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Please download file ( Answer Question) and answer all  Questions. Use all those website and documents upload.   https://www.countyhealthrankings.org/ https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm https://health.gov/healthypeople https://www.wku.edu/crw/hep/index.php please Read and answers all 276Journal of Clinical Sleep Medicine, Vol. 7, No. 3, 2011 Study Objectives: We examined the effects of a cognitive behavioral self-help program (Refresh) to improve sleep, on sleep quality and symptoms of depression among first-year college students. Methods: Students in one residence hall (n = 48) participated in Refresh and students in another residence hall (n = 53) par- ticipated in a program of equal length (Breathe) designed to im- prove mood and increase resilience to stress. Both programs were delivered by e-mail in 8 weekly PDF files. Of these, 19 Refresh program participants and 15 Breathe program partici- pants reported poor sleep quality at baseline (scores ≥ 5 on the Pittsburgh Sleep Quality Index [PSQI]). Participants com- pleted the PSQI and the Center for Epidemiological Studies- Depression Scale (CES-D) at baseline and post-intervention. Results: Among students with poor sleep (PSQI > 5) at base- line, participation in Refresh was associated with greater im- provements in sleep quality and greater reduction in depres- sive symptoms than participation in Breathe. Among students with high sleep quality at baseline there was no difference in baseline to post-intervention changes in sleep (PSQI) or de- pressive symptom severity (CES-D). Conclusions: A cognitive behavioral sleep improvement program delivered by e-mail may be a cost effective way for students with poor sleep quality to improve their sleep and reduce depressive symptoms. An important remaining ques- tion is whether improving sleep will also reduce risk for future depression. Keywords: Insomnia, depression, prevention Citation: Trockel M; Manber R; Chang V; Thurston A; Tailor CB. An e-mail delivered CBT for sleep-health program for col- lege students: effects on sleep quality and depression symp- toms. J Clin Sleep Med 2011;7(3):276-281. DOI: 10.5664/JCSM.1072 An E-mail Delivered CBT for Sleep-Health Program for College Students: Effects on Sleep Quality and Depression Symptoms Mickey Trockel, M.D., Ph.D.1; Rachel Manber, Ph.D.1; Vickie Chang, Ph.D.2; Alexandra Thurston, B.A.3; Craig Barr Tailor, M.D.1 1Stanford University, Stanford, CA; 2University of California San-Francisco, San-Francisco, CA; 3PGSP-Stanford PsyD Consortium, Palo Alto, CA S C IE N T IF IC I N V E S T IG A T IO N S College students often have erratic sleep schedules, poor sleep hygiene, and correspondingly poor sleep quality.1 One report suggests that as many as 89% of college students report poor quality sleep.2 Inadequate or poor quality sleep may put students at increased risk for developing unipolar depres- sive disorders.3-6 In 1989, Ford and Kamerow published data suggesting that poor sleep is a risk factor for subsequent clinical depression and that further research is needed to determine if early recognition and treatment of sleep disturbance can pre- vent subsequent psychiatric problems.4 Since then, several au- thors have published empirical evidence indicating disturbed sleep, measured by self-report or with polysomnography6 is a risk factor for subsequent depression.3,5-12 Poor sleep is a predictor of subsequent depression during adolescence,5 and continues to constitute a risk in young3,7 and older adults.11,12 There is a dose response relationship between sleep disturbance in adolescence and subsequent symptoms of depression, with severe sleep disturbance incurring greater risk than moderate disturbance.13 It is therefore important to devel- op and test the feasibility of potentially cost-effective interven- tions to improve sleep among adolescents and young adults, which might subsequently be used to determine whether early intervention to improve sleep reverses the progression from disturbed sleep to depressive disorder. The present study is an important first step toward this important goal. We developed and evaluated the feasibility and short-term efficacy of an intervention to improve sleep in college freshmen and its immediate effects on depressive symptom severity. In addition to addressing disturbed sleep, the intervention also addressed irregular sleep habits because such habits constitute a risk for insomnia and, importantly, there is evidence that day-to-day variations in bed-times and wake-up times by 2 to 4 h is associated with greater severity of symptoms of depression, even among students who regu- larly obtain ≥ 8 h of sleep.14 Moreover, a recent analysis of risk for depression and suicidal ideation among adolescents suggests having parents who insist on earlier bedtimes is a protective factor, which appears to be partially mediated by sleep duration and perception of getting enough sleep.15 Past research demonstrated that increasing the regularity of times BRIEF SUMMARY Current Knowledge/Study Rationale: College students often have poor sleep and associated symptoms of depressed mood. The purpose of this study is to test the efficacy of an e-mail delivered self-help pro- gram, based on CBT strategies for insomnia, designed for students living in on-campus residence halls. Study Impact: Results of this quasi-experimental study indicate college students with poor sleep can improve their sleep and reduce symptoms of depression by self-administering a cognitive behavior strategy based program delivered via low-cost electronic media. These findings suggest further program development, implementation, and evaluation may help students improve the quality and regularity of their sleep, and perhaps even help halt or slow the progression from poor sleep to depressive illness. 277 Journal of Clinical Sleep Medicine, Vol. 7, No. 3, 2011 CBT for Sleep: Effects on Sleep and Mood incorporated vignette examples specific to college students. Students were encouraged to spend 30 min on each session. The Refresh program has 2 tracks, one for students with poor sleep quality at baseline and a second (attenuated) version of the program for students with no or minimal sleep difficul- ties. Students were assigned a track based on their score on the Pittsburgh Sleep Quality index (PSQI), using a score > 5 to identify those with poor sleep quality.24 The complete program version for students with poor sleep at baseline, addressed: (1) the physiology of sleep with particular emphasis on circa- dian rhythms and recommendations for stabilizing circadian rhythm through anchoring wake time; (2) instructions on a time in bed-restriction protocol to consolidate sleep25; (3) re- laxation training; (4) mindfulness training; (5) stimulus control strategies26; and (6) cognitive strategies to reduce the impact of maladaptive thoughts about sleep. The program encouraged participants to keep daily sleep logs and implement strategies for improved sleep health. The daily sleep log allowed students to record daily bedtimes, time out of bed, minutes in bed be- fore sleep onset, number of night time awakenings, total min- utes spent lying in bed awake during the night, total amount of sleep, number of alcoholic beverages before bedtime, satisfac- tion with sleep, and degree to which the student felt refreshed in the morning. The time in bed restriction protocol was a significant por- tion of the program version for students with poor sleep, begin- ning with session three. The program first showed students how to self-administer sleep restriction. Students were instructed to compute their average total sleep time over the past week and then instructed to be in bed only as long as their average estimated actual sleep time, plus a margin ≤ 30 minutes. Sub- sequent program sessions instructed students to add 30 min to their scheduled time in bed if, on average: (a) they were able to fall asleep within 30 min, (b) they spent < 45 min lying in bed at night, and (c) they felt sleepy during most daytime hours. If students were consistently unable to fall asleep in < 30 min after going to bed or were consistently spending > 45 min per night lying in bed awake, they were asked to review a check- list of strategies to improve sleep presented to them previously in the Refresh program, and to consider adopting one of these strategies. If they had