Theory-based Education

COMT 492-02

Overview
Why

we need theories
How to select a theory
Pros & cons of theories
Common theories
Example
Lessons learned

Types of theories?
Linguistic
How we word messages determines whether
people will pay attention & respond
Behavioral Decision-making
Behavior change is complex & involves a series of
stages
Affective or framing theories
Fear appeals and positive framing affect how
people respond to messages

Why do we need theories?

Guides

practice
Leads to more
effective interventions
May save costs
Help develop models
of change

Freudenberg, N., Eng, E., Flay, B., et al. (1995). Strengthening individual
and community capacity to prevent disease and promote health: In search of
relevant theories and principles. Health Education Quarterly, 22 (3) : 290306.

Why do we need theories?

Understanding

antecedents to health

behavior
Promotes better understanding of causes of

behavior

leading to more effective programs

Helps identify groups who are at risk

helping target programs

How to select a theory?

Numerous theories exist

Sociological
Psychosocial
Biological

Numerous theories exist

Sociological

theories

poverty, ethnicity, disorganization, structural causes

Psychosocial

theories

beliefs, personal values, perceived norms, intentions

family education, parenting, stability

Biological

theories

genetics, hormones, and psychological (proximal)

determinants of behavior

How to select a theory?

Theories

must answer:

What are primary causes of

the health problem?

What are links between
interventions & outcomes?
How do community,
individual and societal
factors interact?
Whats role of health
educator?

Links between activities &

outcomes
Understanding

how
and why interventions
work enables us to
replicate effective
change.
Evaluation research
can test whether an
intervention worked in
the way(s) a theory
predicts.

Role of health educator

An

effective intervention should have a

coherent rationale or a theoretical basis
for goals, intervention activities, and role of
the educator.

Weaknesses of theories

Weaknesses of health
education theories
Not

readily available
to practitioners
Emphasize individual
change at expense of
societal factors

Static

or unidirectional
Not very participatory
Dont explain big
picture -- how
problems emerge and
how interventions
work

Common health education

theories

Psychosocial Theories
Elaboration

Likelihood Model
Health belief model
Social cognitive theory
Theory of reasoned action
Theory of self-regulation & control
Stages of Behavior Change
Agenda-setting

Elaboration likelihood model:

Motivation to attend to health
messages

Before you get people to change their behavior,

you need to get them to attend to a message.
Mindless/passive vs. Active/mindful
Peripheral vs. Cognitive (central processing)

An

audience involved with a topic will actively

seek, attend and process messages about that topic.
Uninvolved audiences will process info in a
passive fashion.

Switching cognitive gears

How

do you prompt active thought (Louis

& Sutton, 1991)
Mode of presentation
Unusual, novel or unfamiliar
Positive affect appeals for topics usually associated with
fear (e.g., skin cancer)
Entertainment (e.g., Amazing Spiderman Comics)
Parasocial relationships
Behavior modeling

Switching cognitive gears

(contd)

Content represents discrepancy

When a message is inconsistent w/ whats expected, it prompts
active thought

External or internal request for paying attention

Verbal immediacy
Denotative specificity
Personalizes & simplifies a message
You should wear sunscreen vs. People should
Spatial immediacy
This, these, here vs. those, that and there
Temporal immediacy
Present tense verbs
Avoid qualifiers

Health Belief Model:

Factors influencing behavior
Intention

to engage in the behavior

Environmental constraints
Skills or ability to engage in the behavior

Factors influencing behavior

Intention
Perceived net benefits
Perceived social norms
Self-efficacy
Consistency with self-standards
Emotional reactions

Example: Teen Pregnancy

A person

is more likely to intend to use

contraception if they believe:
Benefits outweigh costs
Others have positive beliefs about

contraception
They can readily obtain contraception
Using contraception is consistent with their self
image

Antecedents of teen
pregnancy & childbearing
No

one antecedent explains all variance in

behavior
Many antecedents weakly or moderately
related
Results can paint picture of youths most at
risk

Antecedents (contd)
Youths

at greatest risk are more likely to:

Live in communities w/ high turnover; low

education, high poverty, high divorce, high

rates of adolescent births
Have parents w/ low education, poor, history of
divorce, history of teen pregnancy
Have parents w/ poor childrearing practices,
less supervision
Have friends who are sexually active

Implications for teen

pregnancy programs
Difficult

to reduce teen pregnancy markedly

Many factors
Many of the factors are structural, biological or distal

Programs

should not focus on any one factor alone

Programs should focus on:
Sexual beliefs, attitudes, perceived norms, self-efficacy,

skills & intentions

Environmental constraints
Structural inequities

Theories of Behavior Change

Social

Learning Theory (Bandura, 1977)

Empowerment Education (Freire, 1973)
Agenda Setting (McCombs, 1978)
Theory of Reasoned Action (Azjen &
Fisbein, 1980)
Stages of Behavior Change (Prochaska &
DiClemente, 1986)

