THEORY
What is theory?

“… a set of interrelated concepts, definitions, and
propositions that presents a systematic view of
events or situations by specifying relationships
among variables in order to explain and predict the
events or the situations.”
 (Glanz, Rimer, and Lewis, p. 25)
Theory


“Effective health promotion and education depends
on practitioners’ marshaling the most appropriate
theory and practice strategies for a given situation.”
“The gift of theory is that it provides conceptual
underpinnings for well-crafted research and
practice.”
(Glanz, Rimer, & Lewis, pp. 30-31)
Theory

Generality

Testability

Shape and boundaries, but not specific topic or
content
Theories are used to …



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Guide the search for why people behave in certain
ways
Help pinpoint information needed before developing
and organizing an intervention program
Provide insight as to how to shape strategies to reach
people
Help identify what should be monitored, measured, and
compared
Concepts & Constructs

Concepts:
 Major

components of theory
Constructs:
 Concepts
that have been developed and defined for
use in a particular theory
Variables

Variables
 The

measurable forms of constructs
Variables are a measure of a specific construct in a
specific situation.
Models

“… draw upon a number of theories to help
understand a specific problem in a particular
setting or context.”
 (Glanz, Rimer, & Lewis, pp. 27)
Putting it together


A personal belief is a CONCEPT that has been
shown to relate to various health behaviors.
Using a THEORY that includes the concept of
personal beliefs helps explain why young men don’t
think they will ever get testicular cancer.
More theory

“Habit is habit, and not to be flung out of the
window, but coaxed downstairs a step at a time.”
 Mark Twain
Planning Models

Like a road map
 Present
all possible routes you might take to develop,
implement, and evaluate a program.
Planning Models

PRECEDE/PROCEED

MATCH

CDCynergy
PRECEDE/PROCEED Model
Behavior Change Theories

The specific route(s) you will take to reach your
destination – they suggest a road to follow.
Theories and Levels of Influence

Behavior is very complex
 Influenced
and supported in multiple ways
The Ecological Model

Emphasizes the links and relationships among
multiple factors (or determinants) affecting health
Ecological Model
Public Policy
Community
Institutional or
Organizational
Interpersonal
Individual
Individual / Intrapersonal factors

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Knowledge, attitudes, beliefs (KAB)
Skills
Motivation
Self-concept
Age, gender, genetics
Interpersonal factors

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Social support / social networks
Social norms, cultural environment
Religious affiliation
Access to social and health services
Institutional or organization factors

Educational system

Access to health care

Social Interactions
Community factors

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Living and working conditions
Public safety
Local public health
Housing
Economic development
Environment
Public Policy Factors

Federal, State & Local Policy and Law
 Zoning
 Taxes

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Public Health System
Educational System
Behavior change theories with
individual focus

The Health Belief Model (HBM)

The Transtheoretical Model (TTM)

Theory of Planned Behavior (TPB)
Health Belief Model (HBM)

Developed in the early 1950’s by social
psychologists in the U.S. Public Health Service.

Hochbaum & Rosenstock

TB screening
Constructs of HBM

Perceived threat
 Perceived
 Beliefs
about one’s chances of getting a condition
 Perceived
 Beliefs
susceptibility
severity
about how serious the condition might be
Constructs of HBM

Outcome Expectations
 Perceived
Benefits
 Beliefs
that the advised action will reduce risk or seriousness
of the condition.
 Perceived
 Beliefs
risks/barriers
about the “costs” of taking the advised action
Constructs of HBM

Cues to Action
 Strategies

to activate one’s “readiness”
Self-Efficacy
 Confidence
in one’s ability to take action
Health Belief Model
Modifying Factors:
age, race, ethnicity,
SES, personality
Perceived
Susceptibility
& Perceived
Seriousness
Perceived
Threat
Cues to Action
Outcome Expectations:
Perceived Benefits vs.
Perceived Risks/Barriers
Likelihood of taking
recommended action
Self-efficacy
Theory of Reasoned Action (TRA)

Constructs:
 Attitude
toward the behavior
 Beliefs
about the behavior
 Evaluation of behavioral outcomes
 Subjective
 What
norms
others think about your behavior
 How motivated you are to comply with the expectations of
others
TRA Cont.