already implemented these strategies, they were encouraged to decrease total time in bed by 30 min per night, to a minimum of 6 h per night if needed. Students were instructed not to attempt the sleep restric- tion protocol if they believed any of the following applied to them at baseline: (1) “You have Bipolar Affective Disorder”; (2) “You have a family member with Bipolar Affective Disor- der”; (3) “You have had a period of time lasting one week or longer during which you felt euphoric, felt like you had special abilities other people don’t have, or felt persistently irritable”; (4) “Within the last 2 months you started a medication to treat depression or anxiety”; (5) “You frequently have trouble stay- ing awake while driving or performing other activities in which drowsiness may have fatal consequences”; (6) “You have a long road trip coming up within the next 3 weeks and you have to be the driver, or you have to perform other activities in which drowsiness may have fatal consequences.” The attenuated version of the Refresh program developed for students with good sleep quality at baseline included the same into and out of bed in college students improves sleep, sleepi- ness, and mood.16 Cognitive behavioral therapy for insomnia (CBT-I) has been established as an effective treatment for primary insomnia in adults when delivered in person,17-19 as a self-help intervention mailed to participants,20 or delivered via interactive Internet programs.21,22 In addition, a pilot study found that addition of CBT-I to pharmacologic treatment of depression led to im- proved outcomes in patients with insomnia and Major Depres- sive Disorder.23 We have therefore adapted CBT-I methods to the special circumstances of college life and to be delivered as a self-help intervention in 8 separate installments via e-mail. In this report, we present data from a quasi-experimental design study of the effects on sleep quality and symptoms of depressed mood of an e-mail delivered cognitive and behavior strategy based sleep health improvement program, which was delivered to college students living in on-campus residence halls. METHODS Participants We invited all students 18 years of age or older in 2 first- year student residence halls in a large private university to par- ticipate in a health promotion program. We presented the study at the first house meeting of the quarter and gave students an opportunity to ask questions and sign informed consent forms to participate in the study. Students were offered one unit of course credit for their participation in the study. The institu- tional review board approved the study protocol prior to com- mencement of the study. Students in one residence hall were invited to participate in an 8-week CBT-I based sleep-health promotion program called Refresh. More than two-thirds (70% [58 of 83]) of eligible stu- dents elected to participate in the program. Students in the sec- ond residence hall were invited to participate in another health promotion program (called Breathe) designed to help students cope with stress and to improve their emotional health by using skills common to cognitive behavioral therapy (CBT) for de- pression. Fewer than half (41% [67 of 162]) of eligible students elected to participate in the program. The baseline sample consisted of 61 women (32 in Re- fresh and 29 in Breathe) and 64 men (26 in Refresh and 38 in Breathe). Sixty-three (50%) identified themselves as White/ Caucasian, 17 (14%) as Latino/Hispanic or Mexican American, and 14 (11%) as Chinese/Chinese American. Fewer than 5 stu- dents identified themselves as part of any other single racial or ethnic group, and 9 elected not to answer the question on race/ ethnicity. Ninety-nine participating students were 18 years of age at the time they enrolled in the study, and the other 26 were between 19 and 22 years of age. We sent students a link to online baseline and post-interven- tion surveys by e-mail, using Survey Monkey. For both baseline and post-intervention data collection, we sent as many as 3 re- minder e-mails to students who had not yet responded. Interventions Both interventions were delivered in 8 weekly sessions, sent via e-mail messages with attached PDF files. Both programs 278Journal of Clinical Sleep Medicine, Vol. 7, No. 3, 2011 M Trockel, R Manber, V Chang et al Statistical Analyses The analyzable sample consisted of all individuals who provided both pre and post measures. We computed change in PSQI and CES-D scores by subtracting baseline scores from post-intervention scores. We then used t-tests for independent samples to test for between-groups differences in PSQI and CES-D score changes from baseline to post-intervention. We also calculated Cohen’s d effect sizes for within-group changes from baseline to post intervention on both outcome measures. Separate analyses were conducted for students with high (PSQI > 5) and low (PSQI ≥ 5) baseline sleep quality. We completed analyses using SPSS version 18.0. RESULTS Forty-eight of the 58 students (83%) participating in the Refresh program and 53 of 67 students (79%) participat- ing in the Breathe program completed baseline and post-test PSQI and CES-D measures, and thus constitute the sample for this study. The 24 students who began the study but failed to complete one or both post-test measures did not differ signifi- cantly in baseline PSQI (4.4 vs. 4.8; t = −0.93; df = 123; p = 0.36), baseline CES-D (11.4 vs. 13.8; t = −1.56; df = 123; p = 0.13), or gender (46% women vs. 50% women; χ2 = 0.11; p = 0.75). Nineteen Refresh program participants and 15 Breathe program participants had poor sleep (PSQI > 5) at baseline. Tables 1 and 2 provide baseline data for students with baseline PSQI scores > 5 (Table 1) and those with lower PSQI scores (Table 2). Among students with PSQI scores > 5 at baseline, there were no statistically significant differences in gender, proportion of white students vs. other racial or ethnic group, or outcome measure (PSQI and CESD) scores at baseline. Among students with lower PSQI scores at baseline, there were statis- tically significant differences between the intervention groups in the proportion of participants who were women and in aver- age baseline CES-D scores. More than half (54%) of the participants who received Re- fresh reported completing the entire program; the majority (94%) reported completing ≥ 4 of 8 sessions. For the Breathe program, 28% reported completing the entire program and 81% reported completing ≥ 4 of 8 sessions. Among Refresh students with baseline PSQI scores > 5, all but 2 (89%) completed ≥ 7 sessions. The remaining 2 Refresh students with elevated PSQI content as the full version, except that it did not include instruc- tion on how to self-administer a time in bed restriction protocol to consolidate sleep. The equal length comparison program, Breathe, was devel- oped to reduce depressive symptoms and improve coping skills for stress. The program integrated concepts and skills from Dialectical Behavior Therapy,27,28 Mindfulness-Based Stress Reduction,29 and Aaron Beck’s Cognitive Therapy.30 Specific topics include (1) recognizing and managing difficult emo- tions, (2) coping with stress, (3) cognitive reframing of nega- tive thoughts, and (4) improving relationships with friends and family. Unlike Refresh, which used cognitive restructuring and mindfulness meditation to address cognitions that interfere with sleep and hyperarousal in bed, Breathe used these strategies to address low mood and general stress. The Breathe program introduces new treatment compo- nents/modules each week, each focused on skill building. These included (1) self-monitoring of stressful events, associ- ated thoughts and emotions, and coping behaviors; (2) chal- lenging automatic negative thoughts; (3) finding solutions to interpersonal conflict; (4) engaging in enjoyable activities; (5) mindfulness meditation; and (6) relaxation. The Breathe pro- gram encouraged students to keep daily logs for a variety of self-monitoring tasks relevant to each module and to complete homework (assigned weekly) on topics such as motivation for the behavior change, time management, relaxation, mindful- ness meditation, and asking for help. Measures The baseline survey included demographic information, the PSQI24 and the Center for Epidemiological Studies-Depression Scale (CES-D).31 Post-treatment measures included the PSQI and the CES-D. The PSQI includes 