The editorial team of the OHPE Bulletin would like to dedicate this issue of the OHPE Bulletin, our 150th issue, to the memory of Karol Steinhouse, who died in a car accident on Wednesday March 29th, 2000. Karol has been a close friend, colleague, mentor and teacher to many people, and she is sorely missed. As a teacher and innovator in community social work at Ryerson Polytechnic University in Toronto, Karol Steinhouse inspired hundreds of students and community workers. Recently, she organized a 'charette' on community mobilization and city planning with multicultural, environmental, poverty action, equity and access, and community economic development leaders throughout the city for two day dynamic sessions with her students, and developing community mentor relationships. Her vision, vibrant energy and commitment to community change, linking beliefs, theories and practice for a healthy future - will be remembered by all.
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This week's feature steps back from the issues, strategies and programs usually explored in the OHPE Bulletin and looks to the foundations of health promotion practice - theories and models. This overview and introduction to the use of theory has been adapted from a distance education course for family support certificate students. The course and the article have been offered and authored by Lorraine Telford, a teacher at Ryerson University in Nursing, Occupational and Public Health and in Family Support; as well as an OHPE bulletin editorial team member.
A. WHY USE THEORY?
Theories are attempts to identify connections between things, and there are many ways to make sense of observations. No theory, framework or model is "right" or can explain everything in the work of health promoters.
David Seedhouse (1997) offers four reasons why health promoters should use theory:
1. Our work involves human values and biases, that is we are not "neutral."
2. What we do is not often done with explicit permission or consent, sometimes the participants can't say "no." (For example, posters on breastfeeding in a centre are for all to see, those who decide to breastfeed and those who do not.)
3. We are obligated to be explicit and accountable to the public we serve - to be able to explain our actions.
4. We must improve for "internal" reasons, for comparison, effectiveness, and efficiency - the theory, politics and ethics must be worked out.
He goes on to say they [theories] make our assumptions and biases more explicit, and they force us to have sound reasons for what we do.
Two kinds of theory are important for health professionals (Goodstadt 1999):
1. Theories that explain health status, health-related behaviours and health problems. It is important to recognize that theories about the cause of a problem do not necessarily tell us how to change or avoid the problem
2. Theories that explain or make propositions concerning how to influence or change health status, health-related behaviours or health problems-these change/influence theories are derived from the social sciences (i.e., psychology, sociology, anthropology, political science, etc.). These theories are especially important and useful in helping us plan, design and implement interventions (i.e., programs, policies and services) to reduce problems and promote health.
There is a vast array of such change/influence theories to draw on. The challenge to health promotion professionals is to identify and combine the strengths of these different theories in an appropriate way.
B. FRAMEWORKS OF CHANGE AND THEORIES TO CONSIDER
This section examines some frameworks of change in human behaviour which may be useful to health promotion practitioners, particularly those in family support programs.
For reflection some theories relevant to individual and social change are discussed. While reviewing them, think of them in light of what you do every day.
For example, think about a specific person you've helped, or a program you know of - what were the explicit or implicit goals for the intervention(s)?
While you read this, focus on the intended outcomes, and how the theory helps you determine next steps that get to these outcomes.
Be critical: if the theory doesn't help much, make note of it - some theories are better for some kinds of change than others.
The frameworks noted in this article, or others you may be aware of, can be used in designing interventions and programs. To do so, you must have as much knowledge about the participants in the intervention or program as possible - what they currently believe, know and do (for example, what stage of change are they at). You need to know what has been tried before and what works.
C. HOW DO WE MAKE CHANGES?
Think of an important decision you made recently, or perhaps a personal change you undertook (successfully or not). For example, you may have decided to be clearer about when you can talk on the phone with your children while at work. Write it down on a paper:
Recently, I decided to.
What circumstances contributed to the decision or change? Why did you make the change at that time, rather than sooner?
Write down the reasons for the change or this particular decision (try to identify all the factors at play):
How many of the factors in your reasons above are intrinsic (e.g. your own motivation, desire, will)?
How many appear to be from or influenced by your immediate environment (e.g. your family, co-workers, friends)?
And are other factors broader in scope (such as life circumstances, community changes, etc)?
If the change has been going well, (or the decision seems to have been a good one) identify what has helped or worked about it. If the change has been going poorly (or it was a bad decision) what didn't work, or didn't help?
Answer the questions: What helped? What didn't help?
It is likely that with a broad examination of the change or decision, there are intrinsic and extrinsic factors at play. Individual motivation is part of the change, but did it come first? Social change theories point to the parts BEFORE the cognitive decision to change is made. It also identifies the supports required to maintain the change. In your decision or change, were there many influences on how the decision or change went? Do these influences point to supports needed AFTER the decision is made, or not?
In addition to your personal example, and others from your experience in health promotion, identify a program example to think about for the rest of this Bulletin.
D. INDIVIDUAL AND SOCIAL CHANGE THEORIES
Change theories take into account what happens before, during and after a decision to make a change happens.
