Epi 246

Intro to Theories of Health Behavior/ Health Behavior Change Focusing on

Individuals’ Behavior

Margaret Handley, PhD MPHAssistant Professor

Dept. Epidemiology and Biostatistics and

Center for Vulnerable Populations, DGIM-SFGH

April 1, 2010

Outline of Today’s Lecture

1. Course overview and structure

2. Behavioral theory’s role in implementation sciences

3. A few to start:

Health Belief Model Theory of Planned Behavior Trans-theoretical Model-Stages of Change

4. Examples/ Discussion

Implementation & Dissemination Sciences

“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

Epi 246 Learning Objectives

1. Using an ecological frame for how behaviors change in society, understand how health behavior theory focused on individuals is critical to implementation and dissemination sciences/ real world application

2. Understand key behavioral theory components with strong evidence for effect and HOW they are used

3. Be able to apply different components to planning, implementing and evaluating health-related behavior and behavior change interventions

4. Understand gaps in different approaches to theory

Which Health Behavior/Behavior Change Theories are Included?

1. Psychological theories with evidence base in health behavior and behavior change

2. Theories that focus on health communication

3. Theories on dissemination of information

4. Theories related to behavioral economics

5. Theories of community building/empowerment

Which Models and Frameworks?

1. Ecological Models

1. Logic models and Intervention Mapping

1. Models with planning and evaluation components

4. Models that integrate across multiple levels

Links 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

Glanz K and Bishop D. Annu Rev Public Health. 31:3990418. 2010Green, L.W.  American Journal of Public Health 96(3): 406-409, Mar. 2006.

Learning Objectives – Lecture 1

1. Understand why health behavior change theory is helpful for implementation and dissemination sciences research and real world application

2. Understand components of Health Belief Model, Theory of Planned Behavior and Trans-Theoretical Model, and how they can be integrated into ecological models

3. Be able to apply components of these theories to health-related behaviors – including both understanding behavior and intervention planning/evaluation

Evidence Continuum – Begin with Theory

Eccles, M e al, 2005. J Clin Epi 107-112. Medical Research Council, 2000

An Individual or a Structural/Ecological Perspective?

A Public Health Ecological Perspective

“The use of collective action to support personal responsibility is central to public health”

Brownell et al, Health Affairs 2010

HOW Individual –Focused Health Behavior Theories Can Be 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. Can understand environmental factors that reinforce or undermine individual behaviors

e.g. Neighborhood ‘walkability’, # of TVs per house

3. Help understand the mechanisms underlying effective interventions – then you can tailor/scale up interventions

NIH Science of Behavior Change, Meeting Summary, June 15-16, 2009

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

Intensity Continuum for Use of Theory

1. Informed by theory – Framework or constructs

identified, but not specifically applied

2. Applied theory - Framework or constructs identified, and

at least one construct specifically applied

3. Testing theory - Framework or constructs identified

and constructs are tested against one another

4. Building/creating theory – Developing new or revised theory using constructs specified, measured, and analyzed in a study

Increasing level of theory in research

Painter, et al, 2008

A Generalized Ecological Perspective

K Glanz and B Rimmer. Theory at a Glance. NCI, 2005

Picture from Glanz book

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 CONSEQUENCES

e.g.FOOD POLICIES, TRANSPORTATION

K Glanz and B Rimmer. Theory at a Glance. NCI, 2005.

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

- Perceived susceptibility

- Perceived severity

- Perceived benefits

- Perceived barriers

- Cues to action

- (Self-efficacy)

Strong Health Beliefs translates into MOTIVATION and ACTION to prevent, screen for or control illness

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 FACTORSAND ENVIRONMENTAge, gender, socioeconomics, Knowledgepersonality

Health Belief Model

Health Belief Model

Example: TB Treatment Adherence

Munro et al, 2007. BMC Public Health; Munro et al, 2007. PlosMedicine

Examples- Using HBMConcept Condom Use Education STI Screen or HIV Testing1. Perceived Susceptibility

Youth believe they can get STIs or HIV or create pregnancy.