19 questions and generates a sleep qual- ity index ranging from 0 to 21. A PSQI score > 5 has good sensitivity and specificity for identifying individuals who are “poor sleepers.”24 The CES-D measures depressive symptoms in a general pop- ulation with 20 items on a 0-3 point scale, for a total scale range of 0 to 60. The CES-D has demonstrated good ROC curve per- formance for detecting college students with clinically signifi- cant depression; it has also demonstrated adequate sensitivity and specificity using a cut off score > 15.32 Table 1—Baseline measures by intervention group, for the subgroup of students with PSQI > 5 at baseline Refresh, n = 19 M (SD) Breathe, n = 15 M (SD) Significance of group difference PSQI 7.7 (1.8) 7.5 (1.5) t = 0.38; p = 0.71 CESD 19.7 (10.4) 14.7 (8.1) t = 1.57; p = 0.13 Age 18.3 (0.4) 18.6 (1.0) t = −1.23; p = 0.24 Women* 0.63 (0.50) 0.73 (0.46) χ2 = 0.40; p = 0.53 White/Caucasian* 0.63 (0.50) 0.53 (0.52) χ2 = 0.33; p = 0.56 *Mean for categorical variables indicates the proportion of students who identified themselves as part of the specified group. Table 2—Baseline measures by intervention group, for the subgroup of students with PSQI ≤ 5 at baseline Refresh, n = 29 M (SD) Breathe, n = 38 M (SD) Significance of group difference PSQI 3.3 (1.5) 3.3 (1.2) t = −0.31; p = 0.76 CESD 9.7 (5.6) 13.7 (8.3) t = −2.23; p = 0.02 Age 18.1 (0.4) 18.2 (0.5) t = −0.40; p = 0.69 Women* 0.55 (0.51) 0.29 (0.46) χ2 = 4.70; p = 0.03 White/Caucasian* 0.48 (0.51) 0.42 (0.50) χ2 = 0.25; p = 0.62 *Mean for categorical variables indicates the proportion of students who identified themselves as part of the specified group. 279 Journal of Clinical Sleep Medicine, Vol. 7, No. 3, 2011 CBT for Sleep: Effects on Sleep and Mood DISCUSSION We focus our discussion primarily on findings among students with disturbed sleep at baseline who received the full version of the e-mail delivered self-help program us- ing validated cognitive behavior therapy for insomnia strate- gies.17-19 The main findings of this study are that, compared to an equal length comparison program, participation in an e-mail delivered self-help CBT-I based program was associ- ated with greater improvements in sleep quality and greater reductions in symptoms of depression among college stu- dents with low sleep quality at baseline. This study extends prior findings that self-help CBT-I is effective for adults with insomnia.17-22 Previous adult self-help CBT-I studies have used written materials20 or the Internet.21,22 Our study sug- gests e-mail delivery of weekly CBT-I based content may be an effective method of helping students with sleep problems improve their sleep. scores completed ≥ 5 of 8 sessions. Among Breathe students with baseline PSQI scores > 5, a third (33%) completed ≥ 7 ses- sions, and just over half (53%) completed ≥ 5 weekly sessions. Table 3 provides completion rates—defined as self-report of having completed ≥ 7 of 8 sessions—by baseline sleep category (PSQI > 5 or PSQI ≤ 5), and by program assignment. For participants with baseline PSQI scores > 5 (Figure 1), the Refresh intervention was associated with significantly greater reductions (t = −2.25; df = 32; p = 0.034) in PSQI scores (7.68 to 5.26 = −2.42 points; Cohen’s d = 1.33) than the Breathe program (7.47 to 6.80 = −0.67 points; Cohen’s d = 0.47). The between-group difference in PSQI change = −1.75 points, CI [−3.36 to −0.15]. For participants with baseline PSQI scores > 5, the Refresh program was also associated with significantly greater reductions (t = –2.19; df = 32; p = 0.036) in CES-D scores (19.69 to 13.75 = −5.94 points; Cohen’s d = 0.57) than the Breathe program (14.73 to 16.00 = 1.27 points; Cohen’s d = 0.16) (Figure 2). The between-group difference in CES-D change was −7.20 points, CI [−14.00 to −0.39]. For participants with baseline PSQI scores ≤ 5, there were no significant dif- ferences in pre to post changes in sleep quality or depressive symptom severity between Refresh and Breathe (p = 0.23 for PSQI and p = 0.80 for CES-D). The average reductions in PSQI scores and CESD scores re- ported by the 2 participants with baseline PSQI scores > 5 who did not complete ≥ 7 units of the program were 0.00 and 1.00 respectively. The small sample number of participants this group (n = 2) is not sufficient to test the statistical significance of these score reductions compared with average score reductions among participants who completed ≥ 7 of 8 units (n = 17), which were 2.71 and 6.51 for PSQI and CESD scores, respectively. 9 8 7 6 5 4 3 2 1 0 Baseline PSQI Post-test PSQI Refresh, good sleepers (n = 29) Breathe, good sleepers (n = 38) Refresh, poor sleepers* (n = 19) Breathe, poor sleepers (n = 15) 7.7 (SD = 1.8) 5.3 (SD = 2.4) Figure 1—Baseline and post-test PSQI scores *Change is significantly greater than observed in alternative treatment control group 21 18 15 12 9 6 3 0 Baseline CESD Post-test CESD 19.7 (SD = 10.4) 13.8 (SD = 7.7) Refresh, good sleepers (n = 29) Breathe, good sleepers (n = 38) Refresh, poor sleepers* (n = 19) Breathe, poor sleepers (n = 15) Figure 2—Baseline and post-test CESD scores *Change is significantly greater than observed in alternative treatment control group Table 3—Completion rates—defined as self-report of having completed ≥ 7 of 8 sessions—by baseline sleep quality category, and program assignment Refresh Breathe Total in category Completers (%) Total in category Completers (%) Baseline PSQI ≤ 5 29 14 (48%) 38 14 (37%) Baseline PSQI > 5 19 17 (89%) 15 5 (33%) 280Journal of Clinical Sleep Medicine, Vol. 7, No. 3, 2011 M Trockel, R Manber, V Chang et al that the observed intervention group differences could be at least partially explained by regression to the mean among Refresh participants. Quasi-experimental design does not have the same fidelity in internal validity inherent in a randomized clinical tri- al. Further research using a true experimental design is needed to establish an evidence base for the effectiveness of electroni- cally delivered CBT-I for improving sleep and symptoms of de- pression among college students with sleep difficulties. Future experimental design research with adequate follow-up time is also needed to determine whether improving sleep will reduce risk of future depression. Selection of students residing at a highly selective private university may limit the generalizability of our results. Com- pared to other groups of college students, the students who par- ticipated in this study may be more motivated and better able to follow a self-directed program to improve sleep through cogni- tive and behavioral strategies. Another limitation of our study is that both sleep quality and depression were each assessed with only one self-report measure. Self-report measures are subject to demand charac- teristics, which could bias our results. The assessment of par- ticipant adherence was limited to self-report of the number of units they had completed. Although limited, these data revealed that a higher proportion of students with poor sleep at baseline completed at least 7 of 8 units, suggesting Refresh is acceptable to a large majority of freshmen with sleep problems. We cannot determine from our data what, if any, informa- tion or intervention may be beneficial for students with no sleep problems. We are also unable to determine from our data wheth- er one or a few components, rather than the whole collection of cognitive and behavior strategies, is associated with observed improvements among students with poor sleep at baseline. Future research might experiment with intervention tailoring, delivering intervention components that fit students’ needs de- termined by baseline assessment. For example, students with a delayed chronotype may benefit from a module that specifically addresses circadian entrainment, and others may not need it. Most students with insomnia will benefit from combined stimulus con- trol and time-in-bed restriction modules. Although the self-report- ed number of units completed was very high, we believe future research will also need to evaluate reasons for dropout and con- sider methods to enhance retention. Perhaps tailored interventions with fewer modules may offer higher adherence without reducing effectiveness, as will adding a motivation enhancement compo- nent, though these possibilities await empirical support. Future research may also determine whether intervention to improve sleep will also