PH720 Quiz 2 Session B
Empahty
- Affective Growth - a peron has a need to physical closeness and to be liked
Expressive
- Affective Prservatoin - asserts their self to the world around them - a person derives gratifaction from physical exertion, risk- taking and fantasy play
Implications for Interventions: Expressive
- Alternative activities - Messages that sepak to unique qualities
Implications for Interventions: Empathy
- Altruistic appeals - Concern for others - ex. donating blood, share the road
Implications for Interventions
- "Be the first one on your block..." - Alternatives
Assetion
- A person is achievement-oriented, longs for success, is competitive and is eager to leave a mark on the world - Affective Growth
Affirmative Action
- A policy designed to redress past discrimination against women and minority groups through measures to improve their economic and educational opportunities - the practice by some universities to take an applicant's race into account for admission
Identification
- Affective Growth - A person has a need to create and expand a distinctive identity - Can have numerous roles - bystander messaging: you can feel good about this and be the person that is resisting
Stimulation
- Cognitive growth - a person seeks novelty, play, and excitement
Autonomy
- Cognitive growth - people's need for freedom and control over desiny
motivational interviewing
- Counseling approach which uses a combination of behavior change techniques - Significantly more effective than traditional advice-giving - Directive, client-centered method for enhancing intrinsic motivation by exploring and resolving ambivalence and barriers to behavior change Very clinical and hands-on trying to ultimately allow person to recognize themselves that theyr'e not living the life they want to live or deserve to live
Incentiviation
- Creating expection of reward - ex. using prive draws to induce attmpts to stop smoking
Validity in Qualitative Research
- Credibility - Transferability - Dependability - Confirmability
Qualitative Analysis Overview
- Describe sample - Process Data = Code and Summarize data - Draw conclusions from data, relate to other data sources if applicable - remember values of triangulation
All the ways we can intervene
- Education - Persuasion - Incentiveization - Coercion - Training - Restriction - Environmental restructuring - Modelling - Enablement - Michie
Implications for Inverntions: Tension-Reduction
- Fear approaches: "Why... Why didn't we listen" blaming ads - streses reduction messages
Steps in conducting Key Informant Interviews
- Identify key informants: get the people together you want to talk to - Select type of interview [structured vs. semi-structured] - Prepare an interview guide [introduction, questions, probes, summary] - Conduct the interview - Record data [both handwritten and recorded, Record body language: did person open up and close up] - Process data - Analyze data
Identification: Implications for Interventions
- Identity formation through positive action -ex. friends don't let friends drink and drive - ex. all mother know, putting a baby on their back to sleep is best
Enablement
- Increasing means/reducing barriers to increase capability or opportunity - Behavioral support for smoking cessation, medicaiton for cognitive deficits, surgery to reduce obesity, prostheses to promote physical activity
COM-B system
- Michie - Flow chart: take capability and opportunities which lead and interact with motivation which then interacts with behavior - think about what sort of target would be and what you would need to activate in order to get there - What do you need to be capable of, what do they need to have the opportunity to do and what do they need to motivate them to have a behavior
How are theories useful
- Models are concepts, not representations of behavior ---> Show factors that influence behavior but don't explain the processes for changing behavior - Behavior is complex, models are deliberately simle ---> Models aid understanding, but are deliberately simplistic and do not capture all the factors that account of behavioral outcomes - Limit to how far they will stretch ---> Developed in the context of a specific behavior, and tend to work best in that context (some do have wider applicability) - Models don't tend to differentiate between people ---> Show behavior of a statistical 'everyman' - and need to be adapted in order to cover different audience groups - useful starting place: find out where we are and determinants - but will always have people that will react differently to stimuli - cand help standardize action plans so you can delegate one intervention against another instead of individualized programs (helpful to standardize interventions otherwise we can't compare them and learn from them - means not different interventions for each person) - Room for theories to overlap
Collecting Qualitative Data
- Observation: direct and participant [Just sit where things are happening and you watch and you learn patterns and outliers. Start to see participants in natural environment; Good to build trust because the person gets to know you and the more likely they are to talk to you: the more stigmatized a population, the more time you need to spend observing] - Mapping [Draw the connection and then about who you are talking to and how are they connected to other things; Or what are all the things that affect a health outcome] - In-depth interviews: unstructure, semi-structured, structured - Focus group disucsison (FGDs) [Discussion: bring group together and ask questions collectively Review documents: reports, attendance records: see patterns and interesting info] - Documentation review - Narratives [ask peopole to tell their story- not an interview where you ask questions - Case Studies [dig deep into one issue, one problem]
Implications for Interventions: Autonomy
- PH highlights when you're being manipulated - works well when there's an enemy - so if you change your behavior, you're acting with ur own free-will - build resentment against control by others - portray behavior change as an expansion of one's freedom
Limitation of Focus
- Participant's response not independent - Dominant members can skew session [sometimes people are jerks or they dominate the convo] - Requires skilled and experienced moderator [to keep convo moving and on track] - Data analysis requires skill and experience [because of volume of info - will get a lot more than if you interviewed each person individually]
Advantages of Focus Groups
- Participants not required to read & write [Works well with children; Participants with low literacy levels] - Allows participants to explore and clarify views with each other [Info no generated by 1-on-1 interview; acts as checks and balances on individual perception and option] - can gather rich data in participant's own words - Provides an opportunity for participants to be involved in preliminary analysis ["What is the most important issue we have takled about today?" "What do you thin of that person's response?"]
Assertion: Implications for Intervention
- Power or status themes - you can do this! You are the key. only you can prevent wildfires ex.