Health Belief Model

Health Belief Model

Ones attitudes,

social norms and beliefs about

outcomes of a behavior determine their
behavior
Hell-raiser may expect pregnancy or HIV, and

therefore use condoms more

Romantic Idealist may expect loss of love if she
insists on condom use
Becker, M., 1974

Social Learning Theory

&
Social Cognitive Theory

Social Learning & Cognitive

Theories
People

learn by observing role models being

rewarded or punished for a behavior
Learning is increased if:
Role model is:

Likeable
Similar to target audience
Credible

Skills are clearly demonstrated

Behavior appears easy to do

Bandura, A., 1977, 1986

Empowerment Education

Empowerment Education
Learning

occurs when people are involved

in the process of education or change
Learning is increased if:
People participate more
People are involved with every step of the

process
People agree on end goal
Freire, P., 1973

Agenda-setting

Agenda-setting
Media

sets the agenda for what people think

is important
When media gives high salience to an issue,
it is reflected by popular opinion

Shaw, D. & McCombs, M., 1978

Stages of Behavior Change

Stages of Behavior Change

Behavior

change is not a one-step process

Different messages are needed for each stage
Stages of Behavior Change Model:
Pre-contemplation: No intention of condom use
Contemplation: Intends to use condoms in next 6 months
Ready-for-action: Intends to use condoms from now on
Action: Continual condom use for less than 6 months
Maintenance: Condoms used every time for at least 6 months
Prochaska J, et al. The transtheoretical model of change and HIV prevention: A review. Hth
Ed Quart use of condoms using the stages of change model. Public Health Reports
1996;111(suppl 1):59-68.

Pre-contemplation to
Contemplation
Consciousness-raising:

Increasing
information about oneself in relation to a
particular problem
Dimensional models and risk comparisons
Cumulative and one-shot probability
Qualitative & quantitative probability terms
Framing effect

Dimensional models & risk

comparison
Only

risks with similar dimensional profiles

should be compared.
Health communication can encourage people to

move from PC to C by increasing perceived

risk associated w. a particular behavior and by
making comparisons with activities widely
regarded by society as risky.
Inappropriate comparisons will fail.

Cumulative & one-shot

probabilities
People

underestimate cumulative risk.

Emphasizing cumulative might move people

from PC to C more effectively than talking

about the risks of a single incident.

Qual. & Quant. Terms

People

associate specific numbers with

specific terms.
Communication designers should consult
qualitative probability literature to find the
rage of quantitative equivalents (Bryant &
Norman, 1980).
virtually always = .99
unlikely low probability = .20

Segmenting by Stage of
Behavior Change
Campaigns

that target audience by risk level

are more effective than non-targeted
campaigns
in smoking cessation, exercise adoption, dietary

fat reduction & mammography screening -why not HIV?

Prochaska JO, et al. In search of how people change. American

Psychologist 1992;47(9):1102-14.

CDC Role Models Campaign

CDC Uses Stages of

Change Theory
Campaign
CDCs Role Model Stories in San Francisco, 1993-96

Goal
To change womens HIV risk behavior & community norms

Media
Narrative pamphlets

Target

audience

Welfare mothers ages 17-54

Kinght K, et al. This is my story: A descriptive analysis of a peer education HIV/STD risk
reduction program. Presented at American Public Health Association, New York City,
November, 1996.

Stages of Change Campaign

Different

stories were developed for each

stage of behavior change:
Contemplation:
Kizzy says shell seriously try to use condoms
Ready-for Action:

Mayeisha decides to use condoms with her next man

Action:
Champagne uses condoms, but not every time

Campaign Results
People

who progress from one stage to next early

in campaign are more likely to change behavior
3% pre-contemplators quit smoking
7% pre-contemplators who moved to contemplation

in 1st month quit smoking

20% contemplators took action
41% contemplators who moved to ready-for-action in
1st month took action

ASHA Teen Web Site

www.iwannaknow.org

ASHA Teen Web Site

Employs Theories
Social

Cognitive Theory

Role model similar to target audience

moderates message board

a young adult with extensive STD prevention

counseling experience

Topics teens can relate to

frequently asked questions from other teenagers
Tone of voice appropriate to teenagers

ASHA Teen Web Site

Employs Theories (contd)
Stages

of Behavior Change

Each component of Web site addresses different

stage of readiness to protect against STD/HIV

Question-and-answer format gives knowledge
(contemplation)
Internet games build safe sex negotiation skills
(ready-for-action)
Message boards provide confidence and social
support (maintenance)

Teens can click on topics most appropriate

What are some

lessons learned?

Lessons learned
Message

tailoring
Participant involvement
Integrate individual & community factors
Link health goals to broader social goals
Use existing resources
Build on community strengths
Support diffusion to wider population

Bridging gaps
Work

with researchers from other

disciplines
Multidisciplinary theoretical research
Obtain input from health ed practitioners
Create forums with community leaders,
activists, practitioners, etc.
Define vision of health education within
larger health care system