Some changes are made by individuals, and some are made because of the influence of groups and networks, organizations and society itself. Flora, Maibach, and Maccoby (1989) describe these levels in depth, with numerous examples of media interventions as the main tool.
Feather (1994) presents Green's PROCEED-PRECEDE models related to health promotion in populations. In these models, it is clear that multiple influences on a person are at play at any given time. If this is so, multiple strategies must be considered to have changes become a reality and be sustained. The most successful programs and services involve multiple approaches aimed at several levels or systems. An earlier OHPE Bulletin - (#53.1 in May 1998) on "Intervention Mapping" explored the integration of theoretical models in the planning of health promoting activities, using multiple theories and approaches at one time.
And now, some theories!
i) - Developmental
The following focus on the family models is for purposes of brevity, assuming they may be less familiar to health promoters than child/individual developmental stages. Rosen (1990) discusses the history, characteristics and merits of the Family Life Cycle Framework. Carter and McGoldrick's stages/life cycles offer a useful model for working in interpersonal support or mutual aid situations.
Understanding the developmental stage(s) in which a family is in, and which challenges exist for that stage, should influence the intervention strategies. For example, in working with young women around body image issues, addressing the mother-daughter relationship is necessary. But focusing on it too much would not work for teens wanting increasing autonomy. The model would inform us it would be best to use many non-family examples in discussions with these teens and young adults.
ii) The Health Belief Model (HBM)
The health belief model has been widely adopted in the health education field and beyond.
"It is now believed that individuals will take action.. if they regard themselves as susceptible.., if they believe [there are] potentially serious consequences, if they believe that a course of action available to them would be beneficial in reducing either their susceptibility to or the severity of the condition, and if they believe that the anticipated barriers to (or costs of) taking the action are outweighed by its benefits" (Rosenstock, 1990 p. 42-43)
Rosenstock (1990) acknowledges the importance of the demographic and sociopolitical and structural forces on an individual's perception. He explicitly downplays the role of "motive" (1990 p. 44). Fear (as in susceptibility) and the notion of self-efficacy are described as closely intertwined. Furstenberg and Rounds' (1995) paper is about one construct, self-efficacy, as key to individual change.
iii) The Stages of Change Theory
Closely related to the development model is a model to address specific change. The Stages of Change model was developed using qualitative research methods and a grounded theory approach. Through these methods, five stages of individual change emerged. From the use of the Stages of Change model, it is known that interventions for people at different stages of change require different information and types of support. (Prochaska & DiClemente, 1982)
The processes "behind" the stages that lead to behaviour change are identified as:
* Pre-contemplation "Ignorance is bliss"
* Contemplation "Sitting on the fence"
* Preparation "Testing the waters"
* Action Practicing new behavior for 3-6 months
* Maintenance Continued commitment to sustaining
* Relapse "Fall from grace"
Again it is clear that knowledge alone does not change behavior. Policy and environmental supports are needed.
iv) Social Cognitive Theory
Rosenstock, Strecher and Becker (1988) briefly describe the originally-named "social learning theory" (now SCT) and compare it to the HBM, highlighting the importance of a) the multiple sources of individuals' expectancies and b) the importance of "expectations of self-efficacy" (p. 177). This theory might be more appropriately a "interpersonal level" theory rather than an individual-level theory of change (National Institutes of Health, http://rex.nci.nih.gov)
Thompson and Kinne (1990) have a model called Social Change Theory. They involve a discussion of the construct of change, and those familiar with systems theory would see a natural fit with this theory. These authors also reinforce the notion that social networks, organizations and society as a whole are part of people and therefore part of individual change.
Three other community-level theories for change, which include the network, organizational and societal levels, are discussed in a section of the National Institutes of Health (NIH) document on theories in health promotion practice. Three are succinctly presented in the NIH resource - Community Organization, Diffusion of Innovations Theory and Theories of Organizational Change. See the Resources message or go to http://www.nci.nih.gov/cancerinformation/theory-at-a-glance
Diffusion is briefly discussed here. This is because Rogers (1995) has now a fourth edition of his articulation of the process by which new ideas spread within human society. Valente (1995), once a student of Rogers', has gone further and developed the theory into the way networks have a role in diffusion - "Network Models of the Diffusion of Innovation." It is a complicated series of studies, but the simple knowledge is this: one does not have to reach everyone to have an impact. One can find the key opinion leaders, work with them and support them, to have the reach be far and wide. One could say that family knowledge transfer and family behavioural influences are highly dependent on informal networks.
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There are more theories than are presented here! For example, the Theory of Reasoned Action, Social Expectation, and more. But the idea here is to appreciate what is known about how people make changes, and to take this into account when developing community programs for individuals, groups, and families. Each theory can be used as a lens that gives a different perspective. Different theories can be applied to the same situation producing different interpretations. When one considers many perspectives in planning, the possibilities increase.
It may not be possible or desirable to apply ONE design to any initiative, but it is hoped this brief, and hopefully simple review provides a reminder of the models to apply that will facilitate the greatest change for unique individuals in unique groups.
By Lorraine Telford, M.N. email: email@example.com
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