Introduction to Health Behavior Theories

Let’s Recap…

Factors That Influence Behavior-Change Decisions

Self-Monitoring

• Become aware of your behavior pattern and targets of influence (change)

• Monitor– Behaviors: drinks, steps, miles, calories,

carbs, etc– Targets of influence: determine how frequent

they occur, when, where and record

• Start with a clear baseline for later comparison

Overcoming Obstacles to Behavior Change

Goal of Health Promotion

Health promotion -- process of enabling people to increase control over their health behaviors…to improve their health.

Health Promotion Questions

• Why do people behave in unhealthy (or healthy) ways?

• What strategies are appropriate to:– A: discourage risky behaviors? – B: encourage healthy behaviors?– C: assure healthy social and physical

environments?

Health Behavior Theories

• Guide the search for "why" health-related behaviors occur

• Identify points for possible change

Introduction to Key Terms

What comes to mind when you hear the word theory?

Jot down brief thoughts, beliefs, descriptions that immediately surface to this question…

Theory…?

• The term carries with it, loaded meanings

– Something abstract

– Assumptions about things

– Empirical generalizations - hypotheses

– Causal explanations for certain phenomena

– A scholarly “school-of-thought”

– Models or conceptual frameworks

There are two faces to theory

• Commonsense theories

• Scientific theories

Commonsense Theories

Case 1: Past couple of weeks, my graduate assistants’ behavior “seems a little off.” She arrives late for team meetings, and appears distant and broody when the team interacts. I have an “explanation” for her behavior:-She has been under considerable stress, taking her comprehensive exam, and finalizing a manuscript to submit for publication.

“Explanations” we invoke (on a daily basis) to make sense of events we encounter in our lives – sense-making (conspiracy theories)

My explanation is considered a commonsense theory as it represents a personal attempt to make sense (meaning) of a situation based on the information at hand.

Scientific Theories

• Are more elaborate

• Contain more clearly outlined characteristics

• Have a defined purpose

General Scientific Theories

• Definitions…

…A set of universal statements that furnish an explanation by means of a deductive system (Norman Denzin, 1970)

…a set of interrelated propositions that allow us to explain how and why events occur. It is constructed with several basic building blocks: concepts/ constructs, variables, and statements (Turner, 1986)

Scientific Health Behavior Theories

Behavioral health theories are…

…composed of interrelated propositions, based on stated assumptions that tie selected constructs together and create a parsimonious system for explaining and predicting human behavior (DiClemente et al. 2002)

... a set of interrelated concepts, definitions, and propositions that present a systematic view of situations by specifying relations among variables, in order to explain and predict the situations (Glanz et al. 2008)

Let’s break down these definitions into smaller units. What are some core elements across all of them?

1. Description: theories facilitate the description and understanding of phenomenon being studied so that others can test (and repeat) such descriptions with.

2. Prediction: extends beyond mere description. Theories allow for the construction of interrelated propositions (hypotheses) that make predictions (claims) of why phenomenon (relationships) occur.

3. Explanation: theories permit the explanation of observed events in a logical, ordered, and interconnected manner.

Other Common Components

• Concepts/Constructs

• Variables

• Hypotheses

Concepts & Constructs

• The abstract units that logically build a theory. Often used interchangeably.

• Ideas or notions (that have been “branded into a theory with a technical name”) that are typically “unobservable or latent”

• Examples?– Self-efficacy, perceived severity, social norms

Variables

• Concepts/constructs are operationalized (defined) into “measurable” or “observable” terms called variables– Referred to as the “proxy” for the

concept/construct and can take on two or more values.

• Example? – Self-efficacy– cannot see but can measure it

– perceived ability or skill in certain behavior

Hypotheses

• Helps connect the theoretical dots with empirical assumptions about phenomenon we would expect to observe.– Associations between two or more constructs

• Hypotheses (or assumptions of associations between two or more constructs – measured as variables) can be “tested”…– Ho: no association – H1: association

Now that we have definitions under out belt, how do theories work?

• Need to engage in the “theorizing process…”

…which is more than simply thinking about descriptions, explanations or predictions…

Theorizing or Theoretical Thinking

• Is a dynamic process of theory building…

Asking and Answering specific types of questions

Predicting and Analyzing (testing) specific research questions &

hypotheses

Theory “building” is like Quilting

• Depending on HOW constructs and hypotheses are connected, different explanations for health behavior emerge

Quilt Blocks

Question

Why?

How?

When?

What for?

AnswerExplanations structured logically

“Because….”