Stages of Change include
- Precontemplation = No - Contemplation = Maybe - Planning = Getting ready - Action = Acting differently - Sustaining = more thna 51% Relapse: often part of process and can happen at any point in the stages of changes since change is difficult
Implications for Interventions: Consistency
- Shame - Sensitize to internal inconsistencies --> highlight where people are acting inconsistentily with beleifs, etc. that support your arguments [how do you get people to recognize inconsistencies and how do you help people move to something that is more consistent] --> Show how what you want is consistent with the otehr person's inner systems and social norms
Change at the Individual Level
- Success of any prevention program is dependent on individual participation - Accepting or taking personal responsibility is often central to change - Change is a complex phenomenon - Not a simple Off/On switch
Social Norms
- TPB - Cusomary codes of behavior in a group or culture, together with beliefs about what those codes mean - social norms = standards in a group of people
Subjective Norms
- TPB - Whether behavior is likely to be approved of or diapproved of by social groups of influence - relates to person's beliefs about whether peers and people of importance to the person think he or she should engage in the behavior
Behavioral intention
- TPB - intention to perform the behavior, which is the most preditive of the actual behavior - This refers to the motivational factors that influence a given behavior where the stronger the intention to perform the behavior, the more likely the behavior will be performed.
perceived behavioral control
- TPB - presence or lack of thnkgs that make it easier or harder to perfomr the behavior - person's perception of the ease or difficult of performing the behavior of interest - Perceived behavioral control varies across situations and actions, which results in a person having varying perceptions of behavioral control depending on the situation. This construct of the theory was added later, and created the shift from the Theory of Reasoned Action to the Theory of Planned Behavior.
Control beliefs/perceived power
- TPB -The amount of control/power a person beleives he/she has over performing the behavior - perceived presence of factors that may facilitate or impede performance of a behavior - contribues to perceived behavioral control over each of those factors
Transtheoretical Model
- TTM - developed Prochaska and DiClemente - important to identify stage individual is in and adapt strategies - can be used at individual and/or community level
People change voluntarily when:
- They become interested or concerned about the need for change - They believe that change is in their best interest - They can identify an action plan - They can implement an action plan
Interview Guide
- Topics and questions to be discussed - Sequence of questions --> Introductory fact questions first --> Then key topics, opinions, beliefs --> Appropriate probes "Can you give me examples" "What changes have you noticed" - Design open-ended questions to yield in-depth information - Closing questions should allow respondents to provide any other information or recommendations - don't design questions based on what you think the answer is: "must've been hard when you found our you were HIV +, tell me about that = assuming it was hard for them
Maslow's Hierarchy of Needs Implications for Interventions
- Understand the needs on which people are currently focused - Develop interventions to address those needs first - Encourage people to reach for the higher needs once the lower ones are fulfilled - A threat to lower needs will undermine attempts made at higher needs
Being motivated or "ready" is critical
- Unless individual is willing to modify behavior, interventions will not be effective - Assessing stage of change is critical for success. - Important to meet individual at their particular stage. - Multi-pronged approach often has best success
Persuasion
- Using communication to induce positive or negative feelings or stimulate action - ex. using imagery to motivate increases in physical activity
Fiscal
- Using tax system to reduce to increase financial cost - ex. increasing durty or increasing anti-smuggling activities
Patient Activation Levels
- What can we do to move people up those steps? [passive, don't feel like they have a role to play: this could be cultural: doc's job is to help you and your job is to shut up] (1) Low --> (4) High Level 4. People have adopted many of the behaviors to support their health but may not be able to maintain them in the face of life stressors [may have chronic disease but health outcomes are better than ours] Level 3. People appear to be taking some action but may still lack confidence and skill to support all necessary behaviors [taking some steps and you feel like okay this is my body, but not feeling like you can do it all] Level 2. People may lack basic knowledge and confidence in their ability to manage their health [embarrased to ask questions and also lack knowledge] Level 1. People tend to be passive and may not feel confident enough to play an active role in their own health
Disadvantages of key informant interviews
- Who to interview? - Reaching and scheduling interviews with busy and/or hard-to-reach respondents (active drug user may not show up at scheduled time) - Generalizable? - Overwheming data
Motive
- a construct representing an unobservable inner force that stimulates and compels a behavioral response and provides specific direction to that response - what drives a person
Ego-Defensive
- a person seeks to maintain self-esteem - Affective Preservation
Tension-Reduction
- a person strives to reduce arousal and maintain an emotional equilibrium - Affective Preservation
McGuire's Psychological Motives
- all about understanding consumer behavior - how we going to get people to change their behavior - Set of motives originally developed to account for consumer behavior - Used often in advertising, helps to understand specific motives underlying actions - Focuses on perceived benefits of the action by the "consumer" - Perceived benefits motivate people to act
Environmental Restructuring
- changing the physical or social context - ex. providing on-screen prompts for GPs to ask about smoking behavior
Saturation
- collect data until it reaches this poin where no new info is being obtained - at some point you start hearing the same thing
advantage of qualitative research
- collects in-depth and detailed information [done correctly can be empowering for particpants: people enjoy focus groups and yo uasking them for their time can be empowerring and make them feel good] - tells the story [helps us determine why the phenomena is happening] - uses participant's own words [not putting lables on things, relying on the people to tell you in their own words] - helps us understand the details - seeks wide understanding of entire situation [almost a 360 degree view, looking at whole picure, not just one part]
Dependability
- concept similar to reliability in quantitative methods - there is repeatability of results, and/or results are supported by other data (through triangulation)
TPB Strengths
- considers normative influences - added construct of perceived behavioral control - has shown more utility in PH than HBM
Guidelines
