H571 – Week 1• Introductions

– Name, program, year, prior experiences with HP and interests for this course

– Complete sign-in form – indicating your health behaviors of interest and your preferences for week of presentation

• Review of syllabus– Expectations, assignments, questions

– All communications via email• Use only your ONID email address!

• Activity – Discussion/Brainstorming• Review DSC Chapters 1 & 2 and NCI• Review TTI

Activity 1:

• What Is Your Topic/Area of Interest?– Think about looking upstream from disease to behavior

• Understanding the causes and consequences of a particular health-related behavior

• Promoting a particular desirable behavior or preventing a particular undesirable behavior

– Amenable to individual-, group- and population-level interventions

• List your choice of week to present– See next slide

H571 syllabus/course outline

• PART I: Introduction, Intrapersonal Theories, Interpersonal Theories• Week 1: Introduction to health promotion and health behavior theory

• Week 2: Value-Expectancy Theories

• Week 3: Perceived Threat and Fear Appeals

• Week 4: Stage Models

• Week 5: Social Cognitive Theory

• PART II: Sociocultural Theories• Week 6: Behavioral Economics

• Week 7: Communications theories (HPHB students)

• Week 8: Diffusion of Innovations and Community Theories

• Week 10: Ecological approaches and integrative theories (HPHB students)

Discussion:

• Why is understanding the causes (theories about) and consequences of health behavior important for your topic/area of interest/expertise?

• Why is understanding how to change health behavior (and theories about behavior change) important for your topic/area of interest/expertise?

Brainstorm:

•What are the causes of peoples’ behavior?

OR

•Why do people behave the ways the do?

DSC Chapter 1

• Health Behavior (HB) in the Context of the "New" Public Health (PH)

• Three levels of prevention

• Definition of health promotion (HP)

• Importance of multiple theories for HP

• Understand multiple kinds of theories

• HBs are influenced by multiple environments (physical, social, economic, legal, political) as well as intrapersonal factors

• Thus, need a broad range of theories

Introduction

• What is health?– According to the World Health Organization

(WHO): “Health is not merely the absence of disease or infirmity; rather, health should encompass a state of complete physical, mental and social well-being

• Is this definition comprehensive?

Public Health Issues, 1900 & 1997

Introduction

• Chronic Diseases: manifest over time, are not always apparent, may be long lasting or recurring

• Infectious Diseases: diseases transmitted through a specific form of contact

• How might the role of environment and behavior influence the spread of each disease type?

Key Concepts

• The United States spends more on health care than any other nation in the world (WHO, 2009)

• U.S. only ranks 47th in terms of life expectancy• See Figure 1-2 (next slide)

Key Concepts

Why Emphasize Prevention?

• Some estimates suggest that the U.S. government spends $1,390 per person to treat disease, while spending only $1.21 per person on prevention

• E.g., Type 2 Diabetes• Obesity a modifiable risk factor (i.e. can be

changed)• If obesity and inactivity reduced, should also

experience significant decrease in prevalence of Type 2 Diabetes

Health Behavior is Complex

• Changing behavior is not as simple as it seems– Behavior is complex and influenced by

many factors, therefore changing it requires deep understanding of a range of influences

– Before behavior can be changed, one must understand the determinants of behavior

– Can include: • biological and personality characteristics; • family, peers, and community; • socio-cultural influences, the built environment, etc.

Health Promotion is Complex

• Health promotion involves two aspects: research and practice

• Health promotion research works to understand underlying individual and environmental factors that influence health behavior

• Health promotion practice is responsible for designing and implementing interventions to modify factors and ultimately change behavior

Theory is Complex

• Theory is a tool used in both research and practice

• Definition: Theory is a set of testable propositions that is used to explain a group of facts of phenomena

• In health promotion, theory is viewed as a tool for enhancing our understanding of complex situations versus something that offers universal explanations or predictions (Green, 2000)

