RF_ST_2_SUDHA.pdf
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Behaviour change
* a process
* individual perspective
* environmental perspective
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RF_ST_2_SUDHA
BEHAVIORAL CHANGE: TWO PERSPECTIVES
1. Individual perspective
Focus: changing the behavior in individuals or in groups.
Assumption: Behavior is the result of individual cognitive and
personality determinants: attitudes, social influences and self-efficacy,
personality factors (neuroticism, etc).
Behavioral change is feasible if we change these individual factors.
Health education focuses on the cognitive factors.
2. Environmental perspective.
Focus: changing the environment.
Assumption: Behavior is the result of factors beyond individual control,
such as social, economic, political, cultural and legislative factors.
Behavioral change can
environmental factors.
only
be
realized
if we
change
these
Both perspectives provide a valid explanation.
Practitioners and politicians in health often merge the two perspectives.
A good understanding of the two perspectives is therefore essential.
BEHAVIORAL CHANGE
INFORMATION OF DETERMINANTS STUDY:
*
information on the message that the target group needs,
Method: compare groups with each other to find variable on
which they differ.
*
specific target group characteristics.
INFORMATION OF NEEDS ASSESSMENT:
* information on the preferred channels and methods for the target
group and program providers
GOALS.
.'A* •”•*’*
’ ’
goals attitude
’^1.
s ■
2.
3.
4.
5.
6.
7.
8.
9.
10. 1________________________
goals social influence
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.______________________
goals self-efficacy
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
BEHAVIORAL CHANGE: FOUR PHASES OR STEPS
STEP 1: PROVIDING INFORMATION TO TARGET GROUP
impact ofinforntation is determined by four factors
1. receiver variables; 2. message variables
3. channel variables; 4. source variables
STEP 2: RECEPTION OF INFORMATION BY THE TARGET
GROUP
- a clear reception is determined by:
1. attention; 2. comprehension; 3. evaluation
STEP 3: ENCODING OF INFORMATION
- goal: to stimulate the processing of relevant information
(encoding)
- cognitive and affecting coding processes
- encoding determined by 1.attitudes, 2. social influences, 3. selfefficacy
STEP 4: BEHAVIORAL ACTIONS
- determined by:
1.skills, 2. barriers; 3. feedback; 4. attributions; 5. commitment- ?
Providing information
*
impact of information depends on:
1.
receiver variables:characteristics of the target
group
2.
message variables: persuasive effects of messages
3.
channel variables: characteristics of the methods
* massmedia
* interpersonal
4.
source variables: characteristics of the person
providing the message
* different sources for different messages are
often recommended
* a community approach uses both formal and
informal networks and sources
BEHAVIORAL CHANGE: INFORMATION VARIABLES
Step 1: providing information and increasing the salience of already
existing information that motivates individuals to change.
The function of information: 1. to arouse interest
2. to stimulate conscious decision making.
Persuasive impact of information: 4 types of information variables
1. receiver variables
2. message variables
3. channel variables
4. source variables
Strategic planning of information variable_s is essential to develop an
effective program that will be received, understood, appreciated an
stimulate the target group to think about the information and to change
the behavior.
©
BEHAVIORAL CHANGE: RECEIVER VARIABLES
Receiver variables:
- characteristics of the target group that influence information
processing
- what are important characteristics of the target group that we have to
take in to account
- moderate levels of self-esteem
- age (9-12 years)
e
- educational level
C-j
.Pl
- moderate levels of involvement
- gender: sex differences due to different levels of involvement
- motivational level: precontemplators, contemplators, actors
- cognitive/affective orientation
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TARGET GROUP IDENTIFICATION
target group stratification is feasible using various
dimensions:
* physical dimension (e.g. gender)
* economical dimension (e.g. groups with lowincomes)
* risk dimension (those who will have a high risk of
developing an increased risk; e.g. smokers who drink
much alcohol; pregnant women; adolescents as a
target group for prevention)
$
9
* motivational dimension: precontemplators
contemplators
actors
maintainers
relapsers
BEHAVIORAL CHANGE: MESSAGE VARIABLES
Message variables:
.
