describe how to identify channels for health communication Create program scope and sequence including delivery channels, themes, and list of

needed program materials Match materials to change objectives, methods, and practical applications

Reading/Discussion Questions:

When should you develop materials yourself and when should you bring in experts? Is there an intersection between health literacy and culture? How can you ensure

that cultural and health literacy considerations are taken into account in developing program components and materials.

Readings: Text, Chapter 7, Step 4 (from page 408) 1. Christina Zarcadoolas, The simplicity complex: exploring simplified health

messages in a complex world, Health Promot. Int. (2011) 26 (3): 338-350. 2. Seligman Hilary K; Wallace Andrea S; DeWalt Darren A; Schillinger Dean; Arnold Connie

L; Shilliday Betsy Bryant; Delgadillo Adriana; Bengal Nikki; Davis Terry C, Facilitating behavior change with low-literacy patient education materials., American journal of health behavior 2007;31 Suppl 1.

3. Review Text, Chapter 2 (Theories of Information Processing p.64 & Elaboration Likelihood Model p.97)

4. Institute of Medicine, Executive Summary in Health Literacy: A prescription to end confusion, National Academy of Sciences, Washington DC, April 2004, pp 1- 18

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Session #12

Program Evaluation Learning Objectives:

Describe program outcomes for quality of life, health, behavior, and environment and write objectives and evaluation questions

Use a logic model to inform an evaluation plan Differentiate the purposes of formative, process, and outcome evaluation Identify study designs used to evaluate programs Explain how the findings of a program evaluation can be used

Reading/Discussion Questions:

What are the purposes of an evaluation effort? Who benefits from an evaluation? Who is it for? How might the evaluation differ bases on stakeholder needs? How might the evaluation differ based on the proposed “use”? How might the format of an evaluation affect community members? What are the most important outcomes to measure in an evaluation? How might ‘policy’ and ‘science’ conflict? How might data be manipulated? How do we determine the ‘correct’ perspective on program findings? Is an unbiased evaluation possible? Who does an evaluation consultant work for? Contrast fidelity vs. flexibility

Readings: Text, Chapter 8 Step 5 (skim) Text, Chapter 9, Step 6 Wallerstein N, Power between evaluator and community: Research relationships with New Mexico’s healthier communities, Social Science and Medicine, Vol. 49, Issue 1 (July 1999)

Session #12

Program Evaluation Learning Objectives:

Specify evaluation design and write an evaluation plan Develop indicators and measures

Reading/Discussion Questions:

How is a logic model used in evaluation design? What are some of the challenges of measuring outcomes from communication

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campaigns directed at broad, geographically diffuse populations? Is an RCT the best evaluation design?

Readings: 1. Huhman M, Heitzler C, Wong F. The VERB campaign logic model: a tool for planning

and evaluation. Prev Chronic Dis. 2004;1:A11 2. Berkowitz JM, Huhman M, Heitzler CD, et al.Overview of formative, process, and

outcome evaluation methods used in the VERB campaign. Am J Prev Med. 2008 Jun;34(6 Suppl):S222-9.

3. Huhman M, et al. Evaluation of a national physical activity intervention for children. VERB Campaign 2004-2005 Am J Prev Med. 2008 Jun;34(6 Suppl):S222-9.

4. Potter et al. Methodology of the outcome evaluation of the VERB campaign. 08 Jun;34(6 Suppl):S222-9.

Session #13

Special Topics: Health equity and public health workshop Guest: TBA Learning Objectives:

TBD Readings:

1. Israel B, Checkoway B, Schultz A, Zimmerman M: Health education and community empowerment: Conceptualizing and measuring perceptions of individual, organizational, and community control. Health Educ Behav 21:149-170, 1994

Session #14

Group Presentations Learning Objectives:

Give a brief overview of a project plan to peers Assess project plans and ask questions that build on information presented Respond to questions about a project plan