PUBH 520 Assignment 8
Chapter 6, 7, and 8: behavior change at the intrapersonal, interpersonal and environmental levels
Dr. Michael Reger
PUBH 520: Health Behavior and Health Promotion in Public Health
Hi everyone! This week, we will apply the ecological model even more and talk more specifically about behavior change at the individual, interpersonal and environmental levels.
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Questions of the WEEK
What are the major theories at the intrapersonal level?
What are two key learning behavior theories?
What are the key components of the A-B-C Model of Behavior Change?
What are some salient concepts/theories at the interpersonal level?
What are the key components of social network structure?
How do social networks influence behavior?
What are some social-influence-oriented interventions?
What are some different types of environments?
What are some environmental interventions that have been conducted to change three specific behaviors (diet, physical activity, HIV/AIDS prevention)?
Our questions of the week include:
What are the major theories at the intrapersonal level?
What are two key learning behavior theories?
What are the key components of the A-B-C Model of Behavior Change?
What are some salient concepts/theories at the interpersonal level?
What are the key components of social network structure?
How do social networks influence behavior?
What are some social-influence-oriented interventions?
What are some different types of environments?
What are some environmental interventions that have been conducted to change three specific behaviors (diet, physical activity, HIV/AIDS prevention)?
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Intrapersonal level theories
Health Belief Model
Transtheoretical Model/Stages of Change Theory
Theory of Planned Behavior
Social Cognitive Theory
First, we will start talking about behavior change models at the intrapersonal level, including:
Health Belief Model
Transtheoretical Model/Stages of Change Theory
Theory of Planned Behavior
Social Cognitive Theory
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Health belief model
Perceived susceptibility
Perceived severity
Perceived benefits
Perceived barriers
Cues to action
Self-efficacy
So, among intrapersonal level theories of behavior change, we start with the Health Belief Model.
The Health Belief Model was originally developed in the 1950s by the US Public Health service to figure out why people were not using the free mobile X-ray screening for TB. In short, the model describes how an individual’s perceptions affect the likelihood that he will take health-related action. The model has 6 components. To help you better understand the model, I will apply the model to an example of an obese 25-year old woman who is not interested in engaging in physical activity.
Perceived susceptibility: If a person believes they are at risk or susceptible to the disease or outcome. EX: “Heart disease only happens to old people or men…why should I care?’
Perceived severity: If a person thinks the outcome has serious consequences. Ex: “Heart disease rarely ends in heart attack and even then, can’t you just have surgery?”
Perceived benefits: If a person thinks there are benefits to the desired behavior. EX: “Exercising now and starting this lifestyle now will play a big part in lowering my risk of heart disease.”
Perceived barriers: If a person thinks the benefits outweigh the barriers. EX: “I don’t have time to exercise…I just started this new job! I can’t afford joining a gym!”
Cues to action: If a person is exposed to factors that prompt action. EX: “My aunt died from heart disease at age 50. so maybe I should think about exercising now…”
Self-efficacy: If a person believes he/she can successfully carry out the action. EX: “I believe I can stick to an exercise plan and lose weight.” Self-efficacy is particularly important, because it may vary by the complexity of the behavior as well as the context (e.g. it is easier to have self-efficacy in skipping dessert after dinner at home versus at one’s favorite restaurant).
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Transtheoretical model/Stages of change theory
Now let’s talk about the Transtheoretical Model, or the Stages of Change Theory
An important part of this model is that people go through stages when making behavior change, rather than making a lot of changes at one time. Again, I will use the example of an obese 25-year old woman who is not interested in engaging in physical activity.
So we start with:
Precontemplation: This is when it is not even in the individual’s radar that they need to make any changes in their behavior. Action: Try to determine what the right time would be for the individual would be ready to change. ex: Let her know casually that there is a worksite wellness program. Maybe the right time to bring it up is when the she complains that she get out of breath when she walks from the parking lot to the office.
Contemplation: The individual actively thinks about the health risk and what they need to do to reduce their risk. However, he/she doesn’t actually plan any behavior change. Action: Highlight some of the short-term benefits of exercise, rather than long term benefits (preventing chronic disease)—maybe being able to walk without getting out of breath, being introduced to a new fun sport/social activity with worksite wellness, losing weight, feeling better and having more energy, stress relief. Also, make sure you record the baseline info (how much does she exercise now—ask her to keep a log for 1-2 weeks of current activity)
Preparation: This is when the individual actually makes a plan for change and sets a timetable. Actions: Help her develop some feasible, measurable goals—exercise 15 min a day on treadmill, twice a week…try this out for 1 month and then increase intensity. Also, help her avoid things that may get in the way of the behavior—e.g. eating a heavy meal and then feeling sleepy, not getting enough sleep the night before. Also, offer other support like peer support through the worksite wellness program.