- characteristics of the message that influence information processing
- when will a message be persuasive?
- arguments
-clear
- repetition
- explicit conclusions
- discrepancy with opinions of target group
- should focus on the relevant beliefs
4 fear arousal
Message can focus on:
1. providing information: knowledge, attitudes, etc
2. modeling the "good" behavior via models
3. skills training
4- incentives
5. commitment techniques
|
I
I
Message variables:
* message:
1. content based on the analyses of determinants
2. clear and explicit conclusions
3. repetition
BEHAVIORAL CHANGE: CHANNEL VARIABLES
Channel variables:
- Channel variables refer to the means by which messages are delivered
- Which channels (methods) are most effective
- Massmedia, narrow cast media/individualized media approaches, interpersonal
approaches
Media messages: 4 roles
1. primary change agent: primary or sole method
2. supplementary agent: in combination with other channels
3. promoting programs: familiarizing the target group with program existence
4. supportive: supporting new attitudes, norms and behaviors (e.g. via comedy)
1. Mass media information: television, newspapers
Results: increased knowledge on a particular behavior, attitudinal changes and
changes in the perception of social norms.
Is probably sufficient for innovators who only need attitudinal information.
Not powerful enough to change behavior in individuals who do not have sufficient
self-efficacy levels.
2. Narrow cast media: individualized approaches, specialized cable television,
magazines and local newsletters, self-help materials.
provide information on a particular subject.
Results: if individuals have low self-efficacy levels.
More effective for late adoptersXj^s^* '
Example: self-help materials or group courses: attention for skillstraining; social
support, confidence and self-efficacy; feedback information from other models;
3, Interpersonal contacts: group courses, individual contacts:
Results: if individuals have very low self-efficacy levels (many relapses), if people
need much social support and stimulating models.
More effictive for laggards who are isolated.
How to change attitudes?
1.
enhance positive outcomes of the desired
behavior
2.
enhance negative outcomes of the undesired
behavior
3.
stress short-term advantages of the desired
behavior
4.
indicate alternatives
5.
discuss anticipated negative experiences
How to change the impact of social influences?
s
t
1.
change perceptions on norms about a behavior
2.
change social norms
3.
demonstrate direct and indirect social influence
processes
4.
increase awareness of healthy models
5.
inoculation strategy
6.
assertiveness trainingo
7.
mobilize social support for healthy behavior
How to change self-efficacy expectations?
1. learning experiences
practice (skills training)
realistic & challenging goals
1
2. learning from observations (vicarious learning)
3. persuasion
3
How to stimulate performance and maintenance?
1. skills training
commitment techniques
3. feedback
4. repetition
i. reattribution processes
ELABORATION LIKELYHOOD MODEL
Petty & Cacioppo:
*
*
*
9
*
*
people do not always process information
carefully and intensively
two basic ways of processing information:
1. via a cognitive way
2. via a peripheral/affective way
behavioral change is more enduring if it is
processed cognitively
cognitive processing is dependent on:
1. motivation (relevancy, need for cognitions)
2. abilities
two-step approach: first affective information,
followed by cognitive information
INFORMATION
(receiver, message,
source, channel)
RECEPTION
attention
comprehension
evaluation
<-
ENCODING
cognitive/affective
I
attitude
barriers
reinforcement
commitment
social influences
>-
intention
>-
BEHAVIOR
>-
MAINTE
NANCE"
figure 2.1: model on behavioral change
' self-efficacy
-<
RELAPSE
skills
—>-
attributions
-<-i
BEHAVIORAL CHANQI-: j^ALISTie
ATI@^§
1. Behavior is noi always paFtly ur^bf iRVivtal e8Htf81
changing the eflviF§Rffl@Rt may h p8§§ihlg
-> 1. creating Health ?F@ffl@ti8R gaeilihes
--> 2. dcvel@ping Heal! PF@ffl@tjRg P@Jiejg§
2. Adoption is a $?&§&§§ that takes fiffig.Changing the majofity will take
tiffle
innovators.