However…

• Social scientists have used the term “theory” to mean several different things (there is little consensus):– A set of empirical generalizations– A unified, systematic causal explanation for

various phenomena– A theoretical orientation (or “school-of-

thought”)– A single theory (e.g. Critical Theory)– Hypotheses, models, conceptual frameworks

Important to remember

• Commonsense theories and

• Scientific theories have a key element in common:

They represent efforts at making sense of the world in which humans live; it’s a meaning-attribution activity; an attempt to

“tell stories about how things work”

HOWEVER, ONE BIG DIFFERENCE:

Scientific theories have been tested and found valid across multiple populations and contexts

Definitions from NCI• Concepts are the building blocks—the primary

elements—of a theory.• Constructs are concepts developed or adopted for

use in a particular theory.• Variables are the operational forms of constructs.

They define the way a construct is to be measured in a specific situation. Match variables to constructs when identifying what needs to be assessed during evaluation of a theory-driven program.

• Models may draw on a number of theories to help understand a particular problem in a certain setting or context. They are not always as specified as theory.

Types of Health Behavior Theories

• Explanatory theories– Help understand the causes/determinants of a

behavior– Descriptive

• Change theories– Guide the development of interventions– Process oriented

Theory to Practice

• Effective practice depends on using theories and strategies that are appropriate to a situation:– The target condition or behavior– The target population– Units of analysis or change– The type of behavior to be addressed

The Public Health Approach

• Public health seeks to promote health, prevent early mortality and morbidity, and enhance or ensure quality of life

• Prevention is the basic principle underlying the public health approach

• Public health focuses on populations (or groups of people); it is not clinical (or focused on individuals)

The Public Health Approach

• Prevention of disease requires more than just avoiding clinically observable illness

• Figure 1-3: The wellness/illness continuum

Primary Prevention

• Public health predicated on primary prevention

• Primary prevention: efforts are made to intercept the onset or occurrence of disease, injury or behavior.

• Ex: vaccination programs, abstinence programs, bicycle helmet laws for children

• Involves intervening before disease onset

Public Health Approach

• Universal approach: When an entire population or subgroups of the population are targeted regardless of whether individuals have specific risk factors

• Selective approach: primary prevention efforts targeted at those in the population who are at heightened risk. – Typically targeted based on biological, psychological,

social or environmental risk factors

Secondary Prevention

• Secondary prevention occurs when a disease process is diagnosed in an early stage of progression, thereby enhancing the odds of treatment success.

• Focus is to minimize consequences through early detection and intervention. – E.g., Screening programs for STDs,

mammography or smoking cessation programs

Tertiary Prevention

• Tertiary prevention occurs when a disease state is diagnosed in time to apply treatment that may preserve further organic damage or death

• Involves mitigating the consequences of disease or an injury after the fact

• Difference between Secondary and Tertiary Prevention can be thought of as the difference between early and late diagnosis

Tertiary Prevention

• Indicated approach used in tertiary prevention- designed for individuals who have a risk factor that put them at very high risk

• E.g., Providing mental health counseling for rape victims, providing patients who have Type 2 diabetes with educational pamphlets to help them better manage their disease

• Tertiary prevention in the public health model is similar to treatment in the medical model

Three Levels of Prevention

Activity

• Discussion of the most appropriate level of prevention for your chosen topics

Health Behaviors

• Behavior- the manner in which something acts, functions, responds, or reacts.

• Health behavior- the actions, responses or reactions of an individual, group or system that prevent illness, promote health and maintain quality of life

• E.g., individual health behavior: using a condom, getting vaccinated, buckling your seatbelt

• E.g., group health behavior: improving public parks, instituting a citywide smoking ban

Three Categories of Health Behaviors

• Preventive behavior: Health-related behaviors of people who are healthy and try to maintain their health

• Illness behavior: behavior undertaken by individuals who perceive themselves to be ill and who seek relief or definition of illness

• Sick-role behavior: the treatment plan once an individual is diagnosed with a disease

Health Behaviors

“New” Public Health

• Increased emphasis on the significant role of environmental influences in shaping individual behavior and affective health (i.e. culture, policy, technology, urbanization, built environment)

• Health promotion: the art and science of motivating people to enhance their lifestyle to achieve complete health, not just the absence of disease

Figure 1-6: Health Promotion Strategies

Health Promotion

• What is missing from the last image?