- creating documents that recommend or mandate practice. This includes all changes to service provision - ex. producing and disseminating treatment protocols
Coercion
- creating expectation of punishment or cost - ex. raising the financial cost to reduce excessive alcohol consumption
Service provision
- delivering a service - establishing support services in workplace, communities, etc
Environmental/social planning
- designing and/or controlling the physical or social environment - ex. using town planning
Advantages of Key Informants Interviews
- detailed and rich data - Relatively easy and inexpensive way - establishes rapport with the respondent and clarify questions - provides an opportunity to build or strengthen relationships with importnat community informants and stake holders - can raise awareness, interest, and enthusiasm around an issue - can contact informants to clarify issues and needed
Behavior Change Wheel
- did literature review of 19 frameworks of behavior change - Michie article - came up with idea that there are three categories: Sources of behavior (green), Intervention functions (red), and policy categories (gray) and you can follow the wheel in many different pathways
List of policies
- different from behavior because they're structural - Communication/marketing - Guidelines - Fiscal - Regulation - Legislation - Environment/social planning - Service provision Policy level, not individual level
Reinforcement
- direct reimforcement - self-reinforcement
Disadvantages of Qualitative Research
- due to subjectivity, it is difficult to establish reliability and validity of info gathered [all the stories you heard aren't going to model every story and all research is subjective] - difficult to prevent and detect research induced bias - difficult to discuss all topics because of the in-depth nature of interviews [tough to get to everything, at some point people get exhaused: often lose last couple questions becauses people run out of steam] - difficult to do well: appears decoptively simple, when it is in fact difficult to collect what you are looking for with sufficient detail, and analyze it effectively [people think it is easy to interview or run a focus group (just get come people together and write some quetsions). Biggest issue is you collect too much data and then drown in piles of transcripts that are completely overwhelming and hard to synthesize
Regulation
- establing rules or principles of behavior or practice - ex. Establishing voluntary agreements on advertising
Qualitative data can be critical for
- exploring or refininng questions for survey - pre-testing surveys - understanding the process of change to be measured in surveys - interpreting the meaning (and the how and why) of quantitiative results - ex. of how and why: Teen pregnancy project did not have expected results. Girls were not benefitting from focus groups. --> One big why answered in teen pregnancy project is that the program wasn't being done the way it should be done on paper: was supposed to be giving access to condoms, birth control, behavior change, therapy, but that wasn't what was happening in the groups: checked off boxes that said they had group and that they were there: but a lot of the time the girls would come in and would be in crises and a lot of time the girls talked about okay where do we get you to stay tonight - teen pregnancy program wasn't implemented so can't say it wasn't effective, there were just more immediate concerns that had to be addressed first
Motivational process
- external influences (culture, social status, family, demographics, marketing, etc) and internal influences (perception, learning, memory, motives, attiudes, emotions, personality) affect how something is unfair and contributes to the decision process
Contemplation
- fence sitting - may feel ambivalent about change - may lack confidence - decisional balance-weighs pros/cons - okay to validate lack of readiness - no plan to act within the next month
Focus Groups
- group interview - usually around 8 people (6-10 is typical - Want people to talk to each other and interact with each other and ask questions to each other that you wouldn't even know to ask - moderated by group leader - usually homogenous - members share common characteristims [age, sex, education level, religion, etc.]
Precontemplation
- ignorance is bliss - not thinking about change - may feel resigned - may feel rebellious - rationalize - time for exploration, not action
Training
- imparting skills - ex. advance driver training to increase safe driving
Education
- increasing knowledge or understanding - ex. providing info to promote healthy eating
Legistlation
- making or changing laws -ex prohibiting sale or use - BMC smoking ban
Self-control
- personal regulation of goal-directed behavior
Young Mother
- project services at ROCA - financial, emotional stability - Not pregnant again - Using birth control if that's what they want - Having success parenthging their child
Motivation
- reason for behavior - happens within a person; not done to a person by others - refers to internal dynamics of behavior; not external stimuli - intervnetions appeal to people's motives but cannot motivate them - comes from perceptions of benefits/outcomes; not from knowledge
SCT Constructs
- reciprocal determinism - behavioral capability - observational learning - reinforcement - expectations - self-efficacy
Confirmability
- results can be corroborated by others - If someone else reads your transcript, what would they find? FInd the themes and if everyone found the saem ones, then that must be right. But if someone finds something different, does that mean their wrong? - limitation
Ego-degensive Implications for Interventions
- self-image: the smart thing to do - may respond strongly to social norms to avoid making a "mistake" that would wound the ego
What is a Key Informant Interview
- someone who is an expert, who will help you understand the matter - "community expert" - In-depth interviews conducted by an interviewer with an individual selected for his/her knowledge about the community of population of interest - Collects information from people with a particular knowledge of the problem in the community Someone who can help you better understand - Backgrounds - Behaviors, and attitudes - Culturally relevant considerations
Action
- taking the plunge - practicing new behavior - needs lots of encouragement - focus on social supports and restructuring cues
Relapse
- temporary set back - small bump in the road - learning opportunity - "Always forward, never back"
Triangulation
- the use of multiple research methods as a way of producing more reliable empirical data than are available from any single method - look for stuff in interview key informants and focus groups and observations and you can say it is valid because it was repeated - find the right thing repeatedly - use several diverse methods of data collection
Cognitive Bias
- things we do that get in our way
When to use qualitative methods
- to generate a new hypothesis - to explore complex issues on a deeper level - when details matter more than generalizability - to evaluate/monitor programs - when topics are very sensitive and require flexibility Answer questions like: - Why are we getting a result no one predicted? - Why did this mistake happen? - Why was a program/intervention ot successful - Why did this mistake happen
Improving reliability and validity
- triangulation - saturation
