applying theories and models …to community nutrition programs and strategies

Applying Theories and Models

…to Community Nutrition Programs and

Strategies

Theories & Models of Health Behaviour

We will explore:

Factors that influences our food choice behaviours

Theories & models of health behaviour Community & System level change

strategies (Community Development, Social Marketing, Policy)

Food Choice Behaiours

READ Raine, K. (2005). Determinants

of healthy eating in Canada. An overview and synthesis. Can. J. Public Health, 96, suppl 3, S8-S14.

Personal Food Choices

Physiological factors

Food Preferences Nutritional

Knowledge Perceptions of

Healthy Eating Psychological

Factors

Personal Food Choices?

Environmental Factors Interpersonal influences Physical environment Economic environment Social environment

Creating Supportive Environments - Policy

Food Choices Food choices, eating behaviours and

resulting nutrional health are influenced by a number of complex and inter-related individual, collective and policy-related determinants.

A growing body of research is supporting the relationship between food preparation and cooking skills and food choices of children and adolescents within the family context.

Health Canada, Improving Cooking and Food Preparation Skills, 2011

Food Choices Diet quality of youth related to

frequency of family meals AND involvement in food prep

Taste, nutritional value, cost and time Main factors behind food choice & prep

decisions ACROSS SES groups Low SES report cooking from

‘scratch’ more often AND use of fewer convenience foods

Health Canada, 2011

Best Practices for Interventions

Theoretical basis clear Or minimally based on set of

“defendable community-relevant assumptions”

Experiential/hands-on learning Promotes self confidence through

skill development Include self-assessment of

eating patterns & behaviour change tracking

Health Canada, 2011

Best Practices

Tailored for specific population group

Based on measurable, specific goals

Longer vs. shorter duration programs Provide reinforcement & motivation

Health Canada, 2011

What are food skills? Knowledge

Food safety, label reading, ingredient substitution

Planning Organizing menu, food prep within budget,

teaching children food skills Conceptualizing food

Creative use of leftovers, adjusting recipes Mechanical techniques

Following recipe, chopping, mixing, etc. Food Perception

Using senses, when foods are cooked

Rural Restaurant Customers Preferences

Options most likely to order if available Broiled or baked

meat WW bread Fresh fruit Steamed veg Regular salad

dsg on side

Options least likely to order if available Low-fat sour cream Low-fat salad dsg Low-fat milk Low-calorie dessert Request to hold

high fat ingredients

Income & supplement use Lower income adults less likely to

consume vit/min supplements Higher education linked to greater

supplement use Lower income

Food insecure & poorer diet quality May need supplements most

Findings suggest need for improved access to supplements for lower income

Whiting, Adolphe, & Vatanparast, Oct 2009, DC Current Issues

Food Choice Behaviours

Knowledge behaviour

Food Choice Behaviours Values

Permeate our lives; define who we are & where we stand; learned from socialization (Vanden Heede, et al., 2006)

conception of what is desirable & undesirable Beliefs

conceptions of reality & propositions about how the universe works

Norms principles, rules or standards for behavior - they are

people’s conception of what should occur in a given situation

Culture a guide for behaviour a mental map

Theory

a set of interrelated concepts, definitions, and propositions presents a systematic view of events

or situations by specifying relationships among

variables in order to explain or predict the

events of the situations.

Theory Used as a guide:

WHY people are/are not following health advice

WHAT you need to know before developing or organizing an intervention program

HOW you shape program strategies to reach population and make an impact

WHAT should be monitored, measured, and/or compared in the program evaluation

Theory

Helps us understand behavior Explains dynamics of behavior Explains process for change of behavior Identifies target for programs Identifies methods for accomplishing

change Theories and models EXPLAIN behavior

and SUGGEST ways to achieve behavior change

Theory

Keep in mind that more than one theory may be used to address an issue

No single theory dominates community nutrition activities

Theory Designing interventions for eating

pattern changes can best be done with understanding of relevant theories and of dietary behaviors change and an ability to put them into practice

(Glanz & Eriksen, 1993)

Theories therefore: Guide program development Provide foundation for evaluation

Model

Vehicle for applying theories Provides plan for investigating

or addressing a phenomenon Only represents processes;

does not attempt to explain them

Two models linking theory to practice Scientific model

Theory defined to deduce hypotheses that are tested with experimental research design

Requires replication by practitioners of exact process to find the ‘truth’

Humanistic model Theory define to seek to clarify social values Practitioners use theory to stimulate

dialogue about “eating habits in living the kind of life that community members find most valuable.”