Beliefs and Subjective Norms help predict Intentions

Your Intentions predict your actual Behavior
TRA
Attitude
toward
behavior
Intention
Subjective
Norm
Behavior
Theory of Planned Behavior (TPB)


Developed by Fishbein & Ajzen
An extension of the Theory of Reasoned Action
(TRA)
TPB versus TRA

Adds the construct:
 Perceived
Behavioral Control
 Belief
about personal control in combination with belief
about the one’s ability to do what needs to be done.

Actual Behavioral Control: have the skills and resources needed
to quit.
TPB Cont.

People will perform a behavior if:
 They
believe the advantages of success outweigh the
disadvantages of failure.
 They
believe that other people with whom they are
motivated to comply, think they should perform the
behavior.
 They
have sufficient control over the factors that
influence success or ability to perform the behavior.
TPB
Attitude
toward the
behavior
Intention
Behavior
Subjective
Norm
Perceived
Behavioral
Control
Actual
Behavioral
Control
Transtheoretical Model (TTM)



AKA: Stages of Change
Developed by Prochaska & DiClemente
Major Constructs:
Precontemplation
 Contemplation
 Preparation
 Action
 Maintenance
 Decisional Balance
 Self-Efficacy

Precontemplation
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

“The care is still in the garage!”
Not thinking about changing behavior in the next six
months.
May be unaware of risks or problems.
Needs some work “under the hood.”
Contemplation
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“The engine is started, but we’re not quite in gear!”
Seriously thinking about making a behavior change,
but have not yet made a commitment to action
Preparation

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“We’re in gear and ready for short trips.”
Ready to take action in the very near future (next
30 days)
Have a plan of action
Experimenting with new behaviors
Action

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“We’re on the road on a regular basis.”
Actively engaged in new behavior(s) for less than
six months.
Efforts are sufficient to reduce risk of disease
Maintenance

“We’re on cruise control.”

Sustaining the behavior change for over 6 months.
Decisional Balance

The costs and benefits of changing.
Self-Efficacy

Confidence that one can be successful in the new
behavior across different challenging situations.
Relapse



More likely when you are stressed, anxious, or
feeling depressed.
More likely if you lack social support or are
experiencing interpersonal conflicts
More likely if you return to a setting (environment)
that “cues” your old behavior(s)
Strategies/process to get from one
stage to the next.

Precontemplation to Contemplation
 Awareness
 New
information
 Persuasive communications
 Experiences
Strategies

Contemplation to Preparation
 Knowledge
acquisition
 Information
 Persuasive
communications
 Experiences
Strategies

Preparation to Action
 Deciding
 How-to
information
 Skill development
 Attitude change
Strategies

Action to Maintenance
 Skills
 Reinforcement
 Support
 Self-Management
 Attitude
and attribution change
Strategies

Maintenance
 Continuation
 Relapse
prevention skills
 Self-Management
 Social and environmental support
Precontemplation
Transtheoretical
Model (TTM)
Decisional Balance
Contemplation
Decisional Balance
Preparation
Action
Maintenance
Pro’s of TTM

Encourages less “labeling” terms.
 (Precontemplation

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rather than “loser” or “lost cause”)
Must accept people “where they are”
Behavior change is not viewed as linear
It is easy to stage clients
It is not based on an instant gratification mentality
Allows for stage-matched interventions
Adapted from:
Autobiography in Five Short Chapters
by Portia Nelson
I
I walk down the street.
There is a deep hole in the sidewalk.
I fall in
I am lost … I am helpless
It takes forever to find a way out.
II
I walk down the same street.
There is a deep hole in the sidewalk.
I pretend I don’t see it.
I fall in again.
I can’t believe I am in the same place.
It still takes a long time to get out.
III
I walk down the same street.
There is a deep hole in the sidewalk.
I see it is there.
I still fall in … it’s a habit.
My eyes are open.
I know where I am.
I get out immediately.
IV
I walk down the same street.
There is a deep hole in the sidewalk.
I walk around it.
V
I walk down another street.
Social Cognitive Theory (SCT)