• Health promotion researchers, policy makers and practitioners use theory to guide many of their health promotion strategies.

• Health promotion is a process; therefore, defines itself in terms of its goals and strategies. – Relies on theoretical contributions from many other

disciplines (social psychology, sociology, child development, education, etc.)

DSC – Chapter 2

•Understand: •That health behaviors are diverse

•Proximal and distal influences•And ultimate/fundamental causes

•How Theory Informs Health Promotion and Public Health Practice

•Use of theory in multilevel approaches to prevention/HP

Introduction

• Theory has become an indispensable tool for the development, implementation and evaluation of public health initiatives

• It enables researchers to better understand and change health behavior

Role of Theory

• Theory can be used to:– Define the specific objectives/strategies

• Related to a targeted behavior

– Meant to alter hypothesized mediators• Or causes of the targeted behavior

– To lead to effective behavior change• Note the emphasis on effective – not all HP is effective

– For a large number of people • the objective of public health (in contrast to clinical

services)

Health Behaviors are Diverse

• Three dimensions of health behavior– Complexity, frequency, volitionality

• Complexity: involving higher levels of knowledge, skill or resources to perform than simple behaviors

• E.g., Correct use of the male condom involves at least 10 steps; the more complicated the behavior, the lower the likelihood it will be performed correctly

Health Behaviors are Diverse

• Complexity not always inherent in the behavior, can be a function of the environment

• E.g., Getting a flu vaccine may not be complex for a middle class American with health insurance; however, the same behavior may be high in complexity for a person living in isolated, rural poverty

Health Behaviors are Diverse

• Frequency: Health behaviors can be frequent and repetitive (diet and exercise), one time only (screening for radon), or periodic (obtaining a mammogram)

• Behaviors may be highly complex but only require infrequent repetition (colorectal cancer screening) or complex and require daily repetition (consuming a low-fat diet)

Health Behaviors are Diverse

• Volitionality: the degree of personal control over the behavior– Highly volitional behavior is one over which the

person has complete control; performing the behavior does not require external resources, assistance or support (i.e. flossing)

– Behaviors low in volitionality require reliance on external resources (i.e. consuming fresh produce, may not be affordable or available)

Theory at Multiple Levels

• Much like health behaviors, theories are also diverse

• Theories can be applied at several “levels” within the environment

• See Figure 2-2 (next slide)

Figure 2-2: Socioecological Model

Ecological Framework

• Outer levels influence inner levels all the way down to the individual (“I” in the inner-most circle)

• The individual is often the “target” of the intervention; however, making changes at any of the levels can influence individual health behavior

• Ecological approaches are now widely believed to be more effective than single-level approaches

Proximal vs. Distal Influences

• Proximal Influences: inner-level factors that are close in proximity to the individual (“I”)

• Distal Influences: factors located in the outer levels, that do not always directly or immediately affect the individual due to their location in the model

• See Box 2-1 (next slide)

Box 2-1: Proximal vs. Distal Influences

However …..

• We see a slightly different formulation in the TTI (and in Week 10)

Role of Theory

• Theory helps us to develop an organized, systematic and efficient approach to investigating health behaviors (so we are not just guessing at distal and proximal influences!)