“Given X, then Y…”

“For…”

The Theorizing Process

You may be asking yourself…

• Why should we think theoretically about health promotion?

– Isn’t observing and collecting data related to public health issues and delivering health education practice, enough?

– Because our field is “applied,” why do we need to consider theory in our practice?

Reason 1

Because theoretical thinking…

…infuses ethics and social justice into health education practice

The Tuskegee Study• Study Timeframe: 1932-1972 • Study Goal: to determine the long-term course of syphilis

in the absence of treatment and to note the peculiarities of the disease in black men in particular (as there was widespread belief among MDs that blacks responded differently to disease than did whites).

• Study Sample: conducted among a group of 600 black men (399 syphilis cases, 201 controls)

• Study Site: Men from Macon County, Alabama - which exhibited the highest syphilis rates in the U.S. at the time. Hence was seen as a “natural lab” by Tuskegee Institute (worked with govt to obtain needed resources).

What Happened…• To lure into study, men were told they

were sick b/c they suffered from “bad blood.” NONE told that they had syphilis.

• Later when tx for syphilis (penicillin) became available 10 yrs later (in 1943), it was withheld from those who had it.

• Initially imagined as a 6-month study, it lasted until 1972 - for 40 years

Aftermath of Tuskegee Study• Characterized as one of the most infamous man-

made tragedies in the history of American Science that “breeched ethical principles in conducting research”

• 65 yrs later, on May 16, 1997, Pres Bill Clinton apologized in the name of the US Govt to the handful of survivors & their families gathered at the white house for the event. He stated…– …“the people who ran the study at Tuskegee diminished

the stature of man by abandoning the most basic ethical precepts – they forgot their pledge to health and repair”

You may ask…how on earth?

• This was a time when a “code of ethics” outlining the protection of human subjects in research were virtually non-existent…

• Rather, research & practice was based on the medical way:– A process of “peer-review” with emphasis on “preserving

professional autonomy” (not with ensuring ethical research or defining good practice) and

– Medicine, at the time, was a profession (MDs and techs) “almost wholly composed of people uninterested in theorizing”

Jones, 1993

Relevance to Health Education Practice?

• Ethical misconduct occurred b/c medical professionals ignored theory (as they were trained to practice, collect data, and adhere to methods).

• Because theorizing facilitates the groundwork for ethics and promotion of social justice within any profession…it’s very relevant to health promotion given that ethics and social justice are major goals promoted within the practice.

Reason 2

Because theoretical thinking…

…represents a moral duty and professional responsibility for health promotion practice

Notion of Professional Responsibility

• Health promotion professionals are held accountable for adhering to “codes of ethical conduct” and professional competencies (AKA: professional standards).

• Seven core competencies have been defined by the National Commission for Health Education Credentialing (NCHEC).

• Theorizing is a professional standard embedded within 6 of the 7 areas of responsibility (as tasks). Examples:

• “Identify diverse factors that influence health behaviors, i.e., theorizing about cause and effect relationships” (Area I, Sub-Competency C)

• “Identify factors that foster or hinder the process of health education” (Area I, Sub-competency E)

Reason 3

Because theoretical thinking…

…guides the practice of health promotion

For you as a public health professional “in-training”

• The “theorizing process” is a valuable tool needed for the work you are setting out to do…

Importance of Theory-Practice Link

• Theory is a tool for making systematic connections between:

– assessment of a health problem;

– program components; and

– program evaluation

Why, in the current public health environment, is it increasingly

important to demonstrate these connections?

Health Behavior (and change) is Complex

• Health behavior change interventions are not end-all be-all cures…

…record of success in behavioral change for HP 2010 objectives are not 100% successful.

• Illustration: prevalence of adolescent obesity tripled in the past 30 years. Most childhood interventions are rooted in theories of health behavior change. In a review of recent programs, only 3 interventions significantly impacted weight. Given the limited success of most childhood obesity interventions, alternative approaches need to be explored (Chehab et al., 2007).

Reason 4

Because theoretical thinking…

…prevents ideological takeover in health promotion practice

Roots of Health Behavior Theories

• Primary fields from which most current health behavior theories come:

– Psychology– Sociology– Anthropology– Communications – Others…

• There is much overlap between these disciplines in explaining behavior

BEHAVIORIST PSYCHOLOGY

• ASSUMPTION: Behavior is learned through a process of stimulus and response. “Thinking” not a major part of this process.

• Early focus on classical conditioning (Pavlov’s dog), then on operant conditioning (Skinner) -- the conditioning of behavior by positive and negative reinforcements. Idea of shaping behavior via behavior modification.

