prof. frank snyder

MODIFIABLE RISK IN PREGNANCY & HEALTH BEHAVIOUR CHANGE: UTILISING THE THEORY OF TRIADIC INFLUENCE (TTI)

9/9/15 Frank J. Snyder, Ph.D., M.P.H. Assistant Professor of Public Health Department of Health and Kinesiology College of Health and Human Sciences Purdue University [email protected] 1

OUTLINE

o Introduction o History

•  Theory of Triadic Influence (TTI) • Health behavior approaches

o TTI in detail o Implications o Strengths/Limitations o Applications

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ACKNOWLEDGEMENTS

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Brian R. Flay, D.Phil. John Petraitis, Ph.D.

WHAT CAUSES HEALTH BEHAVIOUR?

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RELATED BEHAVIOURS

Successful, Happy, & Caring

Ci4zens

Risk Behaviours

Mental Health

Healthy Behaviours

Prosocial Behaviours

Illicit Medica4ons

Violent Alcohol in Pregnancy

Externalizing Behaviours

Stress Depression Health care

Physical Ac4vity

Nutri4on

Achievement

Connectedness

Law Abiding

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HEALTH BEHAVIOUR THEORY

o  Theory can help us understand behaviour and how to change it

o  Etiology Research •  Help understand the causes/determinants of a behaviour

o  Intervention/program research •  Guide the development of interventions •  Guide evaluation

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HISTORY/REFERENCES

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o  Flay, B. R., & Petraitis, J. (1994). The theory of triadic influence: A new theory of health behavior with implications for preventive interventions. Advances in Medical Sociology, 4, 19-44.

o  Petraitis, J., Flay, B. R., & Miller, T. Q. (1995). Reviewing theories of adolescent substance use: Organizing pieces in the puzzle. Psychological Bulletin, 117(1), 67-86.

o  Flay, B. R., Snyder, F. J., & Petraitis, J. (2009). The theory of triadic

influence. In R. J. DiClemente, R. A. Crosby, & M. C. Kegler (Eds.), Emerging Theories in Health Promotion Practice and Research (Second ed., pp. 451-510). San Francisco, CA: Jossey-Bass.

o  Snyder, F. J. (2014). Socio-emotional and character development: A theoretical orientation. Journal of Character Education, 10(2), 107-127.

A BRIEF HISTORY OF HEALTH BEHAVIOR APPROACHES

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o  Information (is knowledge power?)

o  Values

o  Problem-solving skills (knowledge + values = informed choice)

o  Ecological approach

ECOLOGICAL APPROACH

o  What is an ecological approach? o  An ecological approach targets multiple influences of

health (e.g., availability of alcohol, access medical clinics, price)

o  Involves long-standing changes to the physical, legal, economic, and social environments

o  Quite strong and enduring.

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PERSONAL, SOCIAL, AND ENVIRONMENTAL DETERMINANTS: THE THEORY OF TRIADIC INFLUENCE

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BEHAVIOUR

Intentions/Decision

Attitudes Toward Behaviour

Social Normative Beliefs

Self-Efficacy

Social skills Self management Self-efficacy

Expectancy theories

Attitude theories

Social Norms theories

Conformity theories

Theory of Reasoned Action Theory of Planned Behaviour

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PROXIMAL CORRELATES OF BEHAVIOUR

Environment IntraPersonal

Social Situation

ENVIRONMENT GENETICS

BEHAVIOUR

Intentions/Decision

Class Conflict Low SES, Anomie Social Disorganization Strain Theory (Merton) Radical Theories

Social Control (Elliott) Family Systems (Brooks) Peer Clustering (Oetting)

Biological theories Psychoanalytic theories Resilience (Garmazey) Personality theories Self-Control (Gottfredson & Hirschi)

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DISTAL CAUSES OF BEHAVIOUR PERSON-SITUATION-ENVIRONMENT (LEWIN, 1951)

LEVEL OF TYPES OF INFLUENCE

INFLUENCE INTRAPERSONAL SOCIAL SITUATION/ INTERPERSONAL

ENVIRONMENTAL/ ATTITUDINAL

ULTIMATE Biological theories Psychoanalytic theories Resilience (Garmazey) Personality theories Self-Control (Gottfredson & Hirschi)

Social Control (Elliott) Family Systems (Brooks) Peer Clustering (Oetting)

Class Conflict Low SES Anomie Social Disorganization Strain Theory (Merton) Radical Theories