Informal Steps to the Inductive Approach

1. Your own hunch about the nature of the health behavior and underlying causes

2. Think about the health behavior from a theoretical perspective

3. Conduct an empirical evaluation (relying on published literature) that suggests underlying causes of risk and protective behaviors

Inductive Approach

• These steps serve to identify the determinants of a specific health behavior

• Determinants: factors that influence the health behavior (levels of influence in the Ecological and TTI Models)

• Determinants may range from individual characteristics such as knowledge, attitudes and beliefs, to social factors such as family, friends and community, to environmental (or sociocultural) factors such as laws, economics, politics, religion, culture

Inductive Approach

• It is determinants/mediators that we target to affect behavior change

• By changing multiple determinants, we may be able to induce lasting behavioral change

• Theory helps researchers and practitioners highlight determinants/mediators more quickly and effectively

Program Planning

Multi-level Intervention

• The ecological approach uses theory to create intervention points across several levels

• Multi-level: implies at least two of the following ecological levels have been examined: individual, familial, relational, peer, community, societal or policy/legal

• When interactions between levels are examined, we gain a greater understanding of health behaviors

Hypothesized Mediators

• Mediator: represents the determinant targeted by the intervention and its association with the health behavior

• When the determinant is theory-derived, referred to as a hypothesized mediator

• Hypothesized mediator “comes between” intervention and behavioral outcome

Objectives

• An objective is a quantifiable action that (when achieved) will contribute to achieving behavior change

• E.g., Breastfeeding. Suppose social support is a hypothesized mediator of breastfeeding among first time mothers. If the goal of the intervention is to increase breastfeeding, the objective to enhance social support networks has a chance of being effective.

Objectives

• Theory guides the identification of objectives that (if achieved) will lead to changes in the behavior

• Figure 2-4:

Ecological Approach

• May be most appropriate to health behaviors that are complex, require frequent repetition and require external resources (i.e. changing lifestyle behaviors that lead to obesity and diabetes)

• Some of the most powerful approaches may be too expensive for use by local public health professionals – require access to changing policies/regulations/laws (or poverty!)

Conclusion

• Theory is a vital tool in health promotion practice and research

• Theory selection and use is one essential part of program planning that guides intervention development

• One theory does not fit all needs, program objectives are diverse and, thus, integrated theories or a selection of theories may be useful

The Theory of Triadic Influence

• Snyder & Flay, 2012: Brief introduction to the Theory of Triadic Influence (TTI)

BEHAVIOR

Intentions/Decision

Attitudes TowardBehavior

Social Normative Beliefs

Self-Efficacy

Proximal Correlates of Behavior

Social skills Self management Self-efficacy

Expectancy theories

Attitude theories

Social Norms theories

Conformity theories

Theory of Reasoned ActionTheory of Planned Behavior

EnvironmentIntraPersonal

Social Situation

ENVIRONMENT

GENETICS

BEHAVIOR

Intentions/Decision

Distal Causes of Behavior Person-Situation-Environment (Lewin, 1951)

Class ConflictLow SES, AnomieSocial DisorganizationStrain Theory (Merton) Radical Theories

Social Control (Elliott) Family Systems (Brooks) Peer Clustering (Oetting) 

Biological theories Psychoanalytic theories Resilience (Garmazey)Personality theoriesSelf-Control (Gottfredson & Hirschi)

64

BEHAVIOR

Intentions/Decision

Environment

Attitudes TowardBehavior

Social Normative Beliefs

IntraPersonal

Self-Efficacy

Social Situation

ENVIRONMENT

GENETICS

THE THEORY OF TRIADIC INFLUENCE

DECISIONS/INTENTIONS

SOCIAL SITUATION

BIOLOGY/PERSONALITY

THE THEORY OF TRIADIC INFLUENCE

ATTITUDESTOWARD THE

BEHAVIOR

CULTURALENVIRONMENT

SOCIALNORMATIVE

BELIEFS

Trial Behavior

EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological

SELF-EFFICACYBEHAVIORAL

CONTROL

Nurture/CulturalBiological/NatureIntrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream

Values/Evaluations

Knowledge/Expectancies

PerceivedNorms

Information/Opportunities

InterpersonalBonding

SocialCompetence

Interactions w/Social Instit’s

Others’Beh & Atts

Motivationto Comply

Skills:Social+General

Sense ofSelf/Control

SelfDetermination

1 2 3

7 8 9 10 11 12

13 14 15 16 17 18

4 5 6

19 20 21

22

23

DistalInfluences

ProximalPredictors

Levels ofCausation

UltimateCauses

Social/Personal Nexus

Expectancies & Evaluations

Affect andCognitions

Decisions

Experiences

Once a behavior occurs, the resulting reactions and/or experiences (thoughts and feelings) feed back to change the original causes