3. Behavioral diao^g afid
9
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Program Matrix
* 2 important goals
> 1. for program development:
a. what does the target group need?
b. which messages do we have to develop?
c. which methods might be effective for which
message?
d. which sources can be used for which
message?
2. as a checklist:
a. to analyze existing materials
b. to verify whether all goals of the intended
program are being accomplished
* 2 important applications:
a. program development and analysis
b. program evaluation
Program Matrix
* utilization of the matrix
1.
the matrix identifies 24 different cells
2.
for each cell one can formulate specific
questions regarding program development;
these questions will help to identify the
specific charateristics that should be adressed
for instance-.
cell 1: which characteristic of the target group
will influence the reception of information?
cell 2: which messages may enhance the
reception of the information of the program?
cell 3: which channels may enhance the
reception of the information of the program?
cell 4\ which sources may be needed to
enhance reception?
Program Matrix
* utilization of the matrix (continuation)
3. for each cell one can formulate specific
questions regarding program evaluation
for instance:
cell 1: did the receiver pay attention to the
message?
cell 2: did the messages attract attention?
(e.g. were the messages attractive?)
cell 3: did the channels attract attention?
(e.g. were the methods of the program
attractive?)
cell 4: did the source attract attention?
(e.g. did the persons who were presenting the
program?)
cell 5: did the receiver comprehend the
message?
cell 9: did the receiver change his attitude?
PROGRAM MATRIX
program matrix has two important goals:
1. for program development: identification of the major issues relevant
for program development and planning.
2. checklist: to analyze program or existing materials to check whether
they address all relevant issues.
utilization of matrix:
The matrix identifies 24 different cells.
For each cell one can formulate specific questions.
These questions help to identify the specific characteristics that should
be addressed.
CELL 1: which characteristics of the target group may positively or
negatively influence the reception of information.
CF-T-T- 2: which messages may enhance reception
CELL 3: which channels may enhance reception
CF-T .T, 4: which sources may be needed to enhance reception
Similar questions can be identified for the cells representing the
encoding phase (cells 9-20).
CELL 9: which characteristics of the target group are important with
respect to the attitude; which messages (cell 10), channels (cell 11) and
sources (cell 12) may be utilized to enhance a positive attitude towards
the desired behavior?
Similar questions can be raised with respect to the other cells.
Completion of the questions for all cells identifies the relevant
characteristics and issues that need attention in a particular program.
an
The program matrix (De Vries,
phase
1989)
receiver
message
channel
attention
1
2
3
4
comprehension
5
6
7
8
attitude
9
10
11
12
social influence
13
14
15
16
self-efficacy
17
18
19
20
behavior
21
22
23
24
source
THE PROGRAM MATRIX: QUESTIONS TO BE ASKED
Phase
Questions:_____________________________________________________
attention
1. which characteristics of the targetgroup will (positively or negatively)
influence the attention for the message (cell 1)?
2. which (characteristics of the) message will stimulate/distract the
attention for the message (cell 2)?
3. which channel will stimulate/-distract the attention of the targetgroup
(cell 3)?
4. which sources will attract/distract the attention of the targetgroup (cell
4)?___________________________________________
5. which characteristics of the targetgroup will (positively or negatively)
influence the comprehension for the message (cell 5)?
6. which characteristics of the message will stimulate the comprehension
of the message (cell 6)?
7. which channels will (not) stimulate comprehension of the message
(cell 7)?
8. which sources will (not) stimulate comprehension of the message (cell
8)?
compre
hension
|
attitude
THE PROGRAM MATRIX: QUESTIONS TO BE ASKED
9. which characteristics of the targetgroup will stimulate/distract
creating a positive attitude towards the healthy behavior (cell 9)?
10. which characteristics of the message will stimulate/distract creating a
positive attitude towards the healthy behavior (cell 10)?
