Epi 246

Social Cognitive Theory, Models of Patient-Provider Communication, and

Culture-Centered Health Communication

Margaret Handley, PhD MPH

Assistant Professor DEB and DGIM-SFGH

April 8, 2010

Outline of Today’s Lecture

1. Discuss Social Cognitive Theory and applications of it

2. Describe models for Patient-Provider Communication and examples of different ways of developing theory-informed descriptive and intervention projects

3. Present alternative approaches to health-communication theory and practice that are particularly relevant to community engagement principles and working with marginalized populations

Learning Objectives1 1. Understand components of Social Cognitive Theory

2. Understand models of Health Communication and how functions relevant to health communication relate to diverse theories

3. Be familiar with culture-centered approaches to health communication and their relevance to community engagement with diverse populations

4. Be able to apply components of the presented theories to health-related behaviors and health communication strategies

Theories and Models Related to Interpersonal Behavior and Behavior Change

• Interpersonal health behavior theories such as Social Cognitive Theory fall within social influences on health, yet are delineated from social support and social networks.

• Can be in family, friends, peers and informal settings or in more formal settings, such as clinical settings for patient-provider communication, communication among clinicians in clinics and hospitals, and for teachers and students in variety of settings

• For patient-provider communication specifically, there are many theories that relate to specific functional components of communication – may be more complex to attribute to single theories

I. Social Cognitive Theory

From Bandura

Social Cognitive Theory(formerly Social Learning Theory)

• SCT is a learning theory used in many settings

• Used to explain behavior: we learn from experience, observation, and symbolic communication >> we apply this learning to shape the environment we are in, as well as respond to it, and become adaptable to changes in it

• Often used for health behavior change interventions:

-- Patient-provider communication re cancer pain, school-based HIV prevention programs, self-management for distressed diabetes patients, adult education programs focused on community health problems

Concept Definition Application

Reciprocal Determinism

Behavior changes result from interaction between person and environment; change is bi-directional

Involve the individual and relevant others; work to change the environment/influence

attitudes

Behavioral Capability

Knowledge and skills to influence behavior

Provide information and training about action

ExpectationsBeliefs about likely results of

actionModel positive outcomes of behavior

Self-EfficacyConfidence in ability to take action and persist in action

Point out strengths; use persuasion and encouragement; approach behavior change in

small but specific steps

Observational Learning

Beliefs based on observing others like self and/or physical

results

Show others' experience; identify credible role models to emulate

Reinforcement

Responses to a person's behaviour that increase or decrease the chances of

recurrence

Provide praise; encourage self-reward; decrease possibility of negative responses

that deter positive changes

Social Cognitive Theory

Concept for Promoting Self-Efficacy

Application

Mastery Experience Enable person to succeed in increasingly challenging performance

Patient activation

Social Modeling Showing that others like them can do it

Improving Emotional and Physical States

Improve context in which new behaviors are undertaken

Verbal PersuasionMotivational Interviewing

Encouragement>> boost confidence

Social Cognitive Theory Self-Efficacy Applications

Glanz K, Rimer, B, Viswanath, Health Behavior and Health Education 2009

Application of Social Cognitive Theory to a Tailored Intervention Focusing on Patient Activation for Cancer Pain Control

Kravitz RL et al, 2009 Cancer Health Empowerment for Living Without Pain. BMC Cancer*Kaplan S Greenfield S and others

Conceptual Model – Ca-HELP

- Began with interest in patient activation* for participatory decision making

- Informed by SCT to frame the tailored education intervention

Focus on communication competence skill development

Concept Specific Focus Application*

Reciprocal Determinism

Behavior changes result from interaction between person and environment; change is

bi-directional

Patient activation can change the communication environment and thus

change the provider’s behavior and also patient’s pain control self-efficacy

Behavioral Capability

Knowledge and skills to influence behavior

Increase capacity to talk about pain-knowledge and skills AND adaptability

ExpectationsBeliefs about likely results of

actionIncrease ways to see positive outcomes of behavior (knowledge/overcome barriers)