Buchanan, 2004, JNEB, 36, 146-154.

Theories and models

Intrapersonal level (Individual) Stages of Change (TTM) The Health Belief Model Theory of Reasoned Action

Interpersonal level Social Cognitive Theory

Community and group level Diffusion of innovations

Transtheoretical Model (TTM) – Intrapersonal Developed by Prochaska &

Diclemente Stages of Change Model

Transtheoretical Model (TTM)

Focus Person’s readiness to change or

attempt to change toward healthy behaviour

Transtheoretical Model (TTM) Assumptions

Behaviour change involves series of stages or steps

Common stages across variety of health behaviours

Tailor interventions to be most effective

Encourages us to think about client’s readiness to change

Transtheoretical Model (TTM) Precontemplation – unaware or not

interested in making change Contemplation – thinking about taking

action - next 6 mths Preparation – active decision to change

and planning Action – trying to make change for

<6mths Maintenance -has sustained change for

>6mths Termination – no temptation and 100%

self-efficacy

TTM

Self Efficacy confidence in ability to change

behaviour & to withstand temptations to relapse

Decisional Balance pros and cons of change how an individual perceives these

Decisional Balance

Pros of Change

Cons of Change

Pros of No Change

Cons of No Change

TTM Applications

Intervention strategies should be matched with processes commonly used in particular stage of change cognitive processes used in pre-action

stages Seeking information

behavioral processes used in Prep, Action and Maintenance

Seeking ways to strengthen behaviour

TTM Applications

TTM originated with addictive behaviours research e.g., smoking cessation

Dietary change involves complex combination of removal of one set of behaviours & acquisition of new set of behaviours

Measurement of definite stage of change is more difficult

TTM – use to increase V/F intake in preschool children

Low-income parents & primary caregivers (N=238)

Incorporates staging algorithm for increasing V/F accessibility to PS children, decisional balance, self-efficacy

Hildebrand, & Betts, 2009; JNEB, 41(2), 110-119

TTM – use to increase V/F intake in preschool children Precontemplation/Contemplation (43%)

Best to use methods to share ideas for planning meals and snacks to include V/F

Preparation (29%) Aim to build skills in making quick &

economical V/F Stress parent role-modeling Encourage goal setting

Action/Maintenance To prevent relapse, build in social support

in all learning formatsHildebrand, & Betts, 2009; JNEB, 41(2), 110-119

TTM with low income parents & caregivers Caregivers assessed for stage of

change for increasing V/F access for PS children

43% precontemplation/contemplation 29% preparation Those in action & maintenance

Showed higher self efficacy u Used more behavioral processes

Interventions should be tailored to stage of change Cognitive vs. behavioural

Hildebrand, & Betts, 2009

Health Belief Model - Intrapersonal

Hochbaum, Rosenstock and Kegel - 1950s

to explain why people would/would not use health services

Health Belief Model - Intrapersonal

Focus Person’s perception of a health

problem & appraisal of recommended behaviour to manage or prevent the problem

Health Belief Model – Three Components1. Perception of threat to health

personal threat to health concerned that ‘disease’ carries serious

personal consequences2. Outcome expectations

perceived benefits and barriers to taking specific action

3. Self-efficacy belief that one can make a behaviour change

Other factors affect perceived threat, outcome expectations & efficacy expectations

Thus, factors influence health behaviour indirectly

Using Health Belief Model

Include skill-building components increase self-efficacy

Be aware of times of increased threat perception ↑ likelihood of change

Identify barriers to action develop strategies for helping

clients overcome barriers

Theory of Reasoned Action – Intrapersonal Ajzen and

Fishbein

Behaviour determined directly by intention to perform the behaviour

Theory of Reasoned Action Intention

Instructions given to self to behave in certain way

Consider behaviour outcomes & opinion of significant others when forming opinions