11. which channels will stimulate/distract creating a positive attitude
(cell 11)?
12. which sources will stimulate/distract creating a positive attitude (cell
12) ?
social
13. which characteristics of the targetgroup will stimulate/distract
influences
creating a positive social norm towards the healthy behavior (cell
13) ?
14. which characteristics of the message will stimulate/distract creating a
positive social norm towards the healthy behavior (cell 14)?
15. which channels will stimulate/distract creating a positive social norm
(cell 15)?
16. which sources will stimulate/distract creating a positive social norm
(cell 16)?
THE PROGRAM MATRIX: QUESTIONS TO BE ASKED___________
self-effi
cacy
behavior
17. does the targetgroup has low/high levels of SE to perform the
healthy behavior (cell 17)?
18. which messages will stimulate/distract high levels of SE (cell 18)?
19. which channels will stimulate/distract creating high levels of SE (cell
19) ?
20. which sources will stimulate/distract creating high levels of SE (cell
20) ?
21. which characteristics of the targetgroup will stimulate/hinder perfor
mance of the healthy behavior (cell 21)?
22. which messages will stimulate/hinder performance of the healthy
behavior (cell 22)?
23. which channels will stimulate/hinder performance of the healthy
behavior (cell 23)?
24. which sources will stimulate/hinder performance of the healthy
behavior (cell 24)?
Table I: the program matrix (De Vries, 1989)
PHASE
TARGET GROUP:
which characteristics of the target
group will influence the effectiveness of the program?___________
MESSAGE:
which message does the program
have to contain?
CHANNEL:
which channels (access points
and methods) can be used to
reach the target group?
SOURCE:
which persons are a credible
and acceptable to give infor
mation?
attention
cell 1: which characteristics of the
target group will stimulate or hinder
attention for program?___________
cell 2: which messages will stimu
late attention?
cell 3: which channels can be
used to raise attention for the
program?__________________
cell 4: which sources will
stimulate attention of the target
group for the program?______
comprehension
cell 5: which characteristics of the
target group will stimulate or hinder
comprehension of program?
cell 6: which messages will stimu
late comprehension?
cell 7: which channels can be
used to stimulate comprehension
of the program?_____________
cell 8: which sources will
stimulate comprehension of the
program?________________
attitude
cell 9: which characteristics of the
target group will influence the attitu
de?
cell 10: which messages will
create a positive attitude:
cell 11: which channels can be
used to create a positive attitude?
cell 12: which sources will
stimulate creating a positive
attitude?
social influences
cell 13: which characteristics of the
target group will influence perceptions of social support?
cell 14: which messages are
needed to create (perceptions of)
social support?
cell 15: which channels can be
used to create (perceptions of)
social support or resistance?
cell 16: which sources can be
used to create (perceptions of)
social support?
self-efficacy
cell 17: which characteristics of the
target group will influence their
levels of self-efficacy?
cell 18: which messages are
needed to create high levels of
sei f-efficacy________________
cell 19: which channels can be
used to create high levels of selfefficacy?
cell 20: which sources can be
used to create high levels of
self-efficacy?______________
behavior
cell 21: which barriers hinder beha
vioral change and maintenance, and
which skills does the target group
need to realize behavioral change and
maintenance?
cell 22: which messages are
needed to remove barriers and to
stimulate acquisition of skills for
behavioral change and maintenan
ce?
cell 23: which channels can be
used to remove barriers and to
stimulate acquisition of skills for
behavioral change and maintenan
ce?
cell 24: which sources can be
used to remove barriers and to
stimulate acquisition of behavi
oral skills for behavioral chan
ge and maintenance?