improve students’ academic performance. Chronic sleep disturbance is strongly associated with short-term cognitive impairments,35 and in adolescents has been linked with subsequent impairment in academic performance.36 College stu- dents who report better sleep quality perform better on academic measures than those reporting a poorer quality of sleep,37 and vari- able sleep schedules, specifically later weekend wake-up times, accounts for significant variance in end-of-term grades.38 Students who obtain less REM sleep than needed may also be less able to integrate and store newly learned information.39,40 Even moder- ate sleep disturbance has serious implications for neurobehavioral functions, as sleep duration of six hours or less per night for 14 consecutive nights has been shown to produce cognitive perfor- Most encouraging was our finding that among individuals with poor sleep quality, a sleep enhancement intervention was associated with greater improvement in depressive symptoms than an intervention to improve mood and reduce stress. Our re- sults are consistent with a large body of literature indicating that disturbed sleep constitutes a risk factor for depression3-12 and are consistent with a previous finding that CBT-I improves outcomes among depressed patients receiving antidepressant medication therapy.23 A previous study found that irregular sleep patterns can lead to desensitization of serotonergic receptor systems,33 which suggests a possible biologic mechanism for the relationship be- tween impaired sleep and depressed mood. As our study was conducted with college students, many of whom have irregular sleep schedules, it is possible that the observed improvement in mood is mediated by regularizing the students’ sleep schedules. However, we do not have sufficient data to test this hypothesis. The full version of the program for students with sleep dif- ficulties demonstrated effectiveness. However, we did not find benefit of the sleep-health promotion program in a group of college students with little or no sleep disturbance at baseline. Brown and colleagues found improved sleep quality (PSQI scores) with a single group 30-minute sleep-health education program in a general population college sample.34 It may be that the group of students studied by Brown and colleagues34 had sleep distress at baseline (mean PSQI = 7.3 among intervention group participants and 6.6 among controls) comparable to our sample of students with sleep problems (mean PSQI = 7.7 for Refresh participants and 7.5 for Breathe participants) and dif- ferent from our group of participants without significant base- line sleep problems (mean PSQI = 3.3 for Refresh participants and 3.5 for Breathe participants). It seems reasonable to expect that students with disturbed sleep at baseline may benefit most from a program designed to help them improve their sleep. Importantly, among students with baseline sleep difficulties, tar- geting sleep-health appeared more successful at reducing depres- sive symptoms than an intervention targeting negative self-talk and coping strategies that are common targets of CBT for depres- sion. Given that poor sleep is a modifiable risk factor for depressed mood,3-12 it is encouraging that targeting sleep-health was also as- sociated with reduction in depressive symptoms. Although we do not have long-term data to directly test the assertion that improving sleep will reduce the risk for a future depressive episode, improv- ing sleep might be an important element in depression prevention interventions for students with sleep problems. There are limitations of our study that warrant mention. Per- haps the most important limitation is that students were assigned to intervention groups by residence hall, rather than by random assignment. Although this feature in the design reduced the dan- ger of cross-contamination of treatment, it … NIH Publication No. 05-3896 Printed September 2005 2931-NCI Theory cvr.f 11/17/05 3:18 PM Page 1 Theor y at a Gl ance U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health A G u i d e F o r H e a l t h P ro m o t i o n P ra c t i ce Theory at a Glance A Guide For Health Promotion Practice (Second Edition) U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health Foreword A decade ago, the first edition of Theory at a Glance was published. The guide was a welcome resource for public health practitioners seeking a single, concise summary of health behavior theories that was neither overwhelming nor superficial. As a government publication in the public domain, it also provided cash-strapped health departments with access to a seminal integration of scholarly work that was useful to program staff, interns, and directors alike. Although they were not the primary target audience, members of the public health research community also utilized Theory at a Glance, both as a quick desk reference and as a primer for their students. The National Cancer Institute is pleased to sponsor the publication of this guide, but its relevance is by no means limited to cancer prevention and control. The principles described herein can serve as frameworks for many domains of public health intervention, complementing focused evidence reviews such as Centers for Disease Control and Prevention’s Guide to Community Preventive Services. This report also complements a number of other efforts by NCI and our federal partners to facilitate more rigorous testing and application of health behavior theories through training workshops and the development of new Web-based resources. One reason theory is so useful is that it helps us articulate assumptions and hypotheses concerning our strategies and targets of intervention. Debates among policymakers concerning public health programs are often complicated by unspoken assumptions or confusion about which data are relevant. Theory can inform these debates by clarifying key constructs and their presumed relationships. Especially when the evidence base is small, advocates of one approach or another can be challenged to address the mechanisms by which a program is expected to have an impact. By specifying these alternative pathways to change, program evaluations can be designed to ensure that regardless of the outcome, improvements in knowledge, program design, and implementation will occur. I am pleased to introduce this second edition of Theory at a Glance. I am especially impressed that the lead authors, Dr. Barbara K. Rimer and Dr. Karen Glanz, have enhanced and updated it throughout without diminishing the clarity and efficiency of the original. We hope that this new edition will empower another generation of public health practitioners to apply the same conceptual rigor to program planning and design that these authors exemplify in their own research and practice. Robert T. Croyle, Ph.D. Director Division of Cancer Control and Population Sciences National Cancer Institute Spring 2005 Acknowledgements The National Cancer Institute would like to thank Barbara Rimer Dr.P.H. and Karen Glanz Ph.D., M.P.H., authors of the original monograph, whose knowledge of healthcommunications theory and practice have molded a generation of health promotion practitioners. Both have provided hours of review and consultation, and we are grateful to them for their contributions. Thanks to the staffs of the Office of Communications, particularly Margaret Farrell, and the Division of Cancer Control and Population Sciences and Kelly Blake, who guided this monograph to completion. We appreciate in particular the work of Karen Harris, whose attention to detail and commitment to excellence enhanced the monograph’s content and quality. Table of Contents Introduction viii Audience and Purpose 1 Contents 1 Part 1: Foundations of Theory in Health Promotion and Health Behavior 3 Why Is Theory Important to Health Promotion and Health Behavior Practice? 4 What Is Theory? 4 How Can Theory Help Plan Effective Programs? 