Understanding Physician Behavior: Theory, Evidence, Planning

Transtheoretical Model; Social Cognitive Theory; Heuristics; Social Marketing - - and Formative Research

 Kitty Corbett, PhD, MPHFaculty of Health Sciences

Simon Fraser UniversityBurnaby [Vancouver], BC

UCSF April 8, 2008

ObjectivesParticipants will be able to:

MAKING SENSE OF THEORY• Define & differentiate among 3 approaches to understanding physician

behavior in terms of basic conceptual domains, their components, & methodological approaches– Social Cognitive Theory; Transtheoretical Model; Social Marketng

• Describe where heuristics fit within these approaches

EVIDENCE THAT THEORY HELPS• Describe the strength of the evidence for the utility of these theories• Describe the limitations of these approaches

PLANNING/APPLICATION: THEORY-INFORMED FORMATIVE RESRCH• Apply constructs from these theories to given situations• Describe what formative research is and can offer• Employ exploratory, formative, Social Marketing research strategies

I. MAKING SENSE OF THEORY• There is theory in everything. Theory often

remains unspoken and assumed. • Every project has assumptions about how

change happens, or why people are the way they are, or why there is human diversity or so much conformity– fundamental constructs like "motivation," "emulation“

and “modeling,” "alienation,” “conflict”– an underlying model about process, "prime movers"

etc.

Theory-ladenness of observation

Rabbit or duck?

Like empty coffee cups, Like empty coffee cups, they have shapes & they have shapes & boundaries, but are boundaries, but are useful when filled with useful when filled with practical topics, goals, practical topics, goals, and problems. *and problems. * *NCI, Theory at a Glance

A theory is “a coherent and non-contradictory A theory is “a coherent and non-contradictory set of statements, concepts or ideas that set of statements, concepts or ideas that organises, predicts and explains phenomena, organises, predicts and explains phenomena, events, behavior, etc.”events, behavior, etc.” [Bem & Looren de Jong 1997 (in Eccles 2005, p.108)]

Individual change theory at its most rudimentary

KNOWLEDGEKNOWLEDGE ATTITUDE / ATTITUDE / MOTIVATIONMOTIVATION BEHAVIORBEHAVIOR

[E.g., figure in Cabana article]

Rudimentary individual change theory with context added

KNOWLEDGEKNOWLEDGE ATTITUDE / ATTITUDE / MOTIVATIONMOTIVATION BEHAVIORBEHAVIOR

Context*Context*

* norms, environmental resources, etc.

PATIENT FACTORSSymptoms & their meaningsHealth system experiences Health care coverage or ability to payCultural understandings[Dis]trust re adviceAbx knowledge Abx experiences

SYSTEM FACTORSCost of medicines & careCare setting factors (e.g. schedules, formularies)Health plan featuresPharmaceutical promotionsPharmacy practicesAvailability of technologyRegulatory environment Community factors Cultural context Media / health information

CLINICIAN FACTORSSociodemographicsSpecialty / trainingKnowledge re Abx, resistanceKnowledge of guidelinesJudgment & heuristicsPerceived patient expectationsCommunication style

Negotiation, decision, Negotiation, decision, or action or action (eg, Rx) (eg, Rx) about about antibiotic useantibiotic use

Cross-sectional model of health care behavior; Social determinants of community-based use of Abx

4 and 20 theories baked in a pie: how to

slice it?• Levels in the social ecology [of a targeted change]:

– Individual-level, Organization-level, Community, Societal/Population, Multi-level

• Theoretical domains– Risk assessment, self perception, emotions and arousal,

relationships & social influence, environmental & structural influences

• Snapshots vs Moving Pictures– Cross-sectional vs. dynamic / iterative theories

• Inductive (ground up, empirical) vs deductive (applying & testing existing theory): discovery, planning, application

– Practice-based research vs Theory-based research – or MIXED

• Interaction-oriented / dramaturgical theory

• Force-field theory & analysis

• Cognitive / decision-making: artifacts, heuristics

• Persuasion

Etc.

3 sizes of theory

Arches in Basilica of San Zanipolo (Venice)Photo by Giovanni dall'Orto

(1) Grand (1) Grand Theory - very powerful nomothetic theory, at level of a paradigm perhaps

- evolutionary theory- political economy

Functionalist Theory

• The key questions: how parts contribute to the functioning of the whole– Society as an organism whose various parts

are interdependent– Society characterized by cooperation,

consensus, and balance

• Stresses stability

Spencer, Durkheim, Parsons, Merton

Conflict Theory

• Key Q: Where are the tensions? Who benefits what and why?