Self-EfficacyBoth for communication about pain and ability to

manage the pain effectively

Lay health educators with coaching model: practice skills, older population

Observational Learning

Beliefs based on observing others like self

Show others' experience; identify credible role models to emulate

Reinforcement

Responses to a person's behavior that increase or decrease the chances of

recurrence

Lay health educators with coaching model:

Portray how they want to communicate to reinforce the communication skills

CA-HELP Application of Social Cognitive Theory

*Using the ACT-PREP Paradigm: ASSESS,CORRECT,TEACH,PLAN,REHEARSE,PORTRAY

Feasibility Study Using SCT Constructs inClassroom Discussions/Analysis of Hip-Hop Music

Boutin-Foster C et al J Urban Health, 2010

Challenge - Reaching NYC urban minority youth about HIV/AIDS prevention education and interventions

Response - What education-based practices could match the unique characteristics of this population?

Concept – Hip-Hop creates social env. where music is shared, and so are misconceptions, but this can be re-framed to shape messages. Hip-Hop/Rap music analysis and discussion at school as a means to explore content and feasibility. SCT Focus Areas: •Are lyrics highlighting unrealistic positive outcomes of sexual promiscuity? (behavioral expectations)•What observational learning occurs from watching videos?• How do images act as reinforcements (glamour/wealth) in sustaining risky behavior?

Feasibility Study cont…SCT Construct Topics for discussion (5 sessions, 1.5 hrs. each)

Expectations What is the behavior or behaviors described in this song that increases the risk or chance of becoming infected with HIV/AIDS? What are some bad or negative results of the behavior(s) described in this song?[Discuss the serious and negative consequences of sexually risky behaviors such as teen pregnancy and STIs]

Observational learning

What are some of the lyrics which make this behavior seem desirable or may make someone want to repeat this behavior? [Discuss the risky behaviors described by the artist such as drinking and having sex]

Reinforcement What does the artist say that makes you want to do what he/she is talking about? [Discuss the illusion of money and cars as rewards of sexually risky behavior that is often described in the songs]

Self-efficacy How confident does the artist seem to be? What is the artist saying that gives the impression that he/she is confident?[Discuss the illusion of self-efficacy or over confidence that are often described in some songs]

Boutin-Foster C et al J Urban Health, 2010

SCT-Conceptual Framework for the REDEEM PROJECT (Reduce Distress Enhance Effective Management)

Fisher et al, personal comm. - NIDDK-funded R01

SCT-Conceptual Framework for the REDEEM PROJECT (Reduce Distress Enhance Effective Management)

DD=Diabetes Distress Fisher et al, personal comm. - NIDDK-funded R01

“The model suggests a variety of potential biological, environmental, disease-related and health care burdens and supports that define the personal and social context in which diabetes is managed and D/D is experienced ( ‘layers of potential chronic adversity’). Likewise, the beliefs, role behaviors and disease practices associated with ethnicity, gender, and social class (education, income) serve as filters through which burdens and supports are interpreted and experienced. The major constructs are dynamically interconnected, such that, for example, biological markers can be viewed both as a cause of emotional burden (patient receives a poor lab value after struggling with disease management) and a result of emotional burden (patient’s increased D/D leads to reduced self-management and, eventually, to poor lab values). This framework includes many of the factors known to affect D/D and self-management: social and environmental contributors, how personal, cultural and family based beliefs and roles affect these processes, and how the demands for care posed by diabetes sometimes creates seemingly unending circularities that can lead to both D/D and poor self-management.”

“Our ESL classroom [provides] students with an opportunity to share their personal difficulties, evaluate them against the experiences of others, and begin to recognize them as socially constructed and potentially transformed through social action. We might see this process, and its active facilitation in our classes, as a primary means by which new solidarities and ‘traditions’ are developed within immigrant communities.”

Morgan, B. (1998). The ESL classroom: Teaching, critical practice, and community. Toronto, Canada: University of Toronto Press.