4 Explanatory Theory and Change Theory 5 Fitting Theory to the Field of Practice 5 Using Theory to Address Health Issues in Diverse Populations 7 Part 2: Theories and Applications 9 The Ecological Perspective: A Multilevel, Interactive Approach 10 Theoretical Explanations of Three Levels of Influence 12 Individual or Intrapersonal Level 12 Health Belief Model 13 Stages of Change Model 15 Theory of Planned Behavior 16 Precaution Adoption Process Model 18 Interpersonal Level 19 Social Cognitive Theory 19 Community Level 22 Community Organization and Other Participatory Models 23 Diffusion of Innovations 27 Communication Theory 29 Media Effects 30 Agenda Setting 30 New Communication Technologies 31 Part 3: Putting Theory and Practice Together 35 Planning Models 36 Social Marketing 36 PRECEDE-PROCEED 39 Where to Begin: Choosing the Right Theories 43 A Few Final Words 44 Sources 48 References 49 Tables and Figures Tables Table 1 An Ecological Perspective: Levels of Influence 11 Table 2 Health Belief Model 14 Table 3 Stages of Change Model 15 Table 4 Theory of Planned Behavior 17 Table 5 Social Cognitive Theory 20 Table 6 Community Organization 24 Table 7 Concepts in Diffusion of Innovations 27 Table 8 Key Attributes Affecting the Speed and Extent of an Innovation’s Diffusion 28 Table 9 Agenda Setting, Concepts, Definitions, and Applications 31 Table 10 Diagnostic Elements of PRECEDE-PROCEED 42 Table 11 Summary of Theories: Focus and Key Concepts 45 Figures Figure 1 Using Explanatory Theory and Change Theory to Plan and Evaluate Programs 6 Figure 2 A Multilevel Approach to Epidemiology 10 Figure 3 Theory of Reasoned Action and Theory of Planned Behavior 18 Figure 4 Stages of the Precaution Adoption Process Model 19 Figure 5 An Integrative Model 21 Figure 6 Sociocultural Environment Logic Framework 26 Figure 7 An Asthma Self-Management Video Game for Children 33 Figure 8 Social Marketing Wheel 38 Figure 9 The PRECEDE-PROCEED Model 40 Figure 10 Using Theory to Plan Multilevel Interventions 46 Introduction viii T H E O R Y A T A G LA N C E T his monograph, Theory at a Glance: Application to Health Promotion and Health Behavior (Second Edition), describes influential theories of health-related behaviors, processes of shaping behavior, and the effects of community and environmental factors on behavior. It complements existing resources that offer tools, techniques, and model programs for practice, such as Making Health Communication Programs Work: A Planner’s Guide,i and the Web portal, Cancer Control PLANET (Plan, Link, Act, Network with Evidence-based Tools).ii Theory at a Glance makes health behavior theory accessible and provides tools to solve problems and assess the effectiveness of health promotion programs. (For the purposes of this monograph, health promotion is broadly defined as the process of enabling people to increase control over, and to improve, their health. Thus, the focus goes beyond traditional primary and secondary prevention programs.) For nearly a decade, public health and health care practitioners have consulted the original version of Theory at a Glance for guidance on using theories about human behavior to inform program planning, implementation, and evaluation. We have received many testimonials about the First Edition’s usefulness, and requests for additional copies. This updated edition includes information from recent health behavior research and suggests theoretical approaches to developing programs for diverse populations. Theory at a Glance can be used as a stand-alone handbook, as part of in-house staff development programs, or in conjunction with theory texts and continuing education workshops. For easy reference, the monograph includes only a small number of current and applicable health behavior theories. The theories reviewed here are widely used for the purposes of cancer control, defining risk, and segmenting populations. Much of the content for this publication has been adapted from the third edition of Glanz, Rimer, and Lewis’ Health Behavior and Health Education: Theory, Research, and Practice,1 published by Jossey-Bass in San Francisco. Readers who want to learn more about useful theories for health behavior change and health education practice can consult this and other sources that are recommended in the References section at the end of the monograph. i Making Health Communication Programs Work (http://www.nci.nih.gov/pinkbook/) describes a practical approach for planning and implementing health communication efforts. ii Cancer Control PLANET (http://cancercontrolplanet.cancer.gov) provides access to data and resources that can help planners, program staff, and researchers to design, implement, and evaluate evidence-based cancer control programs. (http://www.nci.nih.gov/pinkbook/) (http://cancercontrolplanet.cancer.gov) Audience and Purpose This monograph is written primarily for public health workers in state and local health agencies; it is also valuable for health promotion practitioners and volunteers who work in voluntary health agencies, community organizations, health care settings, schools, and the private sector. Interventions based on health behavior theory are not guaranteed to succeed, but they are much more likely to produce desired outcomes. Theory at a Glance is designed to help users understand how individuals, groups, and organizations behave and change—knowledge they can use to design effective programs. For information about specific, evidence-based interventions to promote health and prevent disease, readers may also wish to consult the Guide to Community Preventive Services, published by the Centers for Disease Control and Prevention (CDC) at www.thecommunityguide.org. Contents This monograph consists of three parts. For each theory, the text highlights key concepts and their applications. These summaries may be used as “checklists” of important issues to consider when planning or evaluating programs or to prompt project teams to think about the range of factors that influence health behavior. Part 1. Foundations of Theory in Health Promotion and Health Behavior describes ways that theories and models can be useful in health behavior/health promotion practice and provides basic definitions. Part 2. Theories and Applications presents an ecological perspective on health behavior/health promotion programs. It describes eight theories and models that explain individual, interpersonal, and community behavior and offers approaches to solving problems. A brief description of each theory is followed by definitions of key concepts and examples or case studies. The section also explores the use of new communication technologies. Part 3. Putting Theory and Practice Together explains how theory can be used in health behavior/health promotion program planning, implementation, and evaluation. Two comprehensive planning models, PRECEDE-PROCEED and social marketing, are reviewed. 1 IN TR O T H E O R Y A T A G LA N C E http:www.thecommunityguide.org Part 1 Foundations of Theory in Health Promotion and Health Behavior 3 PA R T 1 T H E O R Y A T A G LA N C E 4 T H E O R Y A T A G LA N C E Why Is Theory Important to Health Promotion and Health Behavior Practice? Effective public health, health promotion, and chronic disease management programs help people maintain and improve health, reduce disease risks, and manage chronic illness. They can improve the well-being and self-sufficiency of individuals, families, organizations, and communities. Usually, such successes require behavior change at many levels, (e.g., individual, organizational, and community). Not all health programs and initiatives are equally successful, however. Those most likely to achieve desired outcomes are based on a clear understanding of targeted health behaviors, and the environmental context in which they occur. Practitioners use strategic planning models to develop and manage these programs, and continually improve them through meaningful evaluation. Health behavior theory can play a critical role throughout the program planning process. What Is Theory? A theory presents a systematic way of understanding events or situations. It is a set of concepts, definitions, and propositions that explain or predict these events or situations by illustrating the relationships between variables. Theories must be applicable to a broad variety of situations. They are, by nature, abstract, and don’t have a specified content or topic area. Like empty coffee cups, theories have shapes and boundaries, but nothing inside. They become useful when filled with practical topics, goals, and problems. • Concepts are the building blocks—the primary elements—of a theory. • Constructs are concepts developed or adopted for use in a particular theory. The key concepts of a given theory are its constructs. • Variables are the operational forms of constructs. They define the way a construct is to be measured in a specific