Action: The person actually makes a MEANINGFUL behavior change, but there is a chance he/she may relapse to old habits. Action: Give positive reinforcement for change (incentives/prizes for participating in worksite wellness program or losing certain amount of weight), give positive feedback and support and also know that she may get frustrated and stop exercising. Also emphasize social support/peer support and take things one day at a time
Maintenance: The person basically incorporates the desired behavior into permanent lifestyle change. If they are working on stopping a negative behavior (e.g. smoking), we would want him/her to attain termination of the behavior completely. Action: Reinforce methods for exercising—e.g. how she can continue exercising regularly after worksite wellness program ends; what kinds of things should she keep avoiding that keep her from exercising; what kind of social support does she need to keep exercising (e.g. exercise buddy)?
Further, we have to keep in mind that individuals may not progress through the stages in a linear fashion; people may move in and out of various stages and relapse to previous stages. We also need to think about one’s readiness to change and how it is related to the type of behavior we are trying to change. For example, quitting smoking is pretty clear-cut, but trying to lose weight is multidimensional. Therefore, one may be ready to reduce caloric intake but not ready to exercise regularly.
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Precontemplation
Actions: Prognosticate
Contemplation
Actions: Motivate change
Preparation
Actions: Plan change
Action
Maintenance
Actions: Reinforce change
Actions: Maintain change in order to reach termination
Theory of planned behavior
Then, we have the Theory of Planned Behavior—this is the idea that behavior is basically determined by intention. And what is intention influenced by? One’s attitudes about the behavior, beliefs about whether people important to him approve or disapprove of the behavior, and belief about how much control he has over performing the behavior.
Attitudes toward behavior is determined by behavioral beliefs (exercising at a younger age will prevent heart disease in the long run) and evaluation of behavioral outcomes (I don’t want to get heart disease).
Subjective norm is determined by normative beliefs (my family and friends would approve of me exercising) and motivation to comply (I care about what other people think…).
Perceived behavioral control is determined by control beliefs (beliefs pertaining to facilitators or impediments to engaging in desired behavior—e.g. “I hate getting all sweaty when I exercise, and I hate when my heart races”; “Having an affordable gym nearby is convenient so that I can stop by after work to exercise”) and perceived power (perception of how easy or difficult it is to engage in behavior given the facilitators and impediments—e.g. “The gym is affordable and on the way home from work, and I can start slow with the exercise so that my heart just doesn’t start racing and so I don’t feel uncomfortable”).
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BEHAVIOR
Behavioral intention
Attitude toward behavior
Subjective norm
Perceived behavioral control
Behavioral beliefs
Evaluation of behavioral outcomes
Normative beliefs
Perceived power
Control beliefs
Motivation to comply
Social cognitive theory
Self-efficacy
Observational learning (modeling)
Expectations
Expectancies
Emotional arousal
Behavioral capability
Reinforcement
Locus of control
Reciprocal Determinism
The final intrapersonal theory we will discuss is the Social Cognitive Theory, which originates from Social Learning Theory and basically focuses on the interactions between individuals and their systems as a way to promote behavior change. Basically, it states that changing behaviors requires us to understand cognitive and personal factors (knowledge, skills, attitudes), environment cues or events (peer influence, family support, neighborhood characteristics, work and school environment) and then the interaction between these things.