Restriction
- using rules to reduce the opportunity to engage in the target behavior - ex. prohibiting sales of solvents to people under 18 to reduce intoxication
Quantitative Research
- what, where, when - gather data (objectively) - analysis of numerical data - just the numbers, factual info not always objective: could be bias, also massaging that happens at the end: for many years we've asked people to identify themselves racially and then lump them together so we give illusions that we want to know what you identify as and that we care but then we do this and show we don't actually care
When to use focus grouups
- when you want an in-depth exploration of cultural norms, fellings, attitudes, opinions [what community thinks about a subject, why community things this way - When you want to understand community interaction [explore gropu social processes] - When you want to capture forms of communication not present in individual interviews [jokes, anectodones, teasing, arguing; doesn't require reasoned responses]
Qualitative Research
- why and how - interviewer integral part of gathering data - analysis of words from interviews or observations - subjective: on mission to find the story of the larger picture you're trying to figure out - can't really be validated by quantitative data always descriptive rich text, imagery, may lead you to ask more questions
Preparation
- willing to test the waters - seeking more information - may experiment with small changes - resolving ambivalence - plan to act within next month
Implications for interventions: contagion
-"Get on the bandwagon" - "Together we can end domestic violence"
Contragient
-Affective Growth - A person matches his or her thought, feelings, and behaviors to those of others
Maintenance
-begins to express increased confidence and self-efficacy - beahvior change is becoming a new habit
Process of Motivational interviewing
1) Express empathy (through reflective listening): give them the sense that you're on their team 2) Develop discrepancy (between the individual's goals & current behavior): "Here's what I hear you saying but here's what your goal is saying" 3) Avoid argumentation 4) Roll with resistance (acknowledge and explore the individual's resistance to change, rather than opposing it): nonchalant, "yah really sounds like you have no interest in quitting smoking 5) Support self-efficacy: any little spark of ability
Useful Theories of Motivation
1. Motivational Interviewing 2. Patient Activation 3. Maslow's Hierarchy of Needs 4. McGuire's Psychological Motives
Components of fundamental causes, according to Link and Phelan
1. The cause influences multiple disease outcomes 2. The cause affects disease outcomes through multiple risk factors 3. The cause involves access to resources that can assist in avoiding health risks or to minimize the impact of disease once it occurs 4. New risk factors that perpetuate the association between the cause and health are constantly emerging. Specific cause mentioned in reading is SES but perhaps also race, sexual orientation (MSM in Ghana) Ex. McD stops selling $1 value meals but now they sell salads with thousands of calories in them - so risks are always changing
Two Assumptions of HBM
1.) Individual values the outcome related to the behavior 2) Individual expects the behavior will result in that outcome
Types of Key Informant Interviews
1.) Unstructured discussion about a topic --> Useful for preliminary information in early stages of inquiry or intervention 2.) Semi-structured interview with set themes -->Probes for broad information, questions flexible --> Same general ideas collected from each interviewee 3.) Standardized, open-ended questions --> Faster interviews, more easily analyzed & compared 4) Closed, fixed-response questions --> Answers are limited and easier to analyze
Patient Activation
A person's ability to manage his or her own health and utilization of health care. - especially low for people with low income, less education, Medicaid enrollees, and people with poor self-reported health: passive recepients of healthcare and often don't ask questions - higher activation levels are associated with much lower levels of unmet need for medical care and greater support from health care providers for self-management of chronic conditions: less pain, nausea, better results, more satisfaction of care
Distal Causes
Act through broader historic, political, social, environmental and economic context - Ambient air pollution across a city - racism - colonialism air pollution impacts some neighborhoods more than others because of how they have been permitted over the years - Ecological Setting: Urban/rural - Culture: Ideology, Social Organization, Technology - Political-economic organization: --> Democratic Features --> Political Economy --> Social Structure --> SES Indirect impact on health - Background or Contextual Factors - Impact through other factors - Considered fundamental or structural causes - Often difficult to change
TPB Flow Chart
Attitude: I believe that vaccinations will protect my child (so I believe the evidence). I think it's good to do this. (But could be - I doubt that vaccinations really have protective value... in fact, I am very dubious that they do anything good). Subjective norm: All my friends get their kids vaccinated. My parents vaccinated me. This is normal and I should make sure to vaccinate my children. Otherwise, if people find out I didn't they might think I'm a bad parent. Might also think of what the doctor would think. But if part of a community where parents are skeptical, then perhaps it would be viewed as being "with it" or appropriately independent to not vaccinate child. Perceived behavioral control: related to inhibiting or facilitating factors and the strength of these factors. For instance: -- I work at home on Fridays and can take child in that day. +3 -- Vs. I work full time and getting an afternoon off is a big deal. It's a major barrier: -3. -- In an international setting, getting to clinic for vaccinations could well be a major challenge. And note difference between perceived behavioral control and actual behavior. Sometimes you want to, you intend to - but you just can't control it and it doesn't happen.
SCT, TPB/TRA, HBM, TTM Biological construct Cognitive construct Environmental construct Locus of Change
Biological SCT: Personal factors Cognitive SCT: Personal factors Environmental SCT: Environmental factors Locus of change SCT: Self-efficacy (as a function of perception of control) Biological TPB: not in model Cognitive TPB: attitudes, norms Environmental TPB: subjective norms Locus of change TPB: Attitudes and subjective norms Biological HBM: Modifying factors Cognitive HBM: Perception of risk Environmental HBM: not in model Locus of change HBM: Core beliefs, perceptions of cost/benefit Biological TTM: Not in model Cognitive TTM: Decisional balance; Self-efficacy Environmental TTM: not in model Locus of change TTM: Stages, Processes
How many interview
Depends on resources Depends on subject being explored Ideal: interview until saturation is reached [No new information is emerging]
McGuire's Psychological Motives Realms
Cognitive (thinking) and Affective (feeling) within each of those two, Different ways people will respond or be triggered or be stimulated
Transferability
Data can be transferred to similar context [the research you found, can it be applied in other places?]