Intentions influenced by attitudes and social pressures to perform (subjective norms) Perceived social pressure to perform or

not perform a behaviour

Theory of Trying - Intrapersonal Developed by

Bagozzi Modified Theory

of Reasoned Action

Theory of Trying

Added components that influence intention to try behaviour: past experience (success or

failure) with behaviour mechanisms for coping with

behaviour outcome emotional responses to process

Application of Theories to Practice

Self-assurance seems linked to successful behaviour change self-esteem self-efficacy

Application of Theories to Practice

Could screen clients upon program entry degree of readiness to change degree of past success degree of confidence in ability to

change level of commitment to program

Social Cognitive Theory Developed by

Bandura to explain how

people acquire & maintain behaviours

SLT = Social Learning Theory

Interpersonal Model – Social Cognitive Theory

EnvironmentalFactors

Internal/PersonalFactors

Behavior

(Bandura, (Bandura, 1972)1972)

Social Cognitive Theory

Strength focus on target behaviours rather

than attitudes & knowledge Key concepts and their

implications Table 15-3, page 487

Interpersonal level applications Small Groups

Supplement or substitute individual counseling

Social Support Interacting with positive role models and

problem solving through discussions with people with shared problems

Peer Education Effective at enhancing observational learning

through role models Youth and cultural minority groups

Interpersonal level applications

Point-of-purchase nutrition information Guide food selections in food

establishments, i.e., supermarkets, cafeterias, restaurants

Information during decision making increase awareness and serve as reminder

Community & Group – Diffusion of Innovation

Rogers and Shoemaker, 1970s to explain how

product/idea becomes accepted by majority of consumers

Diffusion of Innovation

Focus Addresses how new ideas,

products & social practices spread within a society or from one society to another


Consists of 4 stages Knowledge Persuasion Decision Confirmation


Spread of innovations largely by word-of-mouth

Speed of diffusion is a function of number of people adopting

Consumers classified by readiness to adopt new innovation

innovators, early adopters, early majority, late majority, late adopters, laggards

Application of Diffusion of Innovation

Diffusion process facilitated by actions of different sectors

Barriers to adoption occur due to disruption of habitual routines

The greater the disruption, the slower the adoption

Knowledge-Attitude-Behaviour

Health Information

Calorie per calorie, whole fruit has more dietary fibre than fruit juice.

ADA position paper, Total diet approach to communicating food and nutrition information, 2007.

Health Belief Model Perceived benefits, threats, barriers

Whole fruits have fibre that helps me feel full. If I drink juice instead of eating whole fruit, I

would get less fibre and have a harder time managing my calorie intake.

That could lead to gaining excess weight which would make me feel less attractive.

However, I may not be able to eat whole fruit as often as I want to because it is easier to find fruit juice when I need something that’s fast and easy from a vending machine or a convenience store.

Social Learning TheoryTTM, & Health Belief Model

Self-efficacy I know that I can eat more fruit

and less juice by learning which fruits are in season and putting those fruits on my weekly shopping list.

Social Learning Theory

Reciprocal Determinism If the vending machines at my

office have fruit, I will be more likely to select it as a snack.

TTM Stages and Processes of Change

I realize that eating whole fruit is a good way to help me increase my intake of fruits & vegetables each day.

I also realize that I have been getting most of my fruit in the form of juice.

I will start buying more whole fruit and less juice the next time I go to the supermarket.