DISTAL Personal competence Self-Esteem theories Self-Derogation (Kaplan) Personal control theories

Social attachment/bonding Social Development (Hawkins) Differential Association Social Learning (Akers, Bandura)

(General knowledge) Cultural Identity Values theories Motivation theories

PROXIMAL Social skills Self regulation/control Self-efficacy (Bandura)

Social Norms theories Conformity theories

Expectancy theories Attitude theories

Fishbein & Ajzen (TRA); Ajzen (TPB)

Feedback Systems Theories

A MATRIX OF THEORIES (PETRAITIS, FLAY & MILLER, PSYCHOLOGICAL BULLETIN, 1995)

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BEHAVIOUR

Intentions/Decision

Environment

Attitudes Toward Behaviour

Social Normative Beliefs

IntraPersonal

Self-Efficacy

Social Situation

GENETICS ENVIRONMENT

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THEORY OF TRIADIC INFLUENCE (TTI)

DECISIONS/INTENTIONS

SOCIAL SITUATION

BIOLOGY/ PERSONALITY

ATTITUDES TOWARD THE

BEHAVIOUR

CULTURAL ENVIRONMENT

SOCIAL NORMATIVE

BELIEFS

Trial Behaviour EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological

SELF-EFFICACY BEHAVIOURAL

CONTROL

Nurture/Cultural Biological/Nature Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream

15 BEHAVIOUR


SOCIAL SITUATION



BEHAVIOUR


SOCIAL NORMATIVE

BELIEFS



CONTROL


Values/ Evaluations

Knowledge/ Expectancies

Perceived Norms

Information/ Opportunities Interpersonal

Bonding Social

Competence Interactions w/ Social Instit’s Others’

Beh & Atts

Motivation to Comply

Skills: Social+General

Sense of Self/Control

Self Determination

1 2 3

7 8 9 10 11 12

13 14 15 16 17 18

4 5 6

19 20 21

22

23

Distal Influences

Proximal Predictors

Levels of Causation

Ultimate Causes

Social/ Personal Nexus

Expectancies & Evaluations

Affect and Cognitions

Decisions

Experiences

16 BEHAVIOUR


SOCIAL SITUATION



BEHAVIOUR


SOCIAL NORMATIVE

BELIEFS



CONTROL


Values/ Evaluations


Perceived Norms


Bonding Social


Beh & Atts




Self Determination

1 2 3

7 8 9 10 11 12

13 14 15 16 17 18

l

4 5 6

19 20 21

22

23

Distal Influences

Proximal Predictors

Levels of Causation

Ultimate Causes




Decisions

Experiences

a

b c d e

f

g h i

j k m n

o

p q r

s

t u v w x

17 BEHAVIOUR


SOCIAL SITUATION



BEHAVIOUR


SOCIAL NORMATIVE

BELIEFS



CONTROL


Values/ Evaluations


Perceived Norms


Bonding Social


Beh & Atts




Self Determination

1 2 3

7 8 9 10 11 12

13 14 15 16 17 18

l

4 5 6

19 20 21

22

23

Distal Influences

Proximal Predictors

Levels of Causation

Ultimate Causes




Decisions

Experiences

a

b c d e

f

g h i

j k m n

o

p q r

s

t u v w x

C F I B E H A D G

18 BEHAVIOUR


SOCIAL SITUATION



BEHAVIOUR


SOCIAL NORMATIVE

BELIEFS



CONTROL


Values/ Evaluations


Perceived Norms


Bonding Social


Beh & Atts




Self Determination

1 2 3

7 8 9 10 11 12

13 14 15 16 17 18

l

4 5 6

19 20 21

22

23

Distal Influences

Proximal Predictors

Levels of Causation

Ultimate Causes




Decisions

Experiences

a

b c d e

f

g h i

j k m n

o

p q r

s

t u v w x

Related Behaviour J

K

C F I B E H A D G

19 BEHAVIOUR

& Personality Biology

BEHAVIOUR

Values Evaluations

Bonding

Sense of Self

Environment

Social Skills

Self Determin-

ation SELF

EFFICACY

Social Competence

Decisions/ Intentions

Religion Culture

Perceived Norms


Others' Beh&&Atts

SOCIAL NORMATIVE BELIEFS Context

Social

DNA

ATTITUDES

Informational Environment

Cultural Knowledge Expectancies

Evaluations Values

Environment

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The TTI Developmental-Ecological System