situation. Match variables to constructs when identifying what needs to be assessed during evaluation of a theory- driven program. • Models may draw on a number of theories to help understand a particular problem in a certain setting or context. They are not always as specified as theory. Most health behavior and health promotion theories were adapted from the social and behavioral sciences, but applying them to health issues often requires that one be familiar with epidemiology and the biological sciences. Health behavior and health promotion theories draw upon various disciplines, such as psychology, sociology, anthropology, consumer behavior, and marketing. Many are not highly developed or have not been rigorously tested. Because of this, they often are called conceptual frameworks or theoretical frameworks; here the terms are used interchangeably. How Can Theory Help Plan Effective Programs? Theory gives planners tools for moving beyond intuition to design and evaluate health behavior and health promotion interventions based on understanding of behavior. It helps them to step back and consider the larger picture. Like an artist, a program planner who grounds health interventions in theory creates innovative ways to address specific circumstances. He or she does not depend on a “paint-by­ numbers” approach, re-hashing stale ideas, but uses a palette of behavior theories, skillfully applying them to develop unique, tailored solutions to problems. Using theory as a foundation for program planning and development is consistent with the current emphasis on using evidence- based interventions in public health, behavioral medicine, and medicine. Theory provides a road map for studying problems, developing appropriate interventions, and evaluating their successes. It can inform the planner’s thinking during all of these stages, offering insights that translate into stronger programs. Theory can also help to explain the dynamics of health behaviors, including processes for changing them, and the influences of the many forces that affect health behaviors, including social and physical environments. Theory can also help planners identify the most suitable target audiences, methods for fostering change, and outcomes for evaluation. Researchers and practitioners use theory to investigate answers to the questions of “why,” “what,” and “how” health problems should be addressed. By seeking answers to these questions, they clarify the nature of targeted health behaviors. That is, theory guides the search for reasons why people do or do not engage in certain health behaviors; it helps pinpoint what planners need to know before they develop public health programs; and it suggests how to devise program strategies that reach target audiences and have an impact. Theory also helps to identify which indicators should be monitored and measured during program evaluation. For these reasons, program planning, implementation, and monitoring processes based in theory are more likely to succeed than those developed without the benefit of a theoretical perspective. Explanatory Theory and Change Theory Explanatory theory describes the reasons why a problem exists. It guides the search for factors that contribute to a problem (e.g., a lack of knowledge, self-efficacy, social support, or resources), and can be changed. Examples of explanatory theories include the Health Belief Model, the Theory of Planned Behavior, and the Precaution Adoption Process Model. Change theory guides the development of health interventions. It spells out concepts that can be translated into program messages and strategies, and offers a basis for program evaluation. Change theory helps program planners to be explicit about their assumptions for why a program will work. Examples of change theories include Community Organization and Diffusion of Innovations. Figure 1. illustrates how explanatory theory and change theory can be used to plan and evaluate programs. Fitting Theory to the Field of Practice This monograph includes descriptions and applications of some theories that are central to health behavior and health promotion practice today. No single theory dominates health education and promotion, nor should it; the problems, behaviors, populations, cultures, and contexts of public health practice are broad and varied. Some theories focus on individuals as the unit of change. Others examine change within families, institutions, communities, or cultures. Adequately addressing an issue may require more than one theory, and no one theory is suitable for all cases. 5 PA R T 1 FO U N D A T IO N S O F A P P LY IN G T H E O R Y IN H E A LT H P R O M O T IO N P R A C T IC E Figure 1. Using Explanatory Theory and Change Theory to Plan and Evaluate Programs Problem Behavior or Situation ChangeTheory Which strategies? Which messages? Assumptions about how a program should work Evaluation Planning Explanatory Theory Why? What can be changed? 6 T H E O R Y A T A G LA N C E Because the social context in which behavior occurs is always evolving, theories that were important in public health education a generation ago may be of limited use today. At the same time, new social science research allows theorists to refine and adapt existing theories. A recent Institute of Medicine report2 observed that several theorists have converged in their views, identifying several variables as central to behavior change. As a result, some constructs, such as self-efficacy, are central to multiple theories. Effective practice depends on using theories and strategies that are appropriate to a situation. One of the greatest challenges for those concerned with behavior change is learning to analyze how well a theory or model “fits” a particular issue. A working knowledge of specific theories, and familiarity with how they have been applied in the past, improves skills in this area. Selecting an appropriate theory or combination of theories helps take into account the multiple factors that influence health behaviors. The practitioner who uses theory develops a nuanced understanding of realistic program outcomes that drives the planning process. Choosing a theory that will bring a useful perspective to the problem at hand does not begin with a theory (e.g., the most familiar theory, the theory mentioned in a recent journal article, etc.). Instead, this process starts with a thorough assessment of the situation: the units of analysis or change, the topic, and the type of behavior to be addressed. Because different theoretical frameworks are appropriate and practical for different situations, selecting a theory that “fits” should be a careful, deliberate process. Start with the steps in the box at the top of the next page. A Good Fit: Characteristics of a Useful Theory A useful theory makes assumptions about a behavior, health problem, target population, or environment that are: • Logical; • Consistent with everyday observations; • Similar to those used in previous successful programs; and • Supported by past research in the same area or related ideas. Using Theory to Address Health Issues in Diverse Populations The U.S. population is growing more culturally and ethnically diverse. An increasing body of research shows health disparities exist among various ethnic and socio-economic groups. These findings highlight the importance of understanding the cultural backgrounds and life experiences of community members, though research has not yet established when and under what circumstances targeted or tailored health communications are more effective than generic ones. (Targeting involves using information about shared characteristics of a population subgroup to create a single intervention approach for that group. In contrast, tailoring is a process that uses an assessment to derive information about one specific person, and then offers change or information strategies for an outcome of interest based on that person’s unique characteristics.)3 Most health behavior theories can be applied to diverse cultural and ethnic groups, but health practitioners must understand the characteristics of target populations (e.g., ethnicity, socioeconomic status, gender, age, and geographical location) to use these theories correctly. There are several reasons why culture and ethnicity are critical to consider when applying theory to a health problem. First, morbidity and mortality rates for different diseases vary by race and ethnicity; second, there