maurice mittelmark nhprc2013

The influence of settings on well-being: 70 years of insight from Lewin and the war years

to the present

Maurice B MittelmarkUniversity of Bergen

Summary I

• Settings approach to HP has an ‘incomplete’ ecological orientation

– Person situated in an environment

– Intervene on the person and her environment

– Work at multiple ecological levels from person to policy

– Holistic view of health and well-being

– Systems understanding of settings

Dooris M (2001) Holistic and sustainable health improvement: The contribution of the settings-based approach to health promotion. Perspectives in Public Health, 129(1):29-36.

Summary II• Why is this orientation ‘incomplete’?

– Ecology directly related to the health problem in focus

– What can we do to the person and her environment to achieve our aims?

– Little interest in the person’s life in her natural environment

– We assume we are only doing good; not harming her or her environment

Summary III• A robust ecological orientation

– Deep ecological study of a setting before launching health promotion

– Understand the setting’s standing behaviour

– Develop interventions that respect the importance of standing behaviour

– Monitor for planned, unplanned and untoward effects

– Continue study of the setting’s ecology long after the intervention is over

What can we do to the person and

her environment to achieve our

aims?

What is our ecological interest in a setting?

• Settings approach “seeks to increase the sophistication with which knowledge about settings is moblized in the planning, implementation and evaluation of health promotion interventions.”

• To optimize the likelihood of success, careful stock must be taken of the local… context…”

• “Through a careful analysis of the intervention setting, [one] can forestall the possibility that a crucial oversight could … wash the project up, stall progress…”

• “A detailed analysis of the setting… can help practitioners skillfully anticipate and navigate potentially murky waters…”

Poland B, Krupa G, McCall D (2009) Settings for health promotion: An analytic framework to guide interventionDesign and implementation. Health Promotion Practice, 10(4):505-516.

Starting point in a robust ecological approach is to understand the standing behaviour of the

system

Not to examine how we can use some ecological features to our

advantage

What is the ecology of a human setting? I

• It is a habitat

– Biotic and abiotic system

– More or less open/closed

– Interacts with other habitats

– Biotic part is composed of one or more communities (species)

– Community members act and interact (standing behaviour)

– Community members fill specific, multiple niches (roles)

– Niches outlive members

What is the ecology of a human setting? II

• Outsider manipulation of a habitat

– Is ultimately done for the benefit of the outsider

– Always has unplanned and unexpected effects

– Some may be untoward

– Monitoring the habitation for planned and unplanned effects is a

sacred obligation

– Failure to respect and study the habitat’s ecology can lead to

disaster

Standing behaviour in a habitat (setting)

• ‘Behaviour setting’ contra ‘health promotion setting’

• A health promotion setting is composed of several behaviour settings

• Behaviour setting theory of Barker, Gump, etc.

– Gestalt psychology

– Field theory

– Psychological ecology

What is a behaviour setting?

Kurt Lewin, 1890-1944, Psychological ecology

• University of Berlin PhD 1914

• Wounded early in WWI

• University of Berlin, 1918-33– Gestalt psychology– Field theory– B = ∫ (p,e)

• Cornell, 1933-34

• University of Iowa & MIT, 1935-1947– Psychological ecology– Action research– Democracy and leadership– Organisational psychology– Race & religion sensitive training– Roger Barker his Post doctoral fellow 2 years

B = ∫ (p,e)• Social problem

• How to change food consumption during the time of war?

• Research problem:

• Why do people eat what they eat?

• Ecological insight:

• People eat what is before them

• Research question:

• How does food come to the table? What is the system?

• Understanding this is a prerequisite to designing intervention

Lewin K (1943) Psychological ecology. In: D Cartwright (ed.) Field Theory in Social Science. Social Science Paperbacks, London, 289-300.

Lewin K (1943) Psychological ecology. In: D Cartwright (ed.) Field Theory in Social Science. Social Science Paperbacks, London, 289-300.

Psychological factors

• Cultural availability• food for gatekeeper, husband,

children

• Meal suitability• no pizza for breakfast!

• Social meaning of the eating situation• Alone, family meal, banquet• Expectations of ‘eating group’

• Values• Expense, health, taste, status

• Perceived food needs• What is believed to be essential

• Perceived obstacles• Preparation time

Environmental factors & settings

B = ∫ (p,e)

The family meal is the behaviour setting

(not the dining room, the table, the food, the people)

Barber shop Barber setting

Barber setting Barber setting

This is an automobile, not a setting…

how many behaviour settings may it be a part of???

Transport setting

Meal setting

Entertainment setting

Sex setting

Behaviour setting

• Place plus people plus purposive, goal-directed behaviour

– Football game, church dinner, school examination, lunch in the canteen

• Laws of operation are not connected to the particular individuals in the setting

• The setting influences the behaviour of individuals

• Settings are socially and culturally constructed

• Behaviour settings contain more or less ecological resources vis-a-vis the number

of people in the setting

Behaviour settings exert influence on people’s lives

Roger Barker’s Responsibility Theory

(originally called Manning Theory or Undermanning Theory)

Roger Barker’s Responsility Theory

• A setting must do the same work regardless of the manpower available

• Undermanned settings make greater demands on each person

– Work harder

– Do greater and more important work

– Perform a wider variety of activities

– Have less sensitivity to own and others’ needs

– Settle for a lower level of maximum performance

Barker, R. Ecology and Motivation, in Marshall Jones (ed.), Nebraska Symposium on Motivation, University of Nebraska Press, 1960, 1-49