Community-level models

Frameworks for understanding how social systems function and change, and how communities and organizations can be activated


Essential for comprehensive community education

individuals, groups, institutions, and communities

Embody an ecological perspective Complement individually oriented behaviour

change goals with broad aims that include advocacy and policy development

Suggest strategies and initiatives that are planned and led by organizations and institutions,

i.e., schools, worksites, health care settings, community groups, and government agencies

Ecological Perspective Multiple

dimensions of influence on behavior

Interactions across dimensions

Multiple levels of environmental influences

Environments directly influence behaviors

Intra-personalfactors

Inter-personal processes and groups

Institutionalfactors

Communityfactors

Public policy


Community Organization Theories

Organizational Change Theory


Organizational Change theory Focus

Processes and strategies for increasing the chances that healthy policies & program will be adopted & maintained in formal organizations


Community Organization Theories

roots in theories of social networks and support.

Emphasizes active participation & development of communities that can better evaluate and solve health and social problems

Community Change: Key Concepts

Empowerment process by which individuals,

communities or organization obtain mastery over their lives to produce change

Community Competence Community sectors able to

collaborate effectively to engage in problem solving


Participation involvement of all community

members in planning, development, & implementation of programs in the community

Relevance starting where the people are;

beginning with the community’s felt needs


Issue Selection community’s ability to identify &

prioritize issues Critical Consciousness

Developing understanding of the root causes of a problem

Community Level Strategies

Community Development Community Capacity Building

Community Based vs. Community Development

Community based programming is the process of health professionals and/or health agencies Defining the health problem Developing strategies to remedy the

problem Involving local community members and

groups to assist in problem solving Working to transfer major responsibility for

ongoing program to local community members and groups

Labonte, 1993

Community Based vs. Community Development

Community development is the process of organizing and/or supporting community groups in their identification of important concerns and issues, and in their ability to plan and implement strategies to mitigate their concerns and resolve their issues.

Labonte, 1993

Characteristics of community-based

The problem name is given by the professional/institution

There are defined program timelines

Changes in specific behaviours or knowledge levels are the desired outcome

Decision-making rests principally with the professional/institution

Labonte, 1993

Characteristics of community development

The naming of the problem starts with the community group

Work is long term, requiring many hours

A general increase in the group’s capacity is the desired outcome

Power relations are constantly negotiated

Labonte, 1993

Capacity Building “the strengthening of the ability of

people, communities and systems to plan, develop, implement and maintain effective health and social approaches.” (PPHB Atlantic, Health Canada 2001)

“an approach to the development of skills, organizational structures, resources, and commitment to improvement in health and other sectors, to prolong and multiply health gains many times over.” (Hawe, 1999)

Capacity Building

Individual/Personal

Community

Organization

Systems

Society Level Strategies

Social Marketing Policy Change

Social Marketing

“ the use of marketing principles and techniques to advance a social cause, idea, or behaviour”

Vanden Heede & Pelican, 1995

Social Marketing

“…combines the best elements of traditional approaches to social change in an integrated planning and action framework, and utilizes advances in communications technology and marketing skills. It uses marketing techniques to generate discussion and promote information, attitudes, values and behaviors. By doing so, it helps to create a climate conducive to social and behavioral change.”(Health Canada, 2004)

Social Marketing Network http://www.hc-sc.gc.ca/english/socialmarketing/

Social Marketing Aim: to influence the voluntary

adoption of behavior change of the target audience

Uses consumer research i.e. demographics

Focus on conferring benefits & reducing barriers

Primary beneficiaries are the target audience, not the marketing body

The Marketing Mix

The 4 P’s of marketing: Product - the “bundle of benefits” Price - “cost” of the behavior change Place – benefits must be available at

the right place and the right time i.e., “the how” and “the where”

Promotion – methods used to raise awareness and provide education i.e., “the what”

The role of research…

Market research Developing demographic, behavioral and

lifestyle profiles Identifying existing behaviors, actions,

needs, perceptions, attitudes and perceived benefits/barriers of the target audience

Competitive analysis Identifying organizational and

environmental considerations that influence behavior change

Health Canada, 2004

Social Marketing CDC recommends social marketing to

achieve targeted public health goals Self-guided Web course (free)

Social Marketing for Nutrition and Physical Activity

http://www.cdc.gov/nccdphp/dnpa/socialmarketing/training/basics

Basics, problem description, Formative research, Strategy development, Intervention design, Evaluation, Implementation PLUS tips, worksheets, glossary and resources