Social Learning Theory in ESL-Health Partnerships

Social Learning Theory in ESL-Health Partnerships

Learners Lives As Curriculum>>> ‘Re-Storying’ Health Info./Messages

Weinstein G. (1999). Learners' Lives as Curriculum. McHenry, IL: Delta Systems. Handley MA, Santos MG, McClelland J. Reports from the Field.Global Health Prom, 2009Santos MG, Handley MA, McCleland J, Richards A. Under Review J CATESOL

EXAMPLES

•Cancer – Women in SF Asian Communities

•Diabetes Prevention- Statewide

•Obesity Prevention – Fruitvale, Oakland

•Lead Poisoning Prevention - Monterey

1. Build on What learners know

2. Balance Skills and Structures with Meaning-Making and Knowledge Creation

3.Autonomy in Language and Content

4. Shared responsibility for learning among students and teachers

5. Build communities of learner -practitioners

II. Health Communication in the Context

of Patient-Provider Communication • ‘Good communication’ improves health

outcomes, but there is no single theory to what good communication looks like

• Focus on the functions/pathways that could improve health via improved health communication, with particular focus on patient-providers communication

• ‘Patient-centered’ approach/paradigm

Health Communication in the Context of

Patient-Provider Communication

Communications Functions

1. Information Exchange2. Respond to Emotions3. Manage Uncertainty4. Foster Relationships5. Make Decisions6. Enable Self-Management

Proximal Outcomes

UnderstandingSatisfactionClinician-patient agreementTrustFeeling ‘known’Patient feels involvedRapport

Intermediate Outcomes Access to CareQuality Medical decisionCommitment to treatmentTrust in SystemSocial SupportSelf-care skillsEmotional Management

Health Outcomes

SurvivalCure/ImprovementLess sufferingEmotional well-beingPain controlFunctional abilityVitality

Indirect path

Direct path

Direct and indirect pathways from communication to health outcomes. Figure 11.1 fromGlanz, Rimmer, Viswanath, 2008

Health Communication in the Context of Patient-Provider Communication for Diabetes SMS

Communications Functions

Information ExchangeRespond to EmotionsManage UncertaintyFoster RelationshipsMake DecisionsEnable Self-Management

Proximal Outcomes

UnderstandingSatisfactionClinician-patient agreementTrustFeeling ‘known’Patient feels involvedRapport

Intermediate Outcomes Access to careQuality medical decisionCommitment to treatmentTrust in systemSocial supportSelf-care skillsEmotional Management

Health Outcomes

SurvivalCure/ImprovementLess sufferingEmotional well-beingPain controlFunctional abilityVitality

Indirect path

Direct path

Possible direct and indirect pathways from communication to health outcomes using IDEALL/ATSM Diabetes Self-Management Program. Schillinger et al. 2007, 2009

Health Communication in the Context of Interpersonal Communication in the ICU cont.

• Decision-making in ICU when no surrogates- Unexplored area, began with descriptive epidemiology linked to descriptive communication and behavioral processes of decision-making

• Included elements of HBM, TPB, SCT

self-efficacy to make decisions, influence of peers/others in the hospital, relationship to guidelines and cues to action re legal concerns

• Led to larger studies, ethical review project, current policy work on task force for the Am Thoracic Society

White D, et al 2006. White D et al, 2007. Annals Int Med 2007.147:34-40.

Health Communication in the Context of Interpersonal Communication in ICU

Communications Functions

Information ExchangeRespond to EmotionsMD Managing UncertaintyFoster RelationshipsTeam Decision-MakingEnable Self-Management

Proximal Outcomes

UnderstandingSatisfactionClinician-patient agreementTrustFeeling ‘known’Patient feels involvedRapport

Intermediate Outcomes Access to CareQuality Medical decisionCommitment to treatmentTrust in SystemSocial SupportSelf-care skillsEmotional Management

Health Outcomes

SurvivalCure/ImprovementLess sufferingEmotional well-beingPain controlFunctional abilityVitality

Indirect path

Direct path

Direct and indirect pathways from communication to health outcomes. White D et al 2006, 2007