Roger Barker’s Responsibility Theory

• For each individual, undermanned settings produce

– Greater importance

– More responsibility

– Greater self-identity

– Lower performance standards

– Fewer tests for admission, new members eagerly accepted

– Greater insecurity

– More frequent occurrences of success and of failure

Barker, R. Ecology and Motivation, in Marshall Jones (ed.), Nebraska Symposium on Motivation, University of Nebraska Press, 1960, 1-49

Allen Wicker’s research of church size

Wicker AW and Kauma CE. Effects of a merger of a small and a large organization on members’ behaviors and experiences. Journal of Applied Psychology, 1974;59(1):24-30.

Small church member

Large church member

This type of ecological understanding rarely enters today’s

debate about which is best, small school or large schools

Hypothesis:

Merging of schools to produce more efficient learning environments may reduce students’ activities in the

non-classroom settings of a school

Willems EP (1967) Sense of Obligation to High School Activities as Related to School Size and Marginality of Student. Child Development, 38(4):1247-1260.

Ecological variables (school size) rival personal variables (students’ performance) in influencing behaviour

Small school

Under manned settings

Performers

Large school

Over manned settings

Non-performers

Wicker AW. Undermanning. Performances, and students’ subjective experiences in behavior settings of large and small high schools.Journal of personality and social psychology, 1968;10(3):255-261.

Absence ofInvolvement,Challenge, etc.

Involvement,Challenge, etc.

When we do interventions in settings to achieve our goals, we

should consider possible effects on others’ goals

1

We should take the ecological mind set that a well-intended intervention may have unintended and

untoward effects

‘Ecological surveillance’

2

A case:Unanticipated outcomes of crime prevention prograns

McCord, Joan (2003) Cures that harm: Unanticipated outcomes of crime prevention programs. ANNALS, AAPSS, May, 16-30

Joan McCord, 1930-2004Professor of Criminal JusticeTemple University

The Cambridge-Somerville (Mass,) Youth Study I

• Delinquency prevention, started in 1939

• 506 boys ages 5-13, in youth facilities

• Matched case design (age, SES, somatotype, temperament, plus)

• 253 Matched pairs randomised to treatment or control

The Cambridge-Somerville (Mass,) Youth Study II

• Treatment lasted about 5 ½ years

– Regular counsellor visits

– Academic tutoring

– Medical and psychiatric attention

– Youth groups (e.g., YMCA, Boy Scouts)

– Community activity programmes such as sports events

– Summer camps

The Cambridge-Somerville (Mass,) Youth Study III

• 98% of matched pairs located 26-30 years post treatment

• Tracked outcomes

– Law court records

– Mental hospital admissions

– alcoholism treatment records

– Death certificates

The Cambridge-Somerville (Mass,) Youth Study IV

• Results

– 150 pairs did not differ on the objective outcomes

– 103 pairs did differ on the objective outcomes

• Treatment group more likely to have convictions for serious crimes

• Treatment group died about two years earlier than in the control group

• Treatment group significantly more likely to be alcoholic, schizophrenic, depressed

– Adverse effects increased with intensity & duration of treatment

The Cambridge-Somerville (Mass,) Youth Study V

– Adverse effects increased for boys who went to summer camp

– The more summer camp visits, the more adverse the effects

• McCord’s conclusions

– The treatment was effective

– It had long-lasting effects

– The effects were entirely unintended, unexpected and untoward

The Cambridge-Somerville (Mass,) Youth Study VI

• McCord’s ‘diagnosis’

– Treatment imposed middle-class values on lower-class boys

– Treatment created dependency that was unfulfilled after end of treatment

– Treatment group suffered a labelling effect

– Disillusionment due to creation of unrealistic expectations for good outcomes

The Cambridge-Somerville (Mass,) Youth Study VII

• Behaviour settings analysis, summer camp

– Adverse effects increased for boys who went to summer camp

– The more summer camp visits, the more adverse the effects

The Cambridge-Somerville (Mass,) Youth Study VIII

• At summer camp, misbehaving boys had much unsupervised time

– Bragged about deviant exploits

– Bragging effects amplified by more frequent summer camps experiences

The Cambridge-Somerville (Mass,) Youth Study IX

• The ecological point

– Everyone ‘knows’ that summer camp is good for boys

– Therefore no need to monitor the summer camp as a behaviour setting

• Either before, during, or after treatment

– Only long term follow-up and a retrospective analysis revealed the untoward

association of the behavioural setting and the boys’ later deviant behaviour

Ecological surveillance

Behaviour settings

Activity settings

Social ecology

Psychological Ecology

Gestalt scienceEcological

science

Health promotion in

settings

Psychological Ecology

Behaviour settings

Activity settings

Social ecology

Psychological Ecology

Gestalt scienceEcological

science

Health promotion in

settings

Psychological Ecology

Is this realistic ?

• We barely engage in the ‘assessment’ phases

• Forced to take a ‘project’ mentality

– Short-term, firm beginnings and ends

• We are not familiar enough with Ecological Theory (ET)

– Have not used ET to analyse health promotion problems

– ET not seriously taught in our HP education programmes

– Our orientation to ET is weak

It will not be easy

3

Thank you