So it basically uses this concept of reciprocal determinism, which means that there are interrelationships between person-related factors, their social environment, and the health behavior. And if you change one thing, you can essentially change them all somehow. So if you change someone’s attitudes about exercise, they may exercise and then this may get them to start hanging out with healthier peers or they may become role models for their families or friends to also change their exercise behavior
So the social cog theory involves 8 factors:
Self-efficacy – person related factor, belief is one’s ability to take action—I CAN adopt an exercise program
Observational learning (modeling): learning by watching others in their social environment—my co-worker Michelle has started exercising regularly and has kept up with it for a year
Expectations – likely outcome of a certain disease – Exercising will help me lose weight, relieve stress, meet new people, and have good long-term health
Expectancies – the value placed on the outcome of the behavior—losing weight and relieving stress are really important so that I can look and feel better
Emotional arousal – emotional reaction to a situation—when I exercise, I feel better—endorphins are released
Behavioral capability – knowledge and skills needed to engage in the behavior – I need to see what affordable exercise programs there are in my area, or I need to find out where there are available walking or biking trails in my area, I need to learn the best type of exercise I should do to lose weight quickly
Reinforcement – rewards or punishments for performing a behavior—When I don’t exercise, I am too lazy to hang out with my friends; when I do exercise, I look more attractive and am more energetic and people want to be around me
Locus of control – belief of personal power over events – Only I can make myself exercise; I have control over my own actions
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Behavior
Environment
Person
Learning theories
Classical conditioning
Operant conditioning
Now that we have discussed how people may change their behavior at the intrapersonal level, we also need to consider the ways in which people tend to learn. There are two key learning theories, which you have probably heard of before: classical conditioning and operant conditioning.
Classical conditioning: This was first discovered by Ivan Pavlov and explains the process of frequently pairing a stimulus with an emotional or behavioral response. For example, the act of smoking can be paired with feelings of relaxation after repeated “smoke breaks” in which the person steps outside a hectic office to have a cigarette. Therefore, when a person feels stressed or wants to take a break, the first thing that may come to mind is smoking.
Operant conditioning: This is learning that occurs as a result of rewards or punishment for behavior. When a person performs a certain behavior that results in a positive consequence (reward), he or she will be more likely to do the behavior again. This is called reinforcement, or the process of increasing or decreasing a specific behavior using a system of consequences. For example, when someone goes one week without smoking, positive reinforcement would be putting all the money they saved not buying cigarettes to go shopping for something fun at the end of the week. This positive reinforcement may make it more likely for the person to stick to their smoking cessation program.
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A-b-c Model
Antecedents
Identify triggers for behavior
Behavior
Consequences
Identify consequences that increase, maintain, or terminate behavior
Behavior Change
Interventions to modify antecedents
Interventions to modify consequences
Basic Behavioral and Social Science Research (b-BSSR)
Further, we know that theories of behavior change provide proposed explanations and models of health behavior, but the disciplines of basic behavioral and social science contribute more empirically based proposals for mechanisms and processes of behavior change. Thus, the NIH has adopted a basic Behavioral and Social Science Research (b-BSSR) to incorporate basic sciences for more effective clinical and PH interventions. The classic model of intervention using b-BSSR approach is the Antecedent-Behavior-Consequence (A-B-C) model. Based on basic behavior science of behavioral conditioning, learning and motivation, this model emphasizes causal relationships between antecedents, consequences and behaviors.
Antecedents come before the behavior of interest and serve as triggers for that behavior. These triggers may be environmental (e.g. for eating unhealthy food, they could be advertisements, sales on unhealthy food), sensory (e.g. smell of food, appetite), emotional (e.g. boredom, loneliness, depression, happiness), intrapersonal (e.g. belief state), or interpersonal/social (e.g. friends going out to eat).
Consequences that follow a behavior serves as a reinforcement, which increases or maintains the behavior that follows. Here is where positive reinforcement or rewards come in. Reinforcement can also be negative, which means you remove an aversive stimuli after the desired behavior (e.g. reducing insurance premium after smoking cessation). Also, punishments can be used if the person does not do the desired behavior (e.g. increasing the insurance premium if failing to quit smoking).
Basically, the figure shows us that we can work to change behavior by developing interventions to modify the antecedents/triggers of behavior or interventions to modify the consequences of behavior. In turn, all of these interventions are, of course, informed by b-BSSR.
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Interpersonal level concepts
Social Cognitive Theory
Social identities
Social Comparison Theory
Diffusion of Innovations Theory
Social capital
Now’s let’s shift gears and talk about some salient concepts and theories at the interpersonal level. We know that the opinions, thoughts, behaviors, advice, and support of those around us—including peers, family members, friends, coworkers, sex partners, health professionals, and others—influence our behavior and ultimately, our health. Concepts/theories at the interpersonal level include:
Social Cognitive Theory: This theory is applicable at both the individual and interpersonal levels as it contains components from both of these levels. I have already gone over this theory in this lecture. At the interpersonal level, the components of modeling and reinforcement given by members of one’s social networks (e.g. praise, membership into certain social group, etc.) are relevant. Also, the backbone to the SCT is reciprocal determinism, which is the dynamic interaction between the individual and the environment in which they continually influence each other (adjustments in the environment cause changes in the individual and their behaviors, and the adoption of new behaviors can cause changes in the environment and the individual).