Example of PH Framing: Obesity
Dominant: Personal choice, Action: Fat shaming people so they will stop overeating Alternative: people can be healthy and unhealthy at many different shapes and sizes. Solution: Stop corn industry from overloading in foods
Example of PH Framing: Intimate Partner Violence
Dominant: Women should leave the relationships Alternative: Men should stop hurting their partners
Proximate Determinants
Have a direct effect - Biology: HBP - Behaviors: diet, exercise, sleep - Late diagnosis - Inferior Treatment
HBM Diagram
LEVEL 1 Perceived suceptibility and perceived severity lead to perceived threat Perceived benefits and perceived barriers lead to outcome expectations LEVEL 2 Perceived threat and outcome expectations lead to self efficacy LEVEL 2 --> LEVEL 3: Cue to action and modifying factors LEVEL 3 Behavior
Underwood
Looked at structural determinants of Adolescent girls' to HIV since adolescent girls in sub-Saharan Africa were 3-4x more likely than boys to be living with HIV Basically: Why were girls in sub-Saharan Africa more likely than boys to be living with HIV? Proximal Determinants: - Acceptance/commonness of multiple partners: no pausing between partners. Pausing could make dramatic change of STD transmission - Transactional Sex (sex for something in exchange) - Cross-generational Sex: Large age difference; People in a higher risk pool having sex with those in a lower risk pool Distal Determinants: - Safe/unsafe spaces - Poverty and Transactional Sex - Poverty and Economic Exploitation - Consumerism - Alcohol - Violence
Cognitive Growth
Need for Autonomy Need for Stimulation
Cognitive Preservation
Need for Consistency: appeal to natural want for consistency - Beliefs, feelings, and actions are highly interconnected - The person strives to maintain internal coherence among: beliefs, feelings, actions, external messages
Affective Preservation
Need for Tension-Reduction Need for Expression Need for Ego Defense
Limitations of TPB
On slides: -Lacks consideration of ACTUAL control over behavior -Time frames betwen intent and behavior are not addressed - Overlooks environment, economic factors -Assumes person has resources to carry out the behavior -Does not account for other variables that factor into intention (Fear, threat, mood, past experiences) -Linear process
River and Factors
Proximal: very close to you Intermediate: in the middle Distal: all the way up stream
Roca
Roca has taken Prochaska's stages of change and adapted them for a very high-risk youth development model. Backed by evidence from multiple disciplines (e.g.substance abuse, medicine, harm reduction, etc.), promoting young people through the stages of change allows them to develop the intrinsic skills, desires, and capacities to successfully move towards safety and economic independence. e stages of change model.
Bandura
SCT
Focus on a Distal/Upstream Determinant: SES
Social Inequalities - Strong and consistent predicator of morbidity and premature mortality - Individuals lower in SES hierarchy suffer disproportionately from almost every disease - Level of inequality in nation, state, or community also related to health status
Contradictory motices
Some motives are contradictory Autonomy v. Contagion Stimulation v. Tension-Reduction Need to determine the underlying motives of your target population Plan interventions to speak to those motives
Attitudes
TPB - beliefs about what is entailed in performing the behavior and the outcomes of the behavior - degree to which a person has favorable or unfavorable evaluation of the behavior of interest - involves of a series of beliefs that are each assessed as good or bad
Proximal Causes
act through personal health behaviors and conditions: - inactivity - smoking - poor adherence to meds - Genetics - Biology [ex. High Blood Pressure] - Behavior [Diet, Exercise, Sleep] - Attitudes - Beliefs Other ex: Late diagnosis, inferior treatment --> we spend too much time here in PH - working on the individuals because it is often considered easier to change
Self-Efficacy HBM
confidence in one's ability to take action at a particular time and place - was added later to the model
Credibility
data are beleivable from the perspective of participant [test it by going back to the people you got the info from and show them the work and see if you got it right]
Discrimination
differential actions towrad others according to their race
Prejudice
differential assumptions about the abilities, motives, and intentions of others according to their race
Causal Continuum
focus on etiology (what is causing the disease/ health outcome) - can think of this on the three levels
Link and Phelan
fundamental cause theory
Microbicide
gel vaginally and rectally. Vaginal gel would prevent HIV transmission and it would be controlled by the person living in that body. So she should insert the microbicide and not tell her partner Powerful - giving them to power to protect themselves. But also can be disempowering because they weren't able to convince their partner to use protection
Frankenframework
idea of combining multiple theories
Affective Growth
need for Assertion Need for identification Need for empathy Need for contagion
Maslow's Hierarchy of Needs
physiological [breathing, food, water, sleep, sex, homeostasis, erection] safety [security of body, of employment, of resources, of mortality, of the family, of health, of property] love/belonging [friendship, family, sexual intimacy] esteem [self-esteem, confident, achievement, respect of others, respect by others] self-actualization [morality, creativity, spontaneity, problem solivng, lack of prejudice, acceptance of factrs] are people's basic needs getting met? Can't talk about relationships before having physiological met If you don't get basics met, it is going to be really hard to be motivated to move on any other piece 1. All humans acquire a similar set of motives through genetic endowment and social interaction. 2. Some motives are more basic or critical than others. 3. The more basic motives must be satisfied to a minimum level before other motives are activated. 4. As the basic motives become satisfied, more advanced motives come into play. Humans are motivated by unsatisfied needs Lower needs need to be satisfied before higher needs can be addressed As each need is fulfilled a person moves towards growth, and eventually self actualization
Communication/marketing
using print, electronic, telephonic, or broadcase media - ex. conducting mass media campaigns
Internalized Racism
the acceptance and belief by members of devalued races in negative messages about their own abilities and intrinsic worth and those of others of the same race
Self-Monitoring
- Analysis and problem-solving - self-correction
Link and Phelan: Contextualizing Risk Factors
- Attempting to understand how people are exposed to individually-based risk factors (poor diet, high cholesterol, lack of exercise) - This will help us design more effective interventions How do we think about how individuals are exposed to risk and in what context are they exposed to this risk because the goal is that if we can understand this, we can intervene in an effective way
TPB constructs
- Attitudes - Social Norms - Subjective Norms - Control beliefs/Perceived Power - Perceived behavioral control - Behavioral Intention
Causal Map
- Can map out all the distal and proximal factors of a disease - If we focus on the individual level, then you have accepted the intermediate and distal factors for that health condition - We focu on individual factors becuase we can measure it easier - Also easier to control proximal factors than distal factors If you handed out 1000 condoms, but Chalamydia rates are still through the roof. Have to empower women to have the courage to tell their partner to wear it. Teach them how to use it correctly, not just give it to them. How many infections did you stop?