Reciprocal feedback occurs through all streams and levels

Engaging in a behavior changes one’s attitudes, normative beliefs and self efficacy

It also changes one’s knowledge, relationships with parents and peers, and sense of self

THE THEORY OF TRIADIC INFLUENCE Reciprocal Feedback:

67

DECISIONS/INTENTIONS

SOCIAL SITUATION

BIOLOGY/PERSONALITY

THE THEORY OF TRIADIC INFLUENCE

ATTITUDESTOWARD THE

BEHAVIOR

SOCIALNORMATIVE

BELIEFS

Trial Behavior

EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological

SELF-EFFICACYBEHAVIORAL

CONTROL

Nurture/CulturalBiological/NatureIntrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream

Values/Evaluations

Knowledge/Expectancies

PerceivedNorms

Information/Opportunities

InterpersonalBonding

SocialCompetence

Interactions w/Social Instit’s

Others’Beh & Atts

Motivationto Comply

Skills:Social+General

Sense ofSelf/Control

Will: Self-Determination

1 2 3

7 8 9 10 11 12

13 14 15 16 17 18

l

4 5 6

19 20 21

22

23

DistalInfluences

ProximalPredictors

Levels ofCausation

UltimateCauses

Social/Personal Nexus

Expectancies & Evaluations

Affect andCognitions

Decisions

Experiences

a

b c d e

f

g h i

jk m n

o

p q r

s

t u v w

x

Related BehaviorsJ

K

CF

IB E HA D G

CULTURALENVIRONMENT

Feedback changes the likelihood of engaging in the same or a similar behavior in the future

Thus, causes and effects are in a continuous cycle:– With each behavior changing the causes, and – The changed causes leading to the same or similar

behavior over time– Mutually influential individual contextual relations– Developmental regulation

THE THEORY OF TRIADIC INFLUENCE Continuous Cycle of Causation:

Feedback Also Shown This Way

B

I

E

AttSNB

P

SE

S

B

I

E

AttSNB

P

SE

S

B

I

E

AttSNB

P

SE

S

DEVELOPMENT & TIME

The reactions to certain behaviors feed back to influence the causes of RELATED BEHAVIORS– e.g., smoking and other drug use

- Related behaviors have similar causes, with the more distal causes being the most similar

- Less related behaviors (e.g., smoking and skiing) have fewer causes in common

- Even related behaviors have some differences in proximal causes

THE THEORY OF TRIADIC INFLUENCE Role of Related Behavior:

A

single

behavior

Eg,

smoking

Two

closely

related

behaviors.

Eg, smoking

and drinking

Less and

less related

behaviors.

Eg, smoking,

drug abuse,

sex, exercise.

Closely and less related behaviors:Ultimate causes may be the same, distal predictors less so.

E

S P

E

S P

E

SP

E

S P

ES

P

ES

P

E

SP

72

The TTI Developmental-Ecological System

P PS S

S

E

P

Eval

Behavior

SNB SelfEfficacy

Att Att

Intentions

Will + Skill ExpMc NB

KnowValue SocialBonds

RoleModels

Self-Control

Com-petence

SNB

ValuesEnvironment

KnowledgeEnvironment

ENVIRONMENT

Situation

PersonE E

Affective/Control Substream

s

Cog

nitiv

e/C

ompe

tenc

e S

ubst

ream

s

DEVELOPMENT & TIME

UltimateUnderlyingCauses

Levels ofCausation

DistalPredisposingInfluences

ProximalImmediatePredictors

Supplementary Slides

• Reasons for thinking theoretically:– Material from Goodson, Patricia (2010). Theory in

Health Promotion Research and Practice: Thinking Outside the Box. Boston: Jones and Bartlett Publishers.