Social identities
Social Comparison Theory
Diffusion of Innovations Theory
Social capital
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Social identities
Further, we have found that social identities may have powerful influences on behavior. When individuals identify with a group, the collective group concept becomes part of their self-concept. Then, the self is redefined and the individual’s behaviors become more like the group’s goals and actions. Therefore, if you can change the group norm to engage in a healthier behavior, then individuals within the group may be more motivated to adopt this behavior as part of their social identity. Social identity may be linked to membership in groups, neighborhoods, professions, sports teams, ethnic identity, and behaviors.
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Collective group concepts (goals and actions)
Self-concept
Social comparison theory
Next, it has been proposed that an individual’s attitudes and behaviors are influenced by reference groups, which are clusters of people that serve as reference points for behaviors and attitudes. People look to other people in their social environment as a guide to what constitutes appropriate behavior. According to the Social Comparison Theory, individuals not only look at the behaviors of others as a guide, they also COMPARE their own behaviors to those of others. In other words, through observing others’ behaviors and comparing their own actions, norms about which behaviors are appropriate for a given social environment emerge. Also, the most important reference group is one’s social network. For example, adolescents are more likely to smoke if their peers also smoke and especially if an important social network member (best friend, boyfriend, girlfriend) smokes.
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Individual Attitudes and Behaviors regarding smoking, eating and exercising
Reference group for smoking behavior
Reference group for eating behavior
Reference group for exercising behavior
Diffusion of innovations Theory
Next, we have the Diffusion of Innovations Theory. The diffusion of innovations theory is a widely used theory of behavior change at the population level. This theory focuses on how to promote a new idea or practice (an innovation) in a population—the theory includes the innovation itself, the communication channels used to get information about the innovation to the population, the time it takes to adopt the innovation, and the social system in which this all takes place.
Innovation: This is an idea, practice, or object that is new or perceived as new by your target audience (E.g. the HPV vaccine for teens). Things to consider with an innovation are its relative advantage (the extent to which it is better than the idea, practice, or product it is trying to replace), compatibility (it aligns with the values, past experiences, and needs of target audience), complexity (how much difficulty will the target audience have in using it?), trialability (the degree to which it can be experimented on target audience), and observability (the degree to which it can be observed by potential adopters and those around them).
Communication channels: These are the means by which information is shared between two or more people. Mass media channels (e.g. TV) can share information on a large scale, whereas interpersonal channels (e.g. face-to-face meeting) can share information on a smaller scale. Mass media channels are important to create public awareness about an issue or to convey small pieces of information about an innovation. Interpersonal channels are better for persuading individuals to actually adopt the innovation.
Time: This entails three key concepts, including the innovation-decision process, adopter categories, and rate of adoption. The innovation-decision process is the process by which individuals gain information about the innovation and decide whether or not to adopt it. This process has 5 steps, including knowledge (learning new information about the innovation—e.g. there is a new HPV vaccine available, HPV is one of the most common STDs out there and can lead to cervical cancer; cervical cancer can be fatal once you get it but may be easily prevented by using HPV vaccine); persuasion (forming a favorable or unfavorable attitude about innovation--e.g. positive: getting my 15-yr old daughter the HPV vaccine will help prevent her from getting cervical cancer in the future; negative: getting my 15-yr old daughter the HPV vaccine will make her think I’m okay with her having sex at this age); decision (deciding whether or not to adopt the innovation--e.g. Deciding to take daughter to get vaccine); Implementation (Initiating use of the innovation; e.g. The mother takes her daughter to get the vaccine); and confirmation (either continued adoption or rejection of innovation, later adoption or discontinuation of adoption--e.g. The mother can decide whether or not to take her younger kids to get the vaccine when they become teenagers). Further, adopter categories are the five categories based on time of adoption of an intervention, including innovators, early adopters, early majority, late majority, and laggards. The majority of adopters tend to be early majority (34%) and late majority adopters (34%), and the innovators only make up 2.5% of all adopters of the innovation. Finally, the rate of adoption is how fast the innovation occurs over time. Usually, there will be an S-shaped curve if you graph this out—In the beginning, there will be a few innovators, followed gradually by other adopter categories until only a few laggards remain.