Race (mis)used in public health
- Describe vital statistics - Risk indicator - Describe needed services - Marker for unmeasured biological differences - Proxy measure for social factors Say risk factor is that you're AA when you should say that risk factor is growing up AA in a racist society
Mrs. X and Causal Continuum
- Distal: lots of factors she didn't have control over like. Lived in rural area, away from health care - Proximate: Severely income predisposing her to the bad outcome
distal determinants
- Ecological Setting: Urban/rural - Culture: Ideology, Social Organization, Technology - Political-economic organization: --> Democratic Features --> Political Economy --> Social Structure --> SES Indirect impact on health - Background or Contexual Factors - Impact through other factors - Considered fundamental or structural causes - Often difficult to change
Link and Phelan Social conditions
- Factors that involve a person's relationship to other people, such as: - Race - Socioeconomic status - Gender - Sexual orientation - Stressful life events (might include ACEs) - Stress-process factors, such as social support (what are your buffers, What do you have around you that can support you when you experience stress)
Intermediate Determinants
- Family organization - Social support - Social network ties - Health care accessibility - Occupation - Neighborhood or community setting - Don't have direct influence but often a link in the - May serve as buffers for distal factors - May operate as intervening variables
Perceived Barriers
- HBM - Believes the tangible & psychological costs of the action are outweighed by the benefits
Perceived Benefits
- HBM - Believes there are more benefits to be gained by taking the action
Cues to Action
- HBM - Factors or strategies that prompt behavioral action
perceived susceptibility
- HBM - believes at risk (susceptible) for a particular disease or health problem
Perceived severity
- HBM - believes the disease or health problem has serious consequences
Framing: How does this affect the action taking? ex. Teen Pregnancy
- If you think teen pregnancy is a moral problem, you're going to fund pregnancy prevention centers that focus on religious and moral values - If you think it is a financial issue, then your action is going to be based on that: not providing governmental support to mom and baby after first teen pregnancy, for ex. - if you think it is an equity issue, then your action is going
Building Self-efficacy
- Observing successful roles models: the struggle follwed by success and reward - Encouragement from others - Successful performance: managing emotional responses and gradual approximations of the desired behavior, leading to mastery - Explaining failure: attribution to temporary and situational factors v. permanent and internal factors: don't see failures as permanant, but as temporary - People internalize the narriative that is socially told in pulbic: ex. addiction: that they're doing this to themselves and how could they do this to their family -Ex. Pregnant women with substance use disorder who relapses: may not try again because they believe that it really is something internal in them and that they're bad and don't have it in them to get better because that's what the public and media tell them Then they hide and are ashamed and don't get help. Keep the door open so they believe they can make the change
Spanish flu
- Pandemic that spread around the world in 1918, killing more than 50 million people - no censorship in press so Spain was first to announce presence of disease in country even tho it hit other places first - led there to be discrimination, but there were others affected too, even in the US - prevents peopole from getting healthcare treatment because of fear of being shunned
Reinforcements: Implications for interventions
- Promote self-initiated rewards and incentives
Racial Justice Frames
- Propose solutions that ephasize equity and inclusions rather than diversity - Develop strategies to empower stakeholders and target institutional power-holders - make racial justice a high priority in all social justice efforts
Dr. Nancy Kriger
- Race as a biological or social construct - cause of diparity: innate genetic differences OR biological impact of past and present hisotries of racial discrimination and economic deprivation OR Both
Camara Jones
- Racism: the Gardener's Tale 3 Levels or Racism - Institutionalized - Personally Mediated - Interanilized
Socio-Economic Status (SES)
- Ranking of persons according to prestige - Some distinguish from social class, others use synonymously - Strata within groups - authority or power structure in which different classes compete with one another
Maintanance of Behavior
- Reinforcement - Self-control - Self-monitoring
Skill development
- SCT - rehearsal and guided feedback leading to mastery - the mastery of abilities essential to successful functioning in organizations
Process of Learning Behavior
- SCT Acquisition of Behavior Building Self-Efficacy Execution of Behavior Maintenance of Behavior Idea that you can do the behavior, you believe you can do it, you execute it, it works, and you are able to maintain it
Three Processes of Learning
- SCT 1) Direct Experience (that we have) 2) Indirect experience thorugh observing others (role model story) 3) Storing and processing of complex information that results in anticipated consequence of actions and assessment of capabilities (what is going to happen and can I do it)
Expectations
- SCT Construct - Anticipated outcomes of behavior - Ex. I ate salad and I didn't lose any weight! but losing weight is a long process - Benefits and costs - Proximity of benefits and costs (short vs. long-term) - perceptions of how others will view you - How you will veiw yourself Ex. skater punks not wearing a helmet: will be teased and called a dork and benefit of wearing a helmet is too far away so now we have to change everyone not just one person
Self-efficacy
- SCT Construct - confidence in one's ability to take action and overcome barriers - confidence to overcome what gets in your way -Personal subjective evaluation of whether one can complete a task - Strong determinant of behavior, especially those that are complex or difficult
reciprocal determination
- SCT Construct - interaction of the person, behavior, and environment in which the behavior is performed - Triadic: behavior, personal factors, and environmental factors all interact and influence each other - can't just teach the person a behavior
Behavioral Capability
- SCT Construct - knowledge and skill to perform a behavior - brochures don't teach skills - Can be tough sometimes though because, for example, you get better at using a condom when you actually use it...