• Society seen as constantly changing, with social inequality and social conflict as drivers

• Emphasis on power, conflict and change; very little on what produces stability

Marx, Weber, Marx, Weber, other 19other 19thth

century critics century critics

Sizes of theory

(2) NOMOTHETIC THEORY – accounts for facts in many cases. [“relating to, involving, or dealing with abstract,

general, or universal statements or laws”] – What features of social relations and social organization

account for the variation in rates laminectomies & lumbar discectomies across regions in the US?

• (3) IDIOGRAPHIC (elemental) THEORY – accounts for the facts of a particular case– What accounts for patients in Ugandan hospitals who

have pneumonia getting antibiotics within 6 hours?

Interactionist Perspective (incl. Symbolic Interactionism)

• Key questions: How people make sense of the world in which they participate

• Seeks to understand social life and human behavior from the standpoint of the individuals involved in day-to-day interaction

• Human beings create symbols and interpret the meanings

• The “definition of the situation” has consequences and affects social interaction

GH Mead, H Blumer, HS Becker, E Goffman

Socialization, status, role, self-interest, & social interaction

• Interaction ritual in everyday life: impression management, managing “face,” front-stage & back-stage (Erving

Goffman)

• “…doctors are influenced by a complex itneraction of self-interest, concern for their individual patients, and regard for the well being of society at large.”

(Eisenberg 2002, p.1016)

Useful references

• Theory at a Glancehttp://www.nci.nih.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf

• Communication Theory Clusters http://www.tcw.utwente.nl/theorieenoverzicht/

• Change Theories http://www.comminit.com/changetheories.html

7 conceptual “families” of useful theoretical models – evidence from STD/HIV lit

1. Psycho-educational approaches that stress information

2. Cognitive theories that stress internal decision-making processes

3. Behavioral models based on principles from learning theories

4. Theories of motivation & emotional arousal

5. Social influence theories6. Stage theory7. Blended theories

St. Lawrence and Fortenberry, IN Aral & Douglas, 2007

7 conceptual “families” of theoretical models

1. Psycho-educational approaches that stress information

2. Cognitive theories that stress internal decision-making processes

3. Behavioral models based on principles from learning theories

4. Theories of motivation & emotional arousal

5. Social influence theories6. Stage theory7. Blended theoriesTrans-

theoretical Model

Social Cognitive Theory

Social Marketing

5 “Theoretical Domains” – These occur in some form, with some related terminology, with some degree of emphasis, in just about every change

theory dealing with individuals.

1. Risk appraisal

2. Self perception

3. Emotions and arousal

4. Relationships & social influence

5. Environmental & structural influences

Dolcini & Gandelman

1. Risk appraisal

2. Self perception

3. Emotions and arousal

4. Relationships & social influence

5. Environmental & structural influences

SOCIAL NORMS

SELF-EFFICACY

PERCEIVED CONSEQUENCES

http://www.engenderhealth.org/res/onc/hiv/preventing/hiv6p3.html

TTM TTM Stage-transition determinants: info (pros/cons), demos, self-efficacy, support

Albert Bandura, the bobo doll, & Social Learning Theory

Add Self-Efficacy Social Cognitive TheorySocial Cognitive Theory

Application of Social Cognitive Theory (Bandura, 1977) to career choice & behavior (Lent, Brown, & Hackett, 1994)

Past performance

Verbal persuasion

Vicarious learning

Physiological states

Background Contextual

Affordances

Personal inputs-predispositions, gender, ethnicity

Retention

Contextual influences (supports & barriers)

Can I do this ?

What will happen?

Byars-Winston A, Davis D, et al., 2007.