Social systems: This entails sets of interrelated units, such as members of a community, group, or organization that work towards a common goal or set of objectives. There are certain factors that can facilitate or hinder the adoption of an innovation in a social structure, including homophily (the tendency of people to join with others who are similar to them in some way), system norms (set behavioral patterns that are characteristic of a certain group), and opinion leaders and change agents (popular members of a community who can influence others into adopting or rejecting the innovation).
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Innovation
Communication channels
Time
Social systems
Social capital
Next, we have the concept of social capital, which has been conceptualized as a phenomenon that links individuals together through their collective actions and enables them to access resources through processes of trust, cooperation, bonding, and formation and perpetuation of social norms. Social capital is basically formed from the norms of reciprocity (helping each other out) and mutual trust (trusting each other) in a social network. Resources flow through networks, based on who is in the network and the roles that they occupy, and resources may be provided directly by close networks or indirectly through secondary or tertiary members. Numerous studies have shown that having greater social capital has been linked to better physical and mental health and the reduction of disease. There are two key dimensions to social capital:
Bonding social capital: Relationships among people who share similarities (belonging to same family, organization or neighborhood). This reinforces group identity.
Bridging social capital: Relationships among people who are not similar but have shared associations or goals (e.g. relationships among work colleagues or members of different religious institutions).
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Social capital
Norms of reciprocity and mutual trust in social network
Bonding social capital
Bridging social capital
Social network structure
Further, at the interpersonal level, we really focus on the importance of social networks in influencing behavior. A social network is a set of individuals who are connected by relationships. Social network members may be directly or indirectly linked by behaviors, emotions, group memberships, social position, physical settings, or a specific type of interaction (drug sharing, sexual contact, etc.) There are two types of social networks:
Egocentric networks: One individual who is the focal individual, along with his/her social ties. Eg. Egocentric networks for students may be there friends, family members, partners, neighbors, mentors, and classmates.
Sociometric networks: These link individuals (or nodes) and may be considered bonded groups. For example, if we took a class roster, we could if there are friendships between classmates (with 1’s) and lack of friendships between classmates (with 0’s). A pictorial example of a sociometric network is Fig. 7.1 on Page 106 in your textbook.
Further, social network structure refers to who is in the network and what relationships exist among members. Components of social network structure include:
Network size: # of network members
Direction of relationship: unidirectional or bidirectional
Multiplexity: Number of relationships between focal individual (ego) and a network member. This is measured by the # of network members named in two or more functional or relational network domains
Density: Proportion of individuals within a network who are linked to each other divided by the number of possible links.
Centrality: Individuals within the network with the highest numbers of direct and indirect ties.
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Social network: Egocentric or Sociometric
Network size
Density
Centrality
Direction of relationship
Multiplexity
Social network functions
Now that we have described the components of social networks, let us discuss HOW social networks may shape behavior:
As a source of social support and resources: Social network members may provide social support to each other, and social support has been highly associated with positive health outcomes. Social support is intangible or tangible resources offered by one person to another, such as emotional, informational, financial, and material support. Social support may be either perceived or enacted. Perceived social support is the individual’s perception of the type and amount of support he/she is receiving from social network members. On the other hand, enacted social support is support that has been actually provided by social network members. Perceived support is often important for psychological wellbeing, whereas exacted support is often important for caregiving relationships. Interestingly, social support from social networks is particularly important for low-SES individuals as these networks often provide resources that are necessary for basis survival.
As a source of interpersonal conflict: While social networks can support much-need social support, they can also be a source of conflict. Stress caused by problematic social networks have been shown to have a greater impact on health outcomes compared to supportive networks, though in a negative sense,of course.
As a source of social norms: Social networks also influence behavior through the creation and enforcement of norms. There are collective norms and perceived norms. Collective norms are established by the group or social systems. On the other hand, perceived norms are the norms as the individual perceives them. For example, college drinking may not the norm, but students may perceive it as being the norm and therefore engage in this behavior. Also, perceived norms can be descriptive or injunctive. Descriptive norms are our perception of the behaviors practiced by others in our social environment, whereas injunctive norms are our perception of the behaviors, attitudes, and beliefs that are considered appropriate or acceptable in a social group.