24
Table 3. The program matrix applied tq the development of a smoking prevention program (De Vries, 1989)
i
PHASE
TARGET GROUP:
MESSAGE:
CHANNEL:
SOURCE:
attention
-low motivation
-selectivity
-attractive
-brief
-schools
-video-peer-led activities
-manual
-adolescents
-peer leaders
-students
-cartoons
comprehension
-educational level
-clear conclusions
-active learning
-repetition
-video
-manual
-activities
-non-smoking poster
-adolescents
-students
-cartoons
-peer leaders
attitude
-focus on short-term effects
-experimentation is not bad
-smoking has a function
-enhance short-term risks of smoking
and experimentation, and short-term
benefits of non-smoking
-enhance knowledge about
alternatives for smoking
-demonstration on video and
cartoons
-activities to stimulate awareness
of risks and alternatives
-manual
-expert
-adolescents
-cartoons
-students
social influences
-vulnerability to social pressures
-no distinction between
direct/indirect pressure
-indicate pressures, direct/indirect
pressures
-raise resistance
-modeling and inoculation by
video;
-adolescents
-students
self-efficacy
-low SE to cope with pressure
-low SE to find alternatives
-raise SE towards coping pressure
-raise SE towards finding
alternatives to smoking
-modeling on video
-role-plays to raise levels of SE
-adolescents
-peer leaders
-students
behavior
-low levels of refusal skills
-need for feedback
-need for responsibility
-low commitment
-enhance refusal skills
provide feedback;
-enhance responsibility and
commitment
____________________________
-modeling on video
-practice in role-plays
-public poster
-badge
-adolescents
-students
25
Table 4. A program matrix to plan the adoption of a smoking policy at Dutch worksites
PHASE
TARGET GROUP
MESSAGE
CHANNEL
SOURCE
attention
-moderate motivation
-little time for health
issues
-compliance with ARBO
law
-clear messages on
advantages for policies
-discussions
-the policy team
-prior involvement
-preference for easy
language
-dislike for complexity
-concept-plan to help to
outline the basic strategy
-no jargon
-concept plan
-doubts about advantages
-sensitive to non-smoking
employees’ health
-sensitive for work
worksite image
-indicate the advantages of
policies for the smoking and
non-smoking employee, and
for the worksite and its
image
-discussions
-support for policies need for clear non
smoking norms
-indicate and reinforce social
support
-stress the advantages of a
social norm about
smoking/non-smoking
-discussions
self-efficacy
-low SE towards
implementing new
policies
-low SE towards how to
achieve consensus at
worksite
-explain how policies and
consensus can be achieved
-stimulated active problem
solving
-concept plan
-guidelines
-small group meetings
-brainstorming activities
-the policy team
-the management
behavior
-concern about time and
financial resources
-discussion of time resources
-small group meetings
-brainstorming activities
-the policy team
comprehension
attitude
social influences
-small group meetings
-the policy team
-discussions
-small group meetings
-the policy team
-small group meetings
-the policy team
-small group meetings
A program matrix to plan and map a smoking cessation program for pregnant women and their partners (De
Bakker & Kljftr 1994)
PHASE
RECEIVER: which characteristics of the
targetgroup will Influence the Impact of
the program?
MESSAGE: which message does
the program have to give?
CHANNEL: which methods
can be used, and where to
reachthe targetgroup?
SOURCE: which persons
are a credible and acceptable to give Information?
ATTENTION
•low/moderate motivation to quit: other
Issues than smoking are Important
•more LSES
-worthwhile quitting for baby's
health
-you can stop smoking
•do we need to focus on other
issues relevant for pregnancy?
-posters at GP/midwife
-personal communications
-video
-cover self-help manual
-pregnant women
-GP
-midwife
COMPREHENSION
•low/moderate educational level
•brief easy messages
-posters, video
•pregnant women, from
same SES-group • • ■
ATTITUDE
-not convinced of advantages of NS
•not convinced of disadvantages S for
them
•unaware of risk for passive smoking
-pros NS for baby
-pros NS for mother
-risks of passive Smoking for
children
-personal communications
•video messages
•tailored letters
•posters?
-pregnant women
•GP
SOCIAL
INFLUENCES
-Smoking behavior of partner
-level of partner support?
•support midwife and GP?
-support of social environment?
-S-partner should quit
-NS-partner can help mother
•social environment should help
-personal communications?