are differences in the prevalence of risk behaviors among these groups; and third, the determinants of health behaviors vary across racial and ethnic groups. What People in the Field Say About Theory “Theory is different from most of the tools I use in my work. It’s more abstract, but that can be a plus too. A solid grounding in a handful of theories goes a long way toward helping me think through why I approach a health problem the way I do.” — County Health Educator “I used to think theory was just for students and researchers. But now I have a better grasp of it; I appreciate how practical it can be.” — State Chronic Disease Administrator “By translating concepts from theory into real-world terms, I can get my staff and community volunteers to take a closer look at why we’re conducting programs the way we do, and how they can succeed or fail.” — City Tobacco Control Coordinator “A good grasp of theory is essential for leadership. It gives you a broader way of viewing your work. And it helps create a vision for the future. But, of course, it’s only worthwhile if I can translate it clearly and simply to my co-workers.” — Regional Health Promotion Chief “It’s not as hard as I thought it would be to keep up with current theories. More than ever these days, there are tools and workshops to update us often.” — Patient Education Coordinator 7 PA R T 1 FO U N D A T IO N S O F A P P LY IN G T H E O R Y IN H E A LT H P R O M O T IO N P R A C T IC E Part 2 Theories and Applications 9 PA R T 2 T H E O R Y A T A G LA N C E The Ecological Perspective: A Multilevel, Interactive Approach Contemporary health promotion involves more than simply educating individuals about healthy practices. It includes efforts to change organizational behavior, as well as the physical and social environment of communities. It is also about developing and advocating for policies that support health, such as economic incentives. Health promotion programs that seek to address health problems across this spectrum employ a range of strategies, and operate on multiple levels. The ecological perspective emphasizes the interaction between, and interdependence of, factors within and across all levels of a health problem. It highlights people’s interactions with their physical and socio­ cultural environments. Two key concepts of the ecological perspective help to identify intervention points for promoting health: first, behavior both affects, and is affected by, multiple levels of influence; second, individual behavior both shapes, and is shaped by, the social environment (reciprocal causation). To explain the first key concept of the ecological perspective, multiple levels of influence, McLeroy and colleagues (1988)4 identified five levels of influence for health- related behaviors and conditions. Defined in Table 1., these levels include: (1) intrapersonal or individual factors; (2) interpersonal factors; (3) institutional or organizational factors; (4) community factors; and (5) public policy factors. 10 T H E O R Y A T A G LA N C E Figure 2. A Multilevel Approach to Epidemiology Social and Economic Policies Institutions Neighborhoods and Communities Living Conditions Social Relationships Individual Risk Factors Pathophysiological Pathways Individual/Population Health Genetic/Constitutional Factors Envir onm ent Li fe co ur se Source: Smedley BD, Syme SL (eds.), Institute of Medicine. Promoting Health: Strategies from Social and Behavioral Research. Washington, D.C.:, National Academies Press, 2000. Table 1. An Ecological Perspective: Levels of Influence Concept Intrapersonal Level Interpersonal Level Community Level Institutional Factors Community Factors Public Policy Definition Individual characteristics that influence behavior, such as knowledge, attitudes, beliefs, and personality traits Interpersonal processes and primary groups, including family, friends, and peers that provide social identity, support, and role definition Rules, regulations, policies, and informal structures, which may constrain or promote recommended behaviors Social networks and norms, or standards, which exist as formal or informal among individuals, groups, and organizations Local, state, and federal policies and laws that regulate or support healthy actions and practices for disease prevention, early detection, control, and management In practice, addressing the community level requires taking into consideration institutional and public policy factors, as well as social networks and norms. Figure 2. illustrates how different levels of influence combine to affect population health. Each level of influence can affect health behavior. For example, suppose a woman delays getting a recommended mammogram (screening for breast cancer). At the individual level, her inaction may be due to fears of finding out she has cancer. At the interpersonal level, her doctor may neglect to tell her that she should get the test, or she may have friends who say they do not believe it is important to get a mammogram. At the organizational level, it may be hard to schedule an appointment, because there is only a part-time radiologist at the clinic. At the policy level, she may lack insurance coverage, and thus be unable to afford the fee. Thus, the outcome, the woman’s failure to get a mammogram, may result from multiple factors. The second key concept of an ecological perspective, reciprocal causation, suggests that people both influence, and are influenced by, those around them. For example, a man with high cholesterol may find it hard to follow the diet his doctor has prescribed because his company cafeteria doesn’t offer healthy food choices. To comply with his doctor’s instructions, he can try to change the environment by asking the cafeteria manager to add healthy items to the menu, or he can dine elsewhere. If he and enough of his fellow employees decide to find someplace else to eat, the cafeteria may change its menu to maintain lunch business. Thus, the cafeteria environment may compel this man to change his dining habits, but his new habits may ultimately bring about change in the cafeteria as well. 11 PA R T 2 T H E O R IE S A N D A P P LIC A T IO N S 12 T H E O R Y A T A G LA N C E An ecological perspective shows the advantages of multilevel interventions that combine behavioral and environmental components. For instance, effective tobacco control programs often use multiple strategies to discourage smoking.5 Employee smoking cessation clinics have a stronger impact if the workplace has a no-smoking policy and the city has a clean indoor air ordinance. Adolescents are less likely to begin smoking if their peers disapprove of the habit and laws prohibiting tobacco sales to minors are strictly enforced. Health promotion programs are more effective when planners consider multiple levels of influence on health problems. Theoretical Explanations of Three Levels of … Health behavior and Theory: What and why? PH 587: Health Behavior Let’s check in Initial thoughts on reading? Why do we use theory? Questions about sites or readings? Theory at a Glance Healthy People 2030 CDC leading causes of death CBT County health rankings WKU health ed and promotion 2 But first, health behavior What is the difference between health education and health promotion? Examples of each? Both have a central focus of health behavior Health ed focuses on changing health behavior through educational interventions Health promotion is a broader term that encompasses not only educations activities, but also organizational, environmental, and economic interventions that support activities conducive to healthy behavior, 3 Leading causes of death (CDC, 2019) Heart disease: 659,041 Cancer: 599,601 Accidents (unintentional injuries): 173,040 Chronic lower respiratory diseases: 156,979 Stroke (cerebrovascular diseases): 150,005 What social factors are associated with these? What is ACTUALLY the leading causes of death? (Tobacco 4 of the top 5, poor diet/lack of physical activity, alcohol…) Social factors: Low education (245,000 deaths) Racial segregation (176,000 deaths) Low social support (162,000 deaths) Individual-level poverty (133,000 deaths) Income inequality (119,000 deaths) Area-level poverty (39,000 deaths) (Galea, Tracy, Hoggatt, DiMaggio, & Karpati, 2011) 4 Changing context Major causes of death in the U.S. Chronic vs. Infectious Disease Greatest gains come from public health advances not medicine Clean water Sewage Food Etc. Reemergence of infections disease Infectious disease e.g., polio, TB, etc. How do we address these issues? Emerging issues: access, health care issues. More money spent in US than any other country, yet we rank 37 (WHO, 2020). We are also seeing a DECLINE in life expectancy. 