Overall, both egocentric and sociometric networks have been used to learn how diseases spread through a social network. For example, there is a strong relationship between egocentric network factors and substance use and HIV-risk behaviors among the very poor populations in the US and internationally. Network characteristics (network size, composition and density, or how close members are to each other) have been linked to HIV-risk behaviors, such as sharing injection equipment, drug use cessation, having multiple sexual partners, same sex partners or unprotected sex, exchanging sex for money and age mixing of sex partners (having sex with partners who are much older or younger).
An application of the use of sociometric networks is the longitudinal Framingham Heart Study, which examined sociometric social network factors and changes in various health issues such as obesity, smoking, depression, happiness, and alcohol use. They found that participants were substantially more likely to drink heavily if a person they are directly related to also drank heavily. This effect was even observed within three degrees of separation (friend of a friend of a friend). In terms of happiness, they found that happiness was clustered within networks—members of social networks who were surrounded by happy people were more likely to be happy in the future.
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Source of social support and resources
Source of interpersonal conflict
Source of social norms
social-influence-oriented interventions
Now that we have learned more about the structure and functions of social networks, let’s discuss different types of social-influence-oriented interventions. There are two types of such interventions:
Interventions that alter social norms: These interventions focus on changing individual perceptions of their referent group norms. These interventions are often implemented on a community-wide scales and may use multimedia campaigns like billboards, radio and TV. One behavior that this type of intervention has impacted is smoking—in the past, smoking was seen as glamorous (e.g. in Mad Men), and now it is considered social unacceptable. Further, we know that college students often overestimate how much their peers drink alcohol, and this leads to them drinking more. In one particular intervention, they had students use wireless keypads to indicate how much they thought their peers drank and how much they drank…these responses were instantly displayed on an overhead screen in order to correct this misperception.
Peer-based interventions: The goal of peer-based interventions is to use social networks as a way to disseminate information and resources about health promotion and disease prevention. There are two types of peer-based interventions:
Popular Opinion Leader Model: Popular opinion leaders are individuals with high centrality (having a high number of direct and indirect ties or being a person whom resources tend to flow through) or those who are rated by network members as important sources of health information or advice. Once these individuals are identified in a social network, we then train them to disseminate health-related information, promote various health messages, and model health behaviors to fellow network members. This approach has been really effective in HIV risk reduction among gay men in urban settings. Bartenders were identified as popular opinion leaders and were trained to disseminate HIV prevention information to bar patrons.
- Network Oriented Peer Educator Model: This model is based on the assumption that individuals in all positions and that many members of the network can be trained in leadership, communication, and social influence skills. An example of this is the HIV/AIDS prevention intervention (SHEILD) used in Baltimore, in which current and former drug users were trained to conduct HIV prevention outreach to people in their social networks and communities.
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Interventions that alter social norms
Changing individual perceptions of their referent group norms
Peer-based interventions
Popular Opinion Leader Model
Network Oriented Peer Educator Model
Types of environments
Now that we have discussed behavior change at the intrapersonal and interpersonal levels, let us discuss behavior change at the environmental level. Environmental influences (especially those from the social environment) are often less tangible and are less often the target of interventions due to this. However, environmental interventions often deliver “more bang for the buck” because negative environments tend to drive multiple unhealthy behaviors. Therefore, even modest interventions at the environmental level may address multiple behaviors (e.g. adding walking trails to a community may help people increase their physical activity and then be motivated to be healthier in general—eat healthier foods, drink more water, and also walking trails may encourage people in the community meet or form walking groups and therefore build more social cohesion and social capital).
So, first, let us think about what we mean by environment. There are four types of environments:
Geographic: Comprises residential space of individuals and location of home within their neighborhood, city and region; also their activity space (where they work, go to school, shop, and spend leisure time); Also includes the travel routes taken to get to activity spaces and home (e.g. car, bus, train, highways, etc.).
Social environment Extends beyond geographic environment and includes things such as culture (including popular culture), religion, social norms, social networks, modes of communication (TV, social media, etc.), etc….