Reasons for Thinking Theoretically about Health Promotion

• # 1 - Infuses Ethics and Social Justice into Public Health Practice

• # 2 - Represents A Moral Duty and A Professional Responsibility

• # 3 - Guides the Profession• # 4 - Prevents Ideological Take-Over, or

Hegemony• # 5 - Guides and Perfects Practice• # 6 - Builds Scientific Knowledge• # 7 - Provides Roadmaps for Research

Reason # 1: Ethics and social justice

• The Tuskegee Study– Breech of ethical principles in conducting

research.– One of the reasons for ethical mis-conduct:

• According to James Jones (author of the book Bad Blood) – medicine, at the time, was a profession “almost wholly composed of people uninterested in theorizing” (Jones, 1993, p. 96).

Reason # 1

• Tuskegee happened because…– The medical (and public health) profession trained

physicians to become• Healing technicians• Health methodologists• Health strategists

– Not trained to• Reflect• Inquire• Question the status quo• OR: not trained to think theoretically

Reason # 2:Moral duty and Professional responsibility

• Professions have defined tasks and values.

• Professional tasks and values = professional responsibilities

• Most professions CODE OF ETHICS and PROFESSIONAL COMPETENCIES

Reason # 2

Our professional responsibilities include:

•Develop our professional tools•Become more effective and efficient•Reflect continually on our practice•Question our methods•Reform our views, when needed•Build narratives that provide meaning for people’s health promotion efforts•Witness / Listen to our clients’ narratives

Reason # 2

• Theorizing: responsibility embedded in 6 of the 7 areas of professional responsibility for health educators, defined by NCHEC (National Commission for Health Education Credentialing).

• Examples:– “Identify factors that influence health behaviors” (Area

I – sub-competency C)– “Identify factors that foster or hinder the process of

health education” (Area I – sub-competency E)

Reason # 3:Guides the Profession

• Few scholars are thinking theoretically about the direction health promotion/public health is taking.

• Those who have thought theoretically, have contributed:– New theories – New models and perspectives– New approaches– Helpful critiques

Reason # 3

• Few scholars engage in theoretical thinking about public health because:

– It is disquieting– Can be disturbing– Can “rattle the status quo cage”

• Yet: THIS is what theory does…

Reason # 4: Prevent ideological take-over, or hegemony

• Ideology = the integrated assertions, theories and aims that form the collection of plans societies have for governing themselves.

• Hegemony = happens when one social group’s ideology dominates another group and becomes the predominant influence over this group (OR: an ideology take-over).

Reason # 4

• If public health professionals do not build and shape public health’s ideology, professionals outside public health will.

• Consider the influence of other fields of knowledge on public health, historically.

• Public health cannot exist without an ideology (or set of theories).

• Someone has to build these theories and assertions.

• If not public health professionals, who?

Reason # 5: Guides and perfects practice

• Practice = set of activities used to promote health and prevent illness.

• “Practice makes perfect” “Theory makes perfect” (Willinsky, 1998, p.245).

• Prevention interventions: more effective when based on theory

• Many theories suggest strategies for changing specific factors/variables/elements.

• Practitioners may not have to re-invent the wheel, when using these theories.

Reason # 6: Builds scientific knowledge

• The body of knowledge in a given field needs two types of research:1. Descriptive

2. Analytical

• Public Health: too much descriptive research? Not enough analytical?

• “Chaos in the Brickyard” letter by Bernard K. Forscher (Science, 1963)– Too many scattered bricks (data) – No buildings (bricks connected in a planned

manner)

Reason # 7: Provide roadmaps for research

• Most fields: asking for more theory-based research– Provides data that can be generalized more broadly

(applied to a larger number of contexts/contingencies).

– Facilitates conducting and implementing research projects.

– Provides blueprint for selecting which variables to measure.

– Provides parameters for analyzing (and interpreting) what was measured.

– Avoids: Re-inventing the wheel, going around in circles