• Behavior modification technique still used (smoking cessation, addiction, eating disorders, gambling, etc)

• Basic assumptions about learning behavior through positive and negative reinforcements appear in a number of health behavior theories.

COGNITIVE PSYCHOLOGY

• Focus on the THINKING PROCESSES• THINKING PROCESSES include beliefs,

perception, memory, decision-making, interpretation, reasoning, judgment, etc.

• Some cognitive psychologists focused solely on the development of the thinking process (piaget)

• See influence of cognitive psychology focus in many of health behavior theories

SOCIAL PSYCHOLOGY

• Social psychology focuses on the interaction between individuals and the group (relationships, social units)

• See this influence on health behavior theories.

SOCIOLOGY

• Sociology includes the study of society and its phenomena – social groups, social hierarchies, social structures, the nature of social interaction and organization, the interaction between social and economic systems.

• Much of this study is also present in many health behavior theories in terms of the relationship between (social class/hierarchy, group norms, social organization and its impact on behavior).

CULTURAL ANTHROPOLOGY

• Focus on the role of culture in human behavior, the ways in which life-patterns are organized, together with systems of knowledge and belief, language and symbol.

• This may include: cultural beliefs, attitudes, social-cultural roles, gender, language, symbolic expression, social authority and legitimacy, health knowledge systems, healing practices, healers, etc.

• Cultural anthropology has much influence on health behavior theories cultural influence on health behaviors, values and meanings as connected to behavior, cultural constructions of disease and illness.

Health Promotion Ideologies• Even though public health is an “applied field” that borrows

much from these other disciplines, it is vital that health promotion professionals remain critically reflective about the processes by which health behavior theories are translated into PH mainstream

• If health promotion ideology in terms of health behavior theories is not being construed and shaped by the health promotion workforce itself, then other ideologies- developed by others outside the field will fill the void.

• In other words, if we don’t theorize in our practice, we will fall prey to “being practiced & theorized” by other disciplines in the social science field.

Reason 5

Because theoretical thinking…

…builds scientific knowledge in health promotion practice

Where’s the scientific structure?

• In the absence of theory, the knowledge base in health promotion developed via research is not critically grounded and merely a collection of loosely derived nuggets of information (without logical or ordered meaning).

• Need to move beyond mere descriptions of events (which is the role of epidemiology - data/inquiries)

Reason 6Because theoretical thinking…

…provides roadmaps for research in health promotion practice

A blue print for Health Promotion Practice

• Theories are set up to inform associations we look at or test – the why and how of people’s behaviors and behavior changes rather than “fishing” for variables or brainstorming a list of factors that are not grounded in theory

• Using theory-informed research provides a blue print of what to look for (or measure), and also allows for further testing of associations in other settings, with diverse populations for generalizability factor.

How theory informs practice

• Many theories suggest strategies for changing specific variables

• SCT: concepts of self-regulation and self-efficacy• Intervention Goal: increase sedentary lifestyle (daily

levels of physical activity)

– Think about self-regulation and how to build in self-rewards into the program (direct participants to chose self rewards that they value to reinforce new physical activity behs)

– Think about self-efficacy and if in fact an individual can engage in a specific behavior (walk for 30 mins a day). If people are not confident to perform beh it doesn’t matter that they have put in pleasurable self-rewards as the beh will not occur.

Reason # 6

• Theory-based evaluation

– Provides evaluation blueprint for analyzing the effectiveness of a program

• Parameters for analyzing (and interpreting) what was measured.

Study of Health Behavior

• Given that many factors shape and motivate health behavior:– individual’s biology,

family/community environment, & the larger societal landscape

For each of these “factors,” there are corresponding theories related to health behavior

INFLUENCES OF SMOKING BEHAVIOR…

SMOKING

IncomeLeisure facilities

ReligionNicotine addiction

Environment

Gender

Housing

Advertising

Culture of society

Ethnic groupFamily

Employment/unemployment

Taxation level on tobacco

AgeStress

Peer group

Self-image

Locus of control

Education

Intrapersonal(KABS)

Interpersonal(Social networks)

Community(Work, School, Hospital)

Institutional

Organizations- Institutions-Social networks

Public Policy

…Has a Corresponding Health Behavior Theory

Theories of Health Behavior

• Health Beliefs• Theory of Planned

Behavior• Stages of Change• Precaution Adoption

Process

• Social Cognitive Theory• Social Networks/Support• Diffusion of Innovations• Communication Theory