P P S S

S

E

P

Eval

Behaviour

SNB Self Efficacy

Att Att

Intentions

Will + Skill Exp Mc NB

Know Value Social Bonds

Role Models Self-

Control Com-

petence

SNB

Values Environment

Knowledge Environment

ENVIRONMENT Situation Person

E E

DEVELOPMENT & TIME

Ultimate Underlying Causes

Levels of Causation

Distal Predisposing Influences

Proximal Immediate Predictors

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NCI MULTILEVEL EPIDEMIOLOGY

22 NCI MONOGRAPH

BRONFENBRENNER’S: SOCIOECOLOGICAL MODEL

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THE THEORY OF TRIADIC INFLUENCE ECOLOGICAL SYSTEM

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P P S S

S

E

P

Eval

SNB Self Efficacy

Att Att

Intentions

Will + Skill Exp MC NB

Know Value Social Bonds

Role Models

Self Control

Com- petence

SNB

Values Environment

Knowledge Environment

Cultural Environment

Social Situation

Personal

Affective/C

ontrol Sub-stream

s

Cog

nitiv

e/C

ompe

tenc

e S

ub-s

trea

ms

E E

Behavior TIME

Levels of

Causation

Ultimate Underlying Causes

Distal Predisposing Influences

Proximal Immediate Predictors

System Postulates 1,2,&3 1. Provides a meta-theoretical view

•  Higher order description and explanation –  Integrates multiple levels of organization

•  No one existing theory can provide a satisfactory description. It is a model

•  Certainly, no one variable can provide an adequate explanation

2. All behavioural choices are influenced by the interaction of genetic/nature and environmental/nurture factors

3. Each behavioural choice is influenced by a complex system of PERSONAL, SOCIAL and ENVIRONMENTAL factors

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THE THEORY OF TRIADIC INFLUENCE: Implications for Description and Explanation

System Postulates 4 & 5: 4. All three (triadic) streams of influence each have two

substreams (making 6 altogether): –  3 informative/cognitive/thoughts substreams –  3 control/affective/feelings substreams

5. All (sub)streams of influence flow from causes most distant (ultimate and distal) to causes closest to (proximal to) the behaviour of interest -- a cascade of multiple and interacting influences –  Proximal causes predict most behaviour –  Distal and ultimate causes help explain it

THE THEORY OF TRIADIC INFLUENCE: IMPLICATIONS FOR DESCRIPTION AND EXPLANATION

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System Postulates 6-8: 6. Most influences can be positive or negative

–  The more positive influences there are, the more likely positive behaviour

–  The more negative influences there are, the more likely negative behaviour

7. The most proximal control/affect factors have values (probabilities) that range from zero to one

8. Interactions across streams can increase or reduce risks/protection

– e.g., +sense of self can reduce risk in disorganized communities

-sense of self can increase risk in protective families +community/family forces can protect against -sense of self

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System Postulate 9: 9. Once a behaviour occurs, the resulting reactions and/or

experiences (thoughts and feelings) feed back to change the original causes

Reciprocal feedback occurs through all streams and levels

Engaging in a behaviour changes one’s attitudes, normative beliefs, and self efficacy It also changes one’s knowledge, relationships with parents and peers, and sense of self

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FEEDBACK ALSO SHOWN THIS WAY

B

I

E

Att SNB

P

SE

S

B

I

E

Att SNB

P

SE

S

B

I

E

Att SNB

P

SE

S

DEVELOPMENT & TIME 29

System Postulate 10: 10. The reactions to certain behaviours feed back to

influence the causes of RELATED BEHAVIOURS e.g., smoking and other drug use

Thus, causes and effects are in a continuous cycle: –  Mutually influential individual ßà contextual relations

Related behaviours have similar causes, with the more

distal causes being the most similar

- Less related behaviours (e.g., smoking and cycling) have fewer causes in common


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A single

behaviour Eg,

smoking

Two closely related

behaviours. Eg, smoking and drinking

Less and less related behaviours.

Eg, smoking, drug abuse,

sex, exercise.