Youth believe they may have been exposed to STIs or HIV.

2. Perceived Severity

Youth believe consequences of getting STIs or HIV or creating a pregnancy are significant enough to try to avoid.

Youth believe consequences of having STIs or HIV without knowledge or treatment are significant enough to try to avoid.

3. Perceived Benefits

Youth believe that the recommended action of using condoms would protect them

Youth believe that the recommended action of getting tested for STIs and HIV would benefit them

4. Perceived Barriers

Youth identify their personal barriers to using condoms and explore ways to eliminate or reduce these barriers

Youth identify their personal barriers to getting tested and explore ways to eliminate or reduce these barriers

5. Cues to Action

Reminder cues for action - incentives or reminders

Reminder cues for action -incentives or reminders

6. Self-Efficacy

Youth confident in using a condom correctly in all circumstances

Youth receive guidance or training (such as practice in making an appointment).

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

INCREASE MOTIVATION

Cues to action: Increase awareness, media/marketing, prompts, reminders

Health Belief Model

Theory of Planned Behavior

Focus: Key Concepts

Individual’s attitude towards a behavior, perceptions of norms, and beliefs about ease of difficulty of changes

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

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)

MODIFYINGFACTORS ANDENVIRONMENT

Demographic

Attitudes to target Behavior

Personality

INTENTION

Theory of Planned Behavior

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

Theory of Planned BehaviorExample- 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

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

Example- Overall Model to Guide the Study

Process of Care Quality Indicator

Intermediate health outcomes:HA1C, LDL Blood pressure

Retinopathy

Nephropathy

Patient-Important Outcomes

1. Quality of Life

2. Disabilities

3, Actual adverse health events

4. Functional status

5. Goal attainment

6. Utilization

Clinician Factors (Figure 2)

Patient Risk StatusAge, Co-morbidities

Clinical Intervention

Patient Factors(Figure 2)

Example - Application of TPB to Adherence to Screening Recommendations

Attitude toward

adherence Adherence intention

Beliefs that clinician adherence to recommendations will lead to outcomes and the evaluation of such outcomes

Normative beliefs that recommended services should be performed and comply

CLINICIAN:External variables: DemographicsAttitudes towards targetsAttitudes towards patients Subjective

Norm

PATIENT:External variables: DemographicsAttitudes towards targetsAttitudes towards providers

Beliefs that patient adherence to recommendations will lead to outcomes and the evaluation of such outcomes

Normative beliefs that recommended services should be performed and comply

Attitude toward

adherence

Subjective Norm

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

Prochaska-Driven Intervention Design

Pre-Contemplation

Preparation

Contemplation

Action

Maintenance

Mass Media, Motivational Interviewing, etc Skill-Building, Social Support, etc.

Intervention Strategies

Education; Feedback CQI; Incentives; Detailing Regulatory; CQI

Transtheoretical Model/Stages of Change

Action MaintenanceContemplation PreparationPre- Contemplation

PROCESSES

Consciousness raisingDramatic reliefEnv. reevaluation

Self-reevaluation

Self-liberation

CounterconditioningHelping relationshipsReinforcement managementStimulus control

*Social liberation- not stage specific

Applications to Affect Stage with TTM

Chilvers, R British Journal of Psychiatry, 2002

Example – Testing/Building/Creating a Hybrid Theory for Understanding Mammography Utilization

Testing views about: perceived benefits, susceptibility, self-efficacy, intention and subjective norms among Filipina and Latina women using qualitative interviews and the role of context

Found constructs of: relational culture, social capital, and transnationalism, that then were applied to understanding social norms, self-efficacy, and perceived susceptibility in this population

Augmentation of Behavioral Theories to Take Diversity Into Account

Pasick R, et al. Health Ed and Behavior, 2009

Homework For students applying theory to an active project

For one of the behaviors relevant to your outcome, complete atable 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 others at multiple levels?

For students not applying theory to an active project

Select a 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?

How am I supposed to think about the consequences before they happen?