-cessation self-help manual for
mother
-partner booklet?
•video
-how to reach the S-father?
•pregnant women
•husbands who have quit
and support
-friends
SELF-EFFICACY
-low levels of SE towards quitting
-lower levels of SE to maintain quitting
postnatal
-you can cope with the barriers:
($ocial/personal)-> discuss and
show ways of coping
-how to set goals
•video and SH-manual to
model general ways of coping
•tailored letters to give perso
nalized suggestions
-personal communications?
-pregnant women
-husbands who have quit
and support
-friends
BEHAVIOR:
change
-need skills to refrain from smoking
-need alternatives for smoking
•practice skills to cope with
barriers
•SH-manual and tailored let
ters to give exercises
-pregnant women and
husbands
-midwifes and GP?
•experts/Unlversity.?
BEHAVIOR:
maintenance
-need skills to refrain pressure to start
again
-need skills to motivate partner to
continue non-smoking
-continuation of cessation is
important: passive smoking,
parents' health
-how to make issue more perso
nal and appealing for parents?
-post-delivery booklet
•self-help cessation guide
■consults of midwifes
-consultation office?
-pregnant women and
husbands
-midwifes/GP's?
•experts/University?
•midwife
9
23
Table 2. The program matrix identifying evaluation questions for program and effect evaluation
PHASE
TARGET GROUP:
-attended?
-comprehended?
-changed?
MESSAGE:
-sufficient quality?
-achieved its goal?
-implemented (planned/dosage)?
-appreciated?
CHANNEL:
-implemented?
-quality?
-appreciated?
-costs?
SOURCE:
-trained?
-competent?
-appreciated?
-costs?
-costs?
attention
-paid attention to the program and its elements?
-raised attention?
implemented?
appreciated?
-attractive?
-appreciated?
comprehension
-understood the program?
-easy to understand?
implemented?
facilitated
comprehension?
-easy to
understand?
-appreciated?
attitude
-obtained more knowledge?
-obtained a more positive attitude?
-addressed pros and cons of the healthy
and unhealthy behavior?
implemented?
appreciated?
-competent?
-appreciated?
social
influences
-experienced more support and more favorable
social norms?
-experienced changes in other persons’
behavior?
-addressed the relevant social
influences?
implemented?
appreciated?
-competent?
-appreciated?
self-efficacy
-became more self-efficacious?
-addressed how to become more selfefficacious?
implemented?
appreciated?
-competent?
-appreciated?
behavior
-learned new skills?
-changed intentions?
-changed behavior?
-addressed the skills needed to change
behavior?
implemented?
appreciated?
-competent?
-appreciated?
%
Table 5.
A program matrix summarizing the evaluation of the Dutch Smoking Prevention
Project
PHASE
TARGET
GROUP
attention
- target group
received pro
gram
comprehension
attitude
CHANNEL
SOURCE
no problems
reported
- implementation:
Yes
two introducers:
positive
- target group
understood pro
gram
- no problems
reported
- implemented as
intended
- comprehensibili
ty: good for
vocational schoo
ls; too simple for
6yr track of high
schools
two introducers:
positive
- changes in
knowledge
- changes in
attitudes
- short & direct
effects: positive
- alternatives:
positive
- implemented as
adolescents in
video: positive
intended
- video: positive
- manual: positive
- activities: positive
MESSAGE
A
social
influen
ces
- no changes
selfefficacy
- lower levels of
self-efficacy
behavior
- less regular smo skills: positive
king in experi
commitment tech
mental condition niques: positive
peer group pres
sure: positive
- indirect pressure:
positive
modeling: positive
skills: positive
- implemented as
teacher: positive
intended
- video: positive
- manual: positive
- activities: positive
- mostly imple
mented as inten
ded
- video: positive
- manual: positive
- activities: positive
peer leader:
neutral to positi
ve; some peer
leaders in vocati
onal schools
needed assistance
- mostly imple
adolescents in
mented as inten video: positive
ded
- video: positive
- manual: positive
- activities: positive
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