E

S P

E

S P

E S P

E

S P E S

P

CLOSELY AND LESS RELATED BEHAVIOURS: ULTIMATE CAUSES MAY BE THE SAME, DISTAL PREDICTORS LESS SO

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o  OLD APPROACHES TO PREVENTION COULD NOT HAVE WORKED WELL

•  Resistance skills programs often focus on one social skill

•  Only a few recent programs include changing social normative beliefs

•  Informational approaches focus only on knowledge •  Values clarification approaches focus only on values •  Decision-making focuses only on the attitudinal stream

o  USE BEHAVIOURAL CHANGE STRATEGIES FROM ALL SIX SUBSTREAMS

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IMPLICATIONS OF THE TTI

The Big 3 Causes Of Behaviour

INTRAPERSONAL Genetic/Biological, Personality SOCIAL SITUATION/CONTEXT

Family, School, Friends SOCIO-CULTURAL ENVIRONMENT

Culture/Ethnicity, SES, Media Exposure, Social (Dis)organization

The 6 Causes Of Behaviour

Sense of self, self

determination, self control

General competence, social skills

Social attachment to (bonding with) family, friends,

school Observed (modeled)

behaviours & attitudes of others

Value of expected

consequences Knowledge of

expected consequences

Big 3 Self-Efficacy Social Normative Beliefs Attitudes toward the behaviour

Six Reasons for Behaviour Change

I really want to OR I can't help

myself I find it easier to

do than not to To please others -- Social acceptance Because "everyone

else is doing it" To improve myself (or my health) in

ways I value To avoid negative consequences or gain positive ones

6 Classes Of Strategies for Contextual Change

Improve group empowerment

Improve general/social competencies

Change sources and levels of social support

Change normative environnent, role models

Change the socio-cultural/

values environnent

Change the informational environment

6 Classes Of Strategies for Behavioral Change

Improve self control/image; Provide cues &

reminders

Teach, learn, practice

improved (social) skills

Increase social attachments; Provide/find

sources of social support

Model desired behaviour; Correct or alter normative

expectations

Teach cultural values, clarify or

(re)develop values/evaluations

Provide information, change expectations

Instruction in problem-solving and decision-making skills

Modes Or Channels Of Change

Individual counseling, small groups, schools; media for modeling and cues

Modeling and increasing opportunities in communities, schools, families and small groups, parent training, support groups,

Societal opportunities, legislation, policies, taxes, media, communities,

schools, health care systems

Causes, Reasons, and Strategies for Contextual and Behavioural Change

SOME LIMITATIONS

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o  Comprehensiveness à complexity o  Decisions? o  Defining certain variables (e.g. personality variables)

ETIOLOGY APPLICATION STRENGTHS

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o  Help coherently organize behavioural influences o  Structured outline of multivariate hypotheses

•  Mediation •  Moderation

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Bavarian et al. (2014). Using structural equation modeling to understand prescription stimulant misuse: A test of the Theory of Triadic Influence. Drug And Alcohol Dependence, 138, 193-201.

INTERVENTION APPLICATION STRENGTHS

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o  Importance of value-expectancy o  Encourage developers to use multiple options o  Helps anticipate size of program effects o  Helps point toward location of effects o  Encourages careful thought about appropriate target

audiences (interaction/moderation) o  Highlights the importance of ultimate causes and distal

influences o  Provides framework to evaluate and analyze


SOCIAL SITUATION

Values/ Evaluations




BEHAVIOR

Perceived Norms


Bonding Social

Competence


SOCIAL NORMATIVE

BELIEFS

Interactions w/ Social Instits Others’

Beh & Atts




Self Determination


CONTROL

THE POSITIVE ACTION PROGRAM: AN APPLICATION OF THEORY

Program Components: Family Classroom School Community

Self Concept

Self Mgmt: Time Talents Anger

Social & Emotional Health

Feeling Empathy

How to Treat Others

Comm. Skills

Conflict Resolution

How You Like To Be Treated

Health Info

Thinking Skills Creativity Decision- Making

BEHAVIOUR Snyder, F. J. (2014). Socio-‐emo7onal and character development: A theore7cal orienta7on. Journal of Character Educa1on, 10(2), 107-‐127.

4-H PALS PROGRAM

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o  NEW ETIOLOGY RESEARCH AND INTERVENTIONS NEED TO BE BROADER AND DEEPER, … •  But should not throw out all of the content of

traditional approaches •  Consider teaching multiple relevant skills •  Etiology research should consider multiple

influences on behavior •  Special interventions for high-risk groups •  Consider how to change broad sociocultural

influences – Train peer advocates – reduce sales/access (alcohol) – exposure on TV and in movies

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CONCLUDING THOUGHTS