Models and Measures of Patient Centered Communication

P 241-49 Glanz, Rimmer, Viswanath, 2008

Communication Functions

Theoretical ModelsExamples

Example Measures

Decision-Making

Enable Self-Management

Models of predisposing and enabling factors;shared decision making

Integrative model of health behavior, TTM, self-determination theory

Control preference, participatory decision-making scales

5 A’s, health care climate survey

‘Moderators’ of Clinician-Patient Communication Outcomes

Age Personality

EducationRace Gender Language Family Structure

Health Literacy Self-efficacy

Emotions Perceived Risk

Social Distance Clinician Attitudes Representations of Illness Patient Preferences

Cultural Values

Type of Disease

Family Functioning

Social Support Access to Care Disease Progression

III. Culture-Based Theory of Health Communication

“Hierarchies of biomedical knowledge do not lend themselves to identifying who is most capable of deciphering the complex pragmatics of public discourse about health…..why not include people who are ‘experts’ in reading how information is interpellated within their own communities? In doing so, we might learn a lot more about the full range of publics that emerge as discourse about health circulates.”

Briggs C Med Anthro Quartlerly p 313- 2003

Culture-Centered Approach to Health Communication

• A culture-centered approach is an alternative entry point for theorizing about health communication with marginalized populations

• Focuses on understanding health meanings and experiences within the space of marginalized settings

• Based in critical theories, cultural studies, post-colonial

theory

• Critiques a biomedical approach to theories of health communication that can reflect ‘individualistic’ views that are not relevant to many marginalized populations

Dutta MJ. Communicating Health 2008

Culture-Centered Approach to Health Communication

Contextualized health communication as combining: structural forces, which refer to the constellation of

institutional and organizational networks that constrain the availability of resources in marginalized settings

local culture and

agency, which refers to the capacity individuals and communities to be active participants and determining health priorities and solutions

Dutta MJ. Communicating Health 2008

Culture-Centered Approach to Health Communication

Goals of Culture-Centered Approaches:

1. To centralize context and bring to forefront awareness of the socio-structural contexts underlying many health behaviors.

2. To create culture-based health solutions.

3. To explore questions of power, ideology, hegemony and control in the discourses and practices of healthcare.

4. To correct, through health policies, approaches directed at ‘fixing’ marginalized populations’ behaviors.

-- Is an application of community engagement principles.

A Culture-Centered Approach Example- Rural Bengal

Q. How is health problematized and how are health solutions articulated?

Q. What does the interdependence of context, access, and communication in health meaning look like in rural areas?

• Findings: Structural in-access from cost (to healthy foods), are aligned with ways health is seen globally, not a matter if individual knowledge or beliefs about the behavior

• Trust is more important than expertise in health providers

• Responsibility to ‘self-treat’ at family and community level

• Gaps between policy and the execution of policy

Dutta MJ and Basu A. Health Communication 2008 http://web.ics.purdue.edu/~mdutta/

A Culture-Centered Approach Example- Rural Oaxaca

Q. What comprises health? What is valued? What has changed across generations and with migration? How do illnesses get treated? How does health information get communicated? Who is trusted and why?

Q. What does the interdependence of globalized migration, health beliefs and communication about health look like?

Preliminary Findings – • Nutrition promises health but is being lost with shift away from

agrarian life, migration is unhealthy, and others’ land is not trusted to produce healthy food.

• Trust is more important than expertise in health providers

• Pride to ‘self-treat’ at family and community level, including value of companies that give health ‘milagros’

Handley M, Rodrigues M, Perez R, Grieshop J et al in preparation

Homework – Week 2 1. Apply the social cognitive theory to your work and create

a conceptual model as presented in the readings and examples from class. Why or why not, would you use this in your current or planned work?

2. Which aspects of the health communication models/theories can be adapted to your area of interest? Be specific. Provide a detailed example that includes model constructs that incorporate both an individualistic view, and one that takes more into account structural and environmental factors.

3. How might you include a culture-centered perspective in your areas of interest? How do you anticipate it could inform your work?