Epi 246

Individual-Focused Theories of Health Behavior/ Health Behavior Change

Using a Socio-Ecological Perspective

Margaret Handley, PhD MPH

Dept. Epidemiology and Biostatistics and Center for Vulnerable Populations, DGIM

January 6, 2011

Outline of Today’s Lecture

I. Implementation and dissemination sciences

II. Link between IDS and behavior change theories

III. Course overview and structure

IV. Ecological models and individual-focused theory

V. A few explanatory theories to start and applications within IDS-related work

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

I. The Need for Implementation and Dissemination Sciences

“The uptake of research findings into routine practice is a haphazard and unpredictable process”

“Many evidence-based innovations fail to produce results when transferred to communities in the global south, largely because their implementation is untested, unsuitable or incomplete.”

“Implementation science represents a philosophical commitment to bringing the same scientific rigor to health care delivery systems as we bring to biomedical discoveries.”

Eccles et al, 2005; Madon T, et al. 2007 M. Soloman et al.; https://www.aamc.org/newsroom/reporter/dec10

Defining Translational Research and Implementation and Dissemination Sciences

IDS Training at UCSF

“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

US Historical Perspective on IDS Research

IDS research is not new, but new terminology.

IDS research is more developed in the UK and Canada, but after IOM report, ‘Crossing the Quality Chasm’ more US recognition of its importance in reducing disparities

IDS research viewed as a natural progression of biomedical and public health advances-- and thus needs a more coherent research approach.

-- this includes more involvement of theory

and socio-ecological context

II. Behavioral Theory and IDSII. Behavioral Theory and IDS

Reviews of IDS-related research indicate majority of interventions achieve modest effects, yet no empirical basis for selection of appropriate interventions for diverse settings

Interventions with theoretical basis found to be more successful that those without

As behavior change relates to multiple levels, theories at multiple levels need consideration>> relevance of socio-ecological frameworks

Glanz K and Bishop D. 2010;Eccles et al, 2006, Shortell et al, 2001

Research Design Analogy -Evidence Continuum – Begin with Theory

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

III. Epi 246 Learning Objectives

1. Understand key individual-focused health behavior change theories, including components and HOW they are used.

2. Understand linkages between health behavior theory focused on individuals and implementation and dissemination sciences interventions in ‘real world’ applications.

Epi 246 Learning Objectives cont.

3. Use ecological frameworks/planning models/structural determinants perspectives, to describe behavior and develop behavior change interventions.

4. Understand limitations of the different individual-focused approaches to theory.

5. Apply different behavioral theory components to planning, implementing and evaluating health-related behavior and behavior change interventions in your specific area of interest.

Epi 246 Requirements

1. Homework most weeks

--Discussed first 20 minutes of following week--Turned in at end of the day following week

2. Participation

3. Final Project

Which Health Behavior/Change Theories?

Those most relevant to behavior change in clinical and community health contexts:

1. Psychological theories

2. Health communication theories

3. Dissemination of information theories

4. Theories from behavioral economics

5. Theories of community building/empowerment

Learning Objectives – Today’s lecture

1. Understand why health behavior change theories focused at individuals are helpful for IDS research and real world application of interventions

2. Understand components of Health Belief Model, Theory of Planned Behavior, Trans-theoretical Model

3. Become familiar with how to explore components of specific theories and explore across multiple levels related to individual and contextual factors

IV. Individual ‘vs’ Structural/Ecological Perspective?

Individual and Structural Perspectives

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

-Brownell et al, Health Affairs 2010

“There is a confluence of structural forces that shape and determine poverty and it is important to probe beneath the superficial determinants of and presumptions about poverty.” -N Gunewarden Controversies in Education, 2009

A Generalized Ecological Perspective

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

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

V. How Individual-Based Theories Are 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. Help understand environmental factors that reinforce or undermine individual behaviors

e.g. Neighborhood ‘walkability’, access to condoms, ease of appointment scheduling

3. Help understand the mechanisms underlying effective interventions – to tailor/scale up

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

Behavioral Theory Use on a Continuum 1. Informed by theory – Framework or constructs

identified, but not specifically applied

2. Applied theory - Framework or constructs identified--at least one construct specifically applied

3. Testing theory - Framework or constructs identified and tested against one another

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

Painter, et al, 2008

Practical uses of theories

Targeted Behavior or Situation

Explanatory Theory:

Why?What can be

changed?Underlying dynamics?

Change Theory:

Which strategies?Which messages?

Underlying assumptions?

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 Susceptibility and Perceived CONSEQUENCES

e.g. FOOD POLICIES, AVAILABILITY of CONDOMS, DIRECT APPT. SCHEDULING,

TRANSPORTATION

Health Belief ModelFocus: 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.

Usually related to patients and health behavior within community settings

- Perceived susceptibility

- Perceived severity

- Perceived benefits

- Perceived barriers

- Cues to action

- (Self-efficacy)

Strong Health Beliefs translates into MOTIVATION and ACTION to prevent, get screened 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

HBM ExamplesConcept/

Application

Explanatory

Screening or Testing

Educational Interventions fotonovelas, clinician training

1. Perceived Susceptibility

Could I be exposed to TB? Focus on belief that they could get lead poisoning?

2. Perceived Severity

How significant are consequences of TB?

Focus on belief that lead poisoning is bad for you?

3. Perceived Benefits

Is getting tested better than not getting tested?

Focus on belief that not getting lead poisoning will improve health?

4. Perceived Barriers

What barriers are in the way and what might mitigate these?

Focus on belief that identified barriers can be overcome, such as limiting eating high risk foods?

5. Cues to Action

What could help me?

(Reminder cues for action

*Often person-specific)

Focus on reminders/ cues for action?

6. Self-Efficacy What would enable me to follow through? Guidance/ training (practice in making an appointment)

Focus on self-efficacy building/confidence in avoiding high risk foods in all circumstances?

HBM Explanatory Example: TB Treatment Adherence

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

Action

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

HBM: APPLICATIONS FOR CHANGING INDIVIDUAL BELIEFS

Theory of Planned BehaviorFocus: Key Concepts:

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

Often used in clinician as well as patient and community behavior

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

TPB: Explanatory Example Example- 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 too

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

TPB: Explanatory Example Predicting Safer Sex

Mauschbaum et al 2009

Use of components of different levels within Socio-Ecological model to understand where to target condom-based intervention efforts, and differences by location for such interventions:

Individual interviews to capture these constructs for:

Institutional level factors (work env., availability of condoms on site, policies to encourage)

Inter-personal factors (financial arrangements)

Personal factors (condom self efficacy, substance use)

Example Socio-Ecological Model and HIV Risk

Larios et al, 2009

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

Behavior Change and Rationality

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

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 factors at multiple levels?

For students not applying theory to an active project

Select a specific 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