5 Health behavior What “product” are we trying to sell to the public? What are the challenges involved in selling this “product?” What is our competition? Why is changing health behavior so challenging? Perception Why is identifying our population and our setting important? Some topic areas of health ed? Think back to what ACTUALLY causes death. Some settings to address issues? (schools, work, health dept, communities, etc.). 6 Perception versus reality Perception Immediate benefits outweigh long term risk Alcohol use Diet Sedentary lifestyle Unprotected sex Sun-tanning NCHA-III_SPRING-2021_UNDERGRADUATE 7 Factors to consider in designing intervention Health and social characteristics Beliefs Attitudes Values Skills Past behavior Sociodemographic Life cycle stage Disease status Why is it crucial for us to consider these factors? How could not considering them hinder the intervention? Consider the obesity study 8 Introducing…THEORY! 9 What is a theory? presents a systematic way of understanding events or situations. It is a set of concepts, definitions, and propositions that explain or predict these events or situations by illustrating the relationships between variables. by their nature abstract; that is, they do not have a specified content or topic area. Models may draw on several theories to help understand a particular problem in a certain setting or context. They are not always as specified as theory. Many health behavior theories draw from social and behavioral sciences (psychology, sociology, anthropology, and marketing are some examples). This will be obvious as we discuss some of these in greater detail over the course of the semester. 10 Some terms to know Concepts are the primary elements of a theory. Constructs are concepts developed or adopted for use in a particular theory. The key concepts of a given theory are its constructs. Variables are the operational forms of constructs. They define the way a construct is to be measured in a specific situation. Match variables to constructs when identifying what needs to be assessed during evaluation of a theory-driven program. 11 Theory and health behavior We can use theory to investigate the “why,” “what,” and “how” health problems should be addressed. This can help us clarify why people do or do not engage in certain behaviors. Why do people behave in healthy or unhealthy ways? Explanatory theory: why a problem exists. change theory: guides development of health interventions. True or False? If people understood the health risks or benefits of engaging in a particular behavior, they would make wise choices. Many people assume that educating people will resolve the issue. 12 consider Physicians experience some of the highest rates of drug addiction among any profession. Why? How many of you floss, use sunscreen, drive safely, eat in moderation consistently, exercise, and use prophylactics? Why? Many assume educating is sufficient for resolving health behavior issues. But don’t we all know better? How can CBT be used to address health behaviors? 13 Theory and health behavior continued Education is NECESSARY but not SUFFICIENT. Behaviors may be influenced by other factors and not necessarily health concerns. Examples? What is the primary motivation for adolescents to brush their teeth? (kissing) What could be a factor for drinking responsibly? (don’t want to get “sloppy” or hook up with someone you wouldn’t necessarily want to under sober circumstances) 14 Social determinants of health “Social and health programs generally tend to focus on giving people skills to beat the odds to overcome the structural barriers to successful and healthy lives. In the long run, it makes more sense to change the odds so that more people have a wider and more accessible range of healthy choices.” (Wallack et al., 1993, p.204) Social, cultural, economic factors may outweigh health concerns Examples? Reduce poverty/increase jobs HPV vaccine Air bags Interlock ignition devices for cars Removing trans-fat Banning tobacco advertising & use Safe, convenient, inexpensive places to exercise 15 Why use theory? Increases the chance of program success. Program planners use theories to shape the stages of planning and to answer: Why, What and How? Why are people doing what they are doing? What information do they need? What should be monitored? How will the information be received best? Theories and models explain behavior and suggest ways to achieve behavior change. It helps us predict what interventions will work best, then to test those predictions to expand, refute, or modify predictions. 16 Why use theory continued Theories can explain and predict virtually all behaviors Consider survey research Scientists can predict your ATOD, sexual behavior, diet, exercise, etc. based on how you respond to certain questions Interventions can and should be designed based on theoretical research Too often practitioners use their intuition, rather than science to guide their intervention efforts. What is an “anecdote?” 17 Theoretical frameworks Used to organize thoughts and planning or research, analysis, and intervention. Theory packages new knowledge into an understandable form related to something. Assumptions Concepts Constructs Assumptions: what we take for granted 18 Create your own need for theory Get with a partner: Identify all the reasons you exercised in the last week. Identify all reasons you didn’t exercise as much as you wanted to: Did themes emerge? Possible themes: Self-efficacy Habit Social support Peer pressure or norm Expectancies/attitude 19 Evaluating a theory Can it be tested? Is it logical? Is it plausible? Is it useful? Clarity Generality 20 Empirical validity and rigor Finding a good fit for a theory is important. Empirical validity is where you review the literature to assess studies that address or use particular theories. Evaluate the studies as a whole. Are there enough to warrant the use of this theory? Rigor. Determine the strength of the studies. Is there empirical support? Does the purpose of study and the theoretical framework fit? Can hypothesis be deduced from the theory? 21 How to use theory Ideas? 22 Fun theory piano Empirical evidence Consider WHO you want to help change. Age group? Race? Ethnicity? Gender? SES? Disadvantaged? Future leaders? Evaluate How to use theory continued What were they addressing? What was their theory? Why is deciding WHO you want to help important in how you apply theory? 23 24 Let’s recap Thoughts? Why do we use theory? What is our job? 25 Glanz, K., & Rimer, B. K. (1997). Theory at a glance: a guide for health promotion practice. Bethesda, Md.: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Glanz, K., Rimer, B. K., & Viswanath, K. (2008). Health behavior and health education: Theory, Research, and Practice 4th edition. San Francisco, CA: Jossey-Bass. References 26 Question 1 According to the research article on use CBT for a sleep health program among college students, thrw study found that compared to an equal length comparison program, participation in an e-mail delivered self-help CBT-1 based program was associated with greater improvements in sleep quality and greater reductions in symptoms of depression among college students with low sleep quality at baseline · True · False Question 2 Which of these is Not a Leading cause of death in the US? · Homicide · Cancer · Heart disease · stroke Question 3 After reading CBT, how can health educators use concepts from CBT to approach health behavior interventions? Question 4 According to theory at a Glance. “health behavior and health promotion theories draw upon various disciplines, such as’ · psychology · anthropology · sociology · consumer behavior and marketing Question 5 What was your biggest take-way from the reading? Are there any question you have about any the material so far? Question 6 According to theory at a glance, “ Most health behavior and health promotion theories were adapted from the social and behavioral sciences. “ why do you think that is ? Question 7 Why are websites such as healthy people 2030 and county health rankings beneficial when designing an intervention? How can they be used?