Observational Learning
- SCT Construct - modeling - behavioral acquisition that occurs by watching others perform the behavior and the outcomes that result - people learn when they see - how do you model when it is private though like how to use a condom
Reinforcements
- SCT Construct - responses to a person's behavior that increase or decrease the likelihood of reoccurence - can be internal or external reinforcements --> Positive reinforcement: to reward --> Negative reinforcement: remove something undesirable --> Positive punishment: add sanction --> Negative punishment: remove a reward - Not saying: "Don't eat at McD at all", say don't eat there everyday: makes goal more attainable - "Well I already ate badly so its okay if I continue to eat badly" How do we not punish oursevles and stay true to the goal once we've made a mistake once - ex. Having a condom flicked across the room just reinforces that it is hard to use. Having long steps on how to use a condom is discouraging and negative reinforcement - ex. But who says to people addicted to needles that went a day sober -- "Good job!!" - but the reinforcement feels awful because they're addicted and need it and feel awful without it Example: - Some believe that the only way to be certain that things are improving is if they have a reoccurence of the negative behavior and are forgiven - yes you made a mistake but you are still welcome here --> if they continue the bad behavior, then that means the program is wrong --> not just blaming the individual
San Fransisco Health
- Take Google Buses and use Uber and have a system where they don't use public transport - They are so affluent that they do this - right next to people living on the street - leads to negative health outcome
Racial justice
- The creation and proactive reinforcement of policies, practices, attitudes and actions that produce equitable power, access, opportunities, treatment, and outcomes for all people, regardless of race - not just fixing what went wrong but promoting conditions that produce equity (reactive AND proactive)
Acquisition of Behavior
- Vicarious Learning - Skill Development - SCT
Michael Brown
- Was shot in an event that occurred on August 9, 2014, in Ferguson, Missouri, a northern suburb of St. Louis. He was an 18-year-old black man, was a suspect in a "strong-arm" robbery of a convenience store. He was fatally shot by Darren Wilson, a 28-year-old white police officer. - One of the first times white people had to wake up and see police abuse and injustice of black people - Mom running for city council in Ferguson = Lezley McSpadden
Impact of Self-Efficacy
- Whether we'll attempt a behavior - How hard we work to achieve it - How quickly we give up when we don't achieve it - How we feel doing the beahvior
Stigma
- a mark of disgrace associated with a particular circumstance, quality, or person - single most important barrier to public action - main reason why people are afraid to see a doc to determine if they have the disease and seek treatment - social disgrace - stigma around disability and different health conditions - distrusting medical professionals
HBM does not account for
- a person's attitudes, beliefs, other factors that drive behavior - habitual behaviors that drive behaviores - the influence of social acceptability - environmental and economic factors - historical and cultural context ex. communities that have been targetted: Kool tobacco company has focused on the Black community and sponsored jazz festivals which incourages use of tobacco
How does institutionalized racism manifest
- an initial historical insult - structural barriers - inaction in face of need - societal norms - biological deteminism - unearned privilege - flat out segregation - inherent disadvantages
Racial Justic Frames Focuses
- asks us to rewrite the script and stop thinking about prejudice and the individual 1) Focus on structural racism and systemic inequality rather than simply personal prejudice: not just lifting up one person and saying the problem is solved: ex. Saying Obama was president so everything is solved. Not in the individual. Think about structural 2) Focus on impacts rather than intentions: doesn't work to say "well that's not what we meant to have happen, that's just what the outcome is" (ex. Harvard affirmative action case - scores Asian-American lowers, feel they're being discriminated, intention vs impact) 3) Address racial inequality explicity (but not necessarily exclusively): call out racism, racial equity at front of platform
HBM Limitations
- assumes people care about health outcomes, suceptibility to outcomes (perceived severity was not associated with the issue in early studies) - assumes everyone has equal access to info on illness/disease - assumes cues to action exist to encourage people to act
Racist Frames
- black people are stealing, dangerous - white people are "finding" and innocent - Majority colored protesting not framed the same way white people celebrating a sports victory
Limitations of SCT
- broad-reaching so sometimes difficult to operationalize in entirety: lots of different components, hard to know which is more important - Not a unified theory, loosely orgnaized, based solely on the dynamic interplay between person, behavior, and environment. Is one more influencial than another?: not every believes in the triangle, some think it should be - minimal attention to motivation and emotion: what's the motivation for change: do you wanna make that change and are you attached to it emotionally - theory assues that changes in the envrionment will automatically lead to changes in the person, when this may not always be true: Ex. just cuz you put apples out and they take the apple at the school lunch, does not mean they eat it: it goes into the - theory heavily focuses on process of learning and in doing so disregards biological and hormonal predispositions that may influence behaviors, regardless of past experience and expections
institutionalized racism
- differential access to the goods, services, and opportunities of society by race - inherited --> quality education, sound housing, gainful employment, appropriate medical facilities, and clean envrionment - occurs when the normal operation of apparently neutral processes systematically produces unequal results for majority and minority groups - encouraged by larger force
Personally mediated Racism
- done by one person/more individualized prejudice and discrimination; intentional and unintentional - acts of commission - acts of omission - maintains structural barriers - condoned by societal norms People think this is more solvable and that the world can be divided up into people that are racis and those who are not but not that easy. Need to structural problems which requires people to give stuff up - have to go get the racist white people and help them, not distance them and say we hate them
Manifestation of internalized racism
- embracing of "whiteness" - self-devaluation - resignation, helplessness, and hopelessness
Execution of Behavior
- expected outcomes, which are valued - self-efficacy --> have confidence in performing a behavior at particular times and places --> can overcome any barriers to performing the behavior - It's going to go well and if something goes wrong, I will be okay is the mindset you need.
Social Cognitive Theory Basics
- explains how people acquire and maintain certain behavioral patters while also providing the basis for intervention strategies - multidimentinal - how do peopel get their knowledge and maintian their knowledge which creates these behavior patters but also tells us what some of the opportunities around intervention - doesn't just tell us why people do what they do, but also tells us a way of understanding what conditions are needed to change - how do we think about learning not just as an individual, but something that gets reinforced in a group setting
Marmot
- first person to effectively prove research between social class and economic class - richer people's children die less - Brazil had highest rates of C-sections in the world: portrayed in how the richest fifth had more deaths than the second richest
Does HBM work?
- generally ineffective in predicting more complex behaviors that require repeated and long-term actions such as smoking, diet, sexual behavior
Dominant Frames
- ideas, attitudes, and beleifs are shared collectively - evoke certain standards, values, and morals that are reinforced and continued throughout society and across time - racism is: repeated so many times we stop seeing them
Premature death rates by T stop
- if you map deaths based on T stop to the closest health center, it is not a question about access. Hospital are there - there is something else: may be affodability, lack of follow-ups, acceptability, but not that there are not enough buildings
Observational Learning: implications for interventions
- include credible role models of the targeted behavior --> take someone in the community that has made the change that you want othes to make and they can be honest about how it was hard but if the community can relate to that person and that person did it, others may be more inclined to doing it too
How does personally mediated racism manifest?