Theory Focus Key concepts

Stages of Change Model

Individuals' readiness to change or attempt to change toward healthy behaviors

Precontemplation Contemplation Decision/determination Action Maintenance

Health Belief Model

Persons' perception of the threat of a health problem and the appraisal of recommended behavior(s) for preventing or managing the problem

Perceived susceptibility Perceived severity Perceived benefits of action Perceived barriers to action Cues to action Self-efficacy

The Theory of Planned Behavior /Theory of Reasoned Action

Behavioral intention is key, intention is driven by attitude and beliefs about what others who are important think

Behavioral Intention Attitude Subjective Norm Perceived Behavioral Control

Individual Level

Health Belief Model

Age

Gender

Ethnicity

Personality

Socioeconomic status

Knowledge

Perceived

Susceptibilit

y,

Severity,

Benefits,

and Barriers

Self-Efficacy

Behavior

Cues toAction

-Edu/Advice-Symptoms

-Media

Modifying factors Beliefs

Theory of Planned Behavior

How to stage a person

Do you exercise regularly?

No Yes

Do you intend to in the next 30 day?

Have you been doing so for more than 6 months?

No Yes No Yes

Do you intend to in the next six

months?

No Yes

Precontemplation

Contemplation

Preparation Action Maintenance

Precaution Adoption Process Model

• Neil Weinstein’s precaution adoption process model assumes that when people begin new and relatively complex behaviors aimed at protecting themselves from harm, they move through as many as seven stages of belief about their personal susceptibility

Stages of the PAPM

UnawareOf hazard

Unengaged(optimistic bias)

Undecided about acting(action is not nec)

Decide not to act(precaution would be effective)

Decide to act

Acting

Maintaining

Interpersonal Level

Theory Focus Key Concepts

Social Cognitive Theory

Behavior is explained via a 3-way, dynamic reciprocal theory in which personal factors, environmental influences and behavior continually interact

Behavioral capability Reciprocal determinism Expectations Self-efficacy Observational learning Reinforcement

Social Cognitive Theory

Cognitions Behaviors Outcomes

Self Efficacy Outcome

ExpectationsEnvironmental support

Social Network Theories

• Balance theory: a balance is maintained between formal and informal support systems– Formal support: large organizations

(hospitals, etc)– Informal support: family, friends, neighbors– Individuals with strong informal support

networks live longer than those without that type of support.

Community LevelTheory Focus Key Concepts

CommunityOrganizationTheories

Emphasizes activeparticipation anddevelopment of communitiesthat can better evaluate andsolve health and socialproblems

EmpowermentCommunity competenceParticipation and relevanceIssue selectionCritical consciousness

Organiza-tionalChangeTheory

Concerns processes andstrategies for increasing thechances that healthy policiesand programs will be adoptedand maintained in formalorganizations

Problem definition(awareness stage)Initiation of action(adoption stage)Implementation of changeInstitutionalization of change

Diffusion ofInnovations

Addresses how new ideas,products, and socialpractices spread within asociety or from one society toanother

Relative advantageCompatibilityComplexityTrialabilityObservability

Diffusion of Innovations

• A process by which an innovation (practice) is communicated through certain channels over time among the members of a social system.

• Characteristics of the innovation (practice) itself, the diffusion process, persons who adopt it, and the social system will all influence how much and how quickly innovation (practice) is adopted, if at all.

• Attributes of innovations can help to explain the different rates of adoption of innovations by individuals:

1) Relative advantage

2) Compatibility

3) Complexity

4) Trialability or Flexibility

5) Observability

The communications process

MESSAGE -CHANNEL

SOURCES RECEIVER

FEEDBACK

STIMULUS RESPONSE

McGuire’s Communication Persuasion

Matrix Output Input

Source/Message/ Channel/Receiver/Destination

Attention

Comprehension

Acceptance

Retention

Action

Continuation

Principles that Cross Theories

• Acquiring behaviors is a process where people are at different stages

• Knowledge is sufficient for beh change• Importance of knowledge-attitudes-

intention-behavior sequence• Individual motivation important• Beliefs and values matter• Rewarding experiences foster behavior

change• Social relationships/norms important• Behavior not independent of context

Planning Framework

Goal of this lecture:

• Enable each of you to understand what is meant by the infamous saying in terms of the work you do as PH professionals:

There is nothing so practical than a good theory.

Kurt Lewin, 1951

A Good Fit Theory

• Is logical

• Is consistent with observations

• Is similar to those used in previous successful interventions for a similar situation

• Take a stab at theorizing to know you can become more than just a “theory consumer” or a “theory applicator” in a group

Throughout the Course…