Social Marketing Examples

Evidence that providing coupons for nutritious food to university students, low-income seniors, WIC participants (US) improved long term nutrition status

Linking communities with local farms & encouraging pick-your-own intitiatives increased V/F intake ? Reduced obesity risk

FOP Label Understanding Low-CHO claim FOP Only FOP claim seen

Rated low-CHO claim as more helpful to wt management AND lower in calories than same product without claim

Bread with low-cho claim rated more healthful

FOP claim with Nutrition facts panel Rated products with the same nt profile the

same with or without FOP claim Consumers who do not use the NF

panel may misinterpret FOP claims Labiner-Wolfe, Lin, & Verrill, 2010

Online Social Marketing Projects

Social Marketing: Nutrition and Physical Activity http://www.cdc.gov/nccdphp/dnpa/

socialmarketing/training/basics/ Self-guided web course in social

marketing of health Modules take about 15-30 minutes

to complete Tips, worksheets, resources, glossary

Ecological theory and social marketing

Behavior is influenced by a variety of factors. If…

They believe it will reduce risk (intrapersonal)

Their family requests it (interpersonal) Their employers offer a nutrition education

program (organizational) There is an availability of foods that can

reduce risk (community) There is improved product labeling (policy)

Lefebvre, 1995

Milk - some facts… Children main consumers but by teens

consumption reduced Nearly 90% teen girls and 70% teen boys don’t

get the calcium they need Osteoporosis affects 1.4 million Canadians

1 in 4 women and 1 in 8 men over the age of 50 $1.3 billion in health care costs

Milk viewed as high fat & associated with high fat foods

Low fat milk perceived as lower in nutrients

Goeree 1996, Hanley and Josse 1996, NIH Consensus statements 2000

The got milk? program

History of got milk?

In 1993: California Milk Processor Board (CMPB) formed Aim: to make milk more competitive

& to increase consumption in California

Initial target: women aged 25-44 Initial position: skim milk was

healthy for adults

1994: milk consumption in California increased 1%

1995: the got milk? campaign was licensed to the National Dairy Board

1996: billboard ads 1998: Birth of the milk mustache 1999: gotmilk.com born


2000: ads promote chocolate milk 2002: California milk sales

increase 1.6% since 2001 Californians used 746 million

gallons of milk in 2002, the highest since 1992

2003: McDonalds McHappy Meals include milk


History of got milk? By 10th anniversary: Over 95% of Americans recall campaign Spawned hundreds of got milk? rip-offs Has become a multi-million dollar licensing

property Helped defend milk’s share of beverage

consumption in California & the US Dairy industry spends $150 million annually to

support campaign Industry worth $2 billion in California & $20 billion

nationally Competition: products such as Coke and Pepsi and

more recently calcium enriched beverages

4P’s of got milk?

Product: e.g., milk provides vitamins and minerals to aid in the prevention of osteoporosis

Price: resources needed to drink milk Place: magazines, billboards, TV

actual milk: stores, schools, fast food

Promotion: via ads, media campaign, web site

Why television ads?

To reach people in their homes Less than 5% of all milk is

consumed outside the home Aim to get people to “reach for

cookies and milk instead of chips and soda”

Started in 1994 and in 2 years there was a 91% awareness rating

Evidence its reaching the public (Evaluation)

In July 2002 press release: Milk intake increased for the first time in 6

years Soft drink still number one for those 13-17 y Flavored milk big hit Per capita milk consumption among teens in

2001 was 22 gallons, 3% increase increased to 23.5 in 2002

Teens that drink milk get 34.6% of their beverage intake from soft drinks and 29.7% from milk

Non-milk drinkers: soft drink-54.8%

Evidence its reaching the public (Evaluation) Milk Mustache Survey

36% women said the campaign would make them drink more milk

70% who viewed the entire campaign now consider milk cool and contemporary

86% thought milk was delicious after seeing the campaign

1% and skim milk consumption has increased, while 2% and whole has decreased

The campaign got over 60% awareness in just 3 months

applying theories and models …to community nutrition programs and strategies

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