- lack of respect - suspicion - devaluation - scapegoating - dehumanzing
Audre Lorde
- leading thinker around Black Feminism - asked can you use the master's tools or do you need a whole new system?
Vicarious Learning
- learning the consequences of an action by watching others being rewarded or punished for performing the action - observe credible models: based on similarity, status, and likeability - Develop a cognitive representation of the behavior ("script") - bicarious reinforcement - SCT
Punishment
- less effective than reinforcement for teaching and modifying behavior
Alternative frames
- not dominant frames - reflect racial justice approach - new policies and practices that are racially just and equitable, not just a transformation of old practices Examples. 1) Dominant frame: Personal Responsibility Alternative frame: Collective responsibility 2) Dominant: Individualism Alternative: Common good Example: I don't get vaccinated because I am susceptive. Getting vaccinated for person undergoing chemo Example: fluoride in water not for me with dental care - but its for poor people who can't get dental care 3) How do you go from thinking about the world as dangerous (dominant) to thinking of it as a global family with linked fates (alternative frames) 4) Competition to shared prosperity 5) Law & Order to Civil Rights/Human Rights 6) Authority & Control to empathy, dignity 7) meritocracy to equal opportunity, fairness
HIV/AIDs and Stigma
- people thought they were ill bu would be hesitant to get treatment - would talk about the 4 H's as if it was about being a member of that group that determined your HIV status: hemophiliacs, heroine users, Hessians, and homosexuals
HBM Constructs
- perceived susceptibility - perceived severity - perceived benefits - perceived barriers - cues to action - self-efficacy Perceive suceptibility and
Theory of Planned Behavior
- person is likely to intend to take actions if the person believes: 1.) that the behavior will lead to some valuable outcome 2) that others approve of the behavior (social influences) - Added perceived behavioral control (very much like self-efficacy) - Focus is on attitudes, beliefs, norms, and intentions - the idea that people's intentions are the best predictors of their deliberate behaviors, which are determined by their attitudes toward specific behaviors, subjective norms, and perceived behavioral control
Structural Violence
- physical and psychological harm that results from exploitative and unjust social, political, and economic systems - put individuals and popultaions in harm's way - social arrangement embedded in the political and economic organization of our social world - historically and/or economically driven processes and forces conspire to constrain indivdual agency Ex. - Systematic stigma and discrimination (HIV care/AIDS treatment or Incanceration of mentally ill instead of treatment) - Police brutality - gender-based violence - lynching (based on race, as in US) - Sex selective abortion
Annesi Articles
- self-regulatory skill usage strengthens the realtions of self-efficacy for improved eating, exercise, and weight in the severly obese
Frames
- shape everything: how we see problems, attitudes, how we see each other - mental structures that shape the way we see the world. As a result, they shape the goals we seek, the plans we make, the way we act, and what counts as a good or bad outcome of our actions...frames shape our social policies and the institutions we form to carry out policies.
Race
- social construct, not determined by blood tests and biology - not a biological construct - reflects a social construct in the minds of Americans that is imprecisely mapped to the differences that exist among us
Race and Health Status
- sociall meaningful but of limited biological significance - confused with SES - importance of "multiple vulnerability"
SCT: 3 Factors
- three main factors affect whether a person will change a health behavior 1.) Self-efficacy: do I believe I can do it? 2) Goals: seen as realistic, attainable 3) Outcome expectancies: are outcomes desirable? - If a person feels they can change their behavior even when faced with obstacles, and that desirable outcomes occur, they will change behavior - There are things we can highlight and barriers we can remove to make the change more attainable. What are these things?
Example of vaccinating child for DPT using HBM
1) How big is the treat? 2) What are the benefits and costs? 3) Self-efficacy - can I do it? 4) Cue to action - reminders, outreach by a clinic. 5) Modifying factors? What about support by a parent or friend? How hard it is to get to the clinic? My own fears of needles?
Health Belief Model
A theory of health behaviors; the model predicts that whether a person practices a particular health habit can be understood by knowing the degree to which the person perceives a personal health threat and the perception that a particular health practice will be effective in reducing that threat. - value expectancy model: people weight the benefits and costs before deciding what to do
Intermediate Causes
Act through immediate/surrounding norms, infrastructure, resources, and capacities - Mistrust of medical community - lack of support for quitting smoking - Family organization - Social support - Social network ties - Health care accessibility - Occupation - Neighborhood or community setting - Don't have direct influence but often a link in the - May serve as buffers for distal factors - May operate as intervening variables
Link & Phelan: Fundamental Causes
What are the fundamental causes - Access to resources - to avoid risks or to minimize the effects of disease once it starts - Includes knowledge, $, power, prestige, support Ex. If you take a risk in an affluent suburb: you get into a car with too much to drink and you get into an accident but you have good health care and your parents have a good attorney and you got into a good care with safe streets - can mitigate impact of their risk But some people don't have these buffers. Some adolescents walk through their own neighborhoods are are not seen as children. They're seen as dangerous
Causal Continuum and HIV
What causes HIV? HIV virus. How is it transmited? Unprotected sex = proximal cause Why have unprotected sex? - well they're probably engaging in sex work = Intermediate Why can't they use a condom? Why are they unpowered? - Poverty = Distal
Elements of framing for public health
What's the PROBLEM? Who/ What is RESPONSIBLE? What VALUES are highlighted? What's the SOLUTION? What's the needed ACTION?
Ebola stigma
prevented people from getting healthcare and that they though they may be ill but didn't get hlep which allowed the epidemic to continue
Behavioral Capability: Implications for interventions
promote mastery learning through skills training: The opportunity to say words out loud and getting feedback - waggin finger and saying you shouldn't drink is a waste of time --> ask what're you going to do next time someone says "hey let's get a drink"
Reciprocal Determinism: Implication for Interventions
work on all three levels to promote change: consider multiple avenues to behavioral change, including environmental, skill, and personal change