A behavior change theory with an Interpersonal /
Social network focus.
Reciprocal Determinism
Characteristics
of the Person
Environment in
which the behavior is
performed
Behavior of
the person
Constructs of SCT

Behavior Capacity

Self-Efficacy

Expectations

Reinforcement

Expectancies

Self-Control / SelfRegulation


Observational
Learning
Emotional Coping
Responses
Principles of Modeling

Attention

Remembering

Model Similarity
 Age
 Gender

Repetition

Motivation
 Status
 Competence
Reinforcement

Any action or event that increases the desired
behavior
 Present
something positive
 Money
 New
clothes
 Remove
something negative
 Nagging
 Teasing
Punishment

Any action or event that decreases the likelihood
that the desired behavior will occur.
 Present
something negative
 Criticize
 Policies
 Remove
or laws
something positive
 Praise
 Privilege
Political
Population Level
Community
Organizational/Institutional
Framework:
Social
Networks
Interpersonalof Health
Social Determinants
Individual
Ecological Model
Diffusion of Innovations Theory

Rogers, 1983

A behavior change theory with a community focus
Diffusion of Innovations

The progressive adoption by members of a
community or society of an idea or practice over
time.
Categories of Adopters

Innovators (<3%)
 Independent,
risk-takers, eager to try new ideas
 Not necessarily the most respected members of the
community
 Seek info on their own, rely on their own judgment in
making decisions about adoption
 Try out new ideas and provide the first tests of the
utility of the innovation
Categories of Adopters

Early Adopters (14%)
 Respected
members of the community
 Opinion leaders
 Powerful influence on other potential adopters
 Trendy … like to be up on what is good and new
 Seen as opinion leaders
Categories of Adopters

Early Majority (34%)
 Greatly
influenced by mass media and opinion leaders
 By
virtue of their numbers, they begin to form a new
norm
 Lots
of contact with peers, but don’t hold leadership
positions.
Categories of Adopters

Late Majority (34%)
 Skeptical
of change
 Tend
to wait until an innovation is established as a norm
before adopting
 Motivation
 Don’t
is greatly influenced by peers
like risk and uncertainty
Categories of Adopters

Laggards (16%)
 Very
traditional and conservative
 Tend
to have less education and lower SES
 Socially
and geographically mobile
 Narrow
and restricted communication networks
 Suspicious
of innovations and adverse to risk
Adoption Curve
Determinants of Diffusion’s
Speed and Extent

Is the innovation better than what it will replace?

Does the innovation fit with the intended audience?

Is the innovation easy to use?

Can the innovation be tried out before adopting?

Are the results of the innovation observable and
easily measured?
A few more pieces

Predisposing, Reinforcing, and Enabling Factors

Barriers to change
 PRECEDE/PROCEED
behavioral diagnosis phase
Predisposing Factors

Provide the rationale or motivation for a person or
group to act
 KAB
(knowledge, attitudes, beliefs)
 Personal preferences
 Existing skills
 Self-efficacy beliefs

Individual level theories
 Intrapersonal
these factors.
are most appropriate for addressing
Reinforcing Factors

Factors that provide reinforcement and reward for
actions and encourage repetition of the action
 Social
support
 Peer influence
 Significant others (family, spouse, partner)
 Employers, teachers, health providers, community
leaders, decision-makers
Reinforcing Factors Continued


Interpersonal level theories are most appropriate in
addressing these factors
Interpersonal level theories suggest communication
channels (e.g. significant others or social networks)
and methods (e.g. incentives or social supports).
Enabling Factors

Factors that provide the means or make the action
possible.
 Availability
 Accessibility
of programs or services or skills training
of programs or services or skills training
Activity

Pick a theory (Health Belief Model, Theory of Planned Behavior,
Transtheoretical Model, Social Cognitive Theory OR Diffusion of Innovation Theory)

Map out the constructs of the theory

Where do these constructs fit into the Ecological Model?
Give a brief (at least one sentence) explanation of each
construct
 Provide examples for each construct that relates to your
topic
 List as many predisposing, reinforcing, and enabling
factors as you can think of for the topic.
 Keep this model for Wednesday’s class.