Compositional: The composition of the community is the aggregate description of individual characteristics (e.g. percentage of people in a community who have a college education)
Contextual: This extends beyond compositional environment and assigns qualities/characteristics to the whole neighborhood/community—e.g. being a low-SES neighborhood, etc. The contextual environment is especially important because social context (neighborhood characteristics, etc.) affect individual health, over and above the individual’s characteristics. For example, even if a person is highly educated but lives in a low SES-neighborhood, they are still more likely to have a lower quality of life. On the other hand, even if the individual is lower SES and lives in a higher-SES neighborhood, this may be protective because they can still access the shared resources of the neighborhoods (e.g. access to higher quality healthcare, stores with nutritious foods, and clean and safe physical activity spaces).
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Geographic environment
Social environment
Contextual environment
Compositional environment
Types of environmental interventions
Finally, let us discuss some environmental interventions that have been conducted to change three specific behaviors:
Diet: Most interventions aimed at changing people’s eating behaviors have been at the individual level. However, we need to keep in mind that the social environment influences what, how, when, and how much we eat. For example, factors such as food cost, access to supermarkets and other food sources, prevalence of fast food restaurants, culture and social influence all contribute to our food-related behaviors. Environmental interventions can be developed in a variety of settings, including schools, work sites, and community retail stores to address these aspects of the social environmental and improve food-related behaviors. Interventions that address food availability or information in place at the area where food is being purchased have shown success in positively impacting food choices. Food availability interventions increase the availability of healthy foods and may even decrease the availability of unhealthy food. Further, information provided at the point of purchase, such as nutritional content, cost comparisons, and promotion of healthful selections, can help people choose healthier foods. The book provides some great examples of environmental interventions to influence eating behaviors on pgs. 125-126.
Physical activity: The built environment is the part of the physical environment that has been modified by humans. It includes transportation systems, land use, public resources (parks), zoning regulations, and buildings (schools, homes, workplaces). Inadequate access to exercise facilities such as safe recreational parks and sideways may lead to physical inactivity. Also, perceived neighborhood safety, social support and social capital all impact one’s likelihood of engaging in physical activity as well. Environmental intervention to increase physical activity levels include strategies such as informational approaches (point-of-decision prompts to use stairs instead of elevators) and behavioral and social approaches (school-based physical education, social support interventions). One popular type of environmental intervention to increase physical activity is the development of walking groups in the community. You can see some examples of walking interventions on pgs. 127-128 in your textbook.
HIV/AIDS prevention: Here, we will discuss the use of economic incentives as a means of improving health-related behaviors in low-resource populations. These incentives are meant to change the economic dynamics at the group level (families, villages) and because these interventions tie economic incentives to specific behaviors, they serve to change the behavioral norms among cultures and societies; therefore, they may change behaviors among people not directly funded. There are different types of economic incentives used:
- Microcredit interventions: These offer very small loans to impoverished individuals who would otherwise lack the collateral to borrow from banks. They create the capacity for group problem solving and empowerment in settings where borrowers, such as women, may not have previously had opportunities to work with their own economic incentives.
- Microfinance interventions: These go one step further than microcredit and are often coupled with other methods to improve people’s financial wellbeing (insurance, savings programs, and business training). Additional interventions along with financial assistance often include literacy and education or targeted interventions for health and nutrition education. A great example of how microfinance has been applied to HIV/AIDS prevention is the Sonagachi Project in India, which my colleague Dallas Swendeman from UCLA led. This project was geared toward female sex workers and used four strategies among the intervention group to help empower women: community mobilization, microfinance, rights-based framing and advocacy. They also used a control group , who received standard STD care, condom promotion, and peer education. The effects of the intervention included disclosure of profession and reframing of sex work as valid work, more positive thoughts about the future, desire for education, increased social support and interpersonal networks, financial savings and skills in both condom negotiation and refusing undesirable transactions.
- Conditional cash transfer: These provide direct payments rather than loans, and these payments are tied to the achievement of certain behaviors or goals. The idea behind this is to break the intergenerational cycle of poverty in families and so for example, mothers would be paid for their children’s school attendance, well-child medical visits, or nutrition-based behaviors, and then it is hoped that the child will become a healthy adult with maximum earning potential who can give back to the family.
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Diet
Focus on increasing healthy food availability and providing nutrition information at place where food is purchased
Physical Activity
Focus on enhancing built environment to increase opportunities to engage in physical activity
HIV/AIDS Prevention
Use of economic incentives (microcredit, microfinance, and conditional cash transfer) to change behavior in low-resource settings
Focus on modifying social environment to promote physical activity