Social Cognitive Model (Albert Bandura)

Behaviour

Knowledge of health risks

I know what TB is

Benefits of change Taking the medication will

make me feel better

Self efficacy I am confident that I can

take my medication

Outcome expectations

If I take my medication I will feel better, & I want to

Facilitators and barriers It is easy to take my medication

Social Cognitive Theory -- Key Constructs

• Observational Learning: Learn by watching actions of another person; the outcomes, and reinforcement received; more efficient way to learn compared to operant learning (classical conditioning)

• Self-Efficacy: Self-confidence/determination about performing a particular activity; feeling of having control over one’s behavior; KEY for behavior change

• Outcome expectancies: “incentives,” value a person places on an outcome; hedonic principle (max. + or min-)

• Outcome expectations: what an individual expects will occur as a result of certain behaviors in specific situations (as learned through previous experience, observational learning, & physical & emotional responses to situations)

• Behavior capabilities: knowledge about & the skills needed to perform the behavior

• Self-control: self-regulation of goal directed behavior or performance• Managing emotional arousal: some situations can create fear and anxiety

which impair learning and performance. Individuals use different techniques to deal with this (stress management, cognitive reappraisal)

• Environment: factors external to the individual; social (family & friends= models for behavior), physical (urban/rural, room temperature)

• Reciprocal determinism: dynamic interaction of the person, behavior and environment in which the behavior is performed

Stepwise Implementation Model – to achieve a change

The amount and type of interactive guidance should be adjusted to people’s level of self-efficacy & motivation to achieve a desired change.

(Bandura, 2004)

Succeed with minimum guidance.

Half-hearted decisions; Give up when barriers arise.

Habits are beyond their personal control; Need personal guidance & changes in context.

Level 1: individuals with high self-efficacy and positive out-come expectations

Level 2: individuals with self-doubts about both their efficacy and benefits of outcome

Level 3: individuals have no sense of self-efficacy

Heuristics

• Our brains and behaviors evolved to (1) not change strategies too quickly; (2) rely on our own personal observations; (3) be biased towards recent experience; (4) be influenced by a small number of cases, especially if recent and outcomes are severe… (Brass 2003, p. 120)

Appropriate vs questionable cognitive aids [& cognitive artifacts]

• “Fast and frugal” heuristics– Folk maxims

• Expert-vetted and disseminated heuristics– Guidelines– The “5 As” etc. (ask, arrange, advise, assist, etc.)

• Calls for more study!

• Let sleeping dogs lie. [changing behavior of established physicians]

• Safety in numbers [so what the standard of care says]• The patient is a case of one. • When you hear hoofbeats, think horses not zebras.• Common things occur most commonly.• Follow Sutton’s law [go where the money is]• One has to think of the disease to recognize it.• See one, do one, teach one.

Stage-transition determinants: info (pros/cons), demos, self-efficacy, support

Information, mass media, motivational interviewing

Social support, rewards, heuristics

Role models, demos, social support, skills-building, incentives, heuristics

Copyright © 2008 The Royal College of PsychiatristsCHILVERS, R. et al. Br J Psychiatry 2002;181:99-101

Fig. 1 A stages of change model.

HEURISTICS

Social Learning TheoryHEURISTICS

HEURISTICS

Social Cognitive Model (Albert Bandura)

Behaviour

Knowledge of health risks

I know what TB is

Benefits of change Taking the medication will

make me feel better

Self efficacy I can take

my medication

Outcome expectations

If I take my medication I will feel better, & I want to

Facilitators and barriers It is easy to take my medication

HEURISTICS

HEURISTICS

HEURISTICS

II. EVIDENCE THAT THEORY HELPS

“There is nothing so practical as a good theory.”

(Kurt Lewin, Field theory in social science, 1951, p. 169)

“Stages of Change” / TTM

• Very appealing! – Brief– High face validity – Easy to explain – Readily applicable for understanding & interventions– Useful for distinguishing between motivation phase &

volition phase– Stages of change interventions appear in the short

term at least to be somewhat more effective than non-stage matched interventions

Limitations of TTM

The bad news: • Rather weak evidence, mostly from cross-

sectional studies • Stages of change may be unstable over time• Few studies about using TTM in changing

providers’ behavior• Need for prospective studies -- longitudinal,

experimental designs

Sutton S. Interpreting cross-sectional data on stages of change. Psychol Health. 2000;15:163–171.Adams JWM. Why don't stage-based activity promotion interventions work? Health Educ Res. 2004;20:237–243.

Limitations of SCT

• So many constructs that researchers can use them to describe almost any phenomenon– need to narrow down which phenomena they apply to

(thru empirical evidence) & in which situations it doesn’t apply

• Many of the constructs have modest reliability– Improvements in measurement procedures could

improve the constructs’ ability to explain behavior & the effects of interventions.

• Little evidence in interventions with physicians

What makes “good” theory?

• Application & scientific merit– “a theory is a good theory if it satisfies two requirements: It must

accurately describe a large class of observations on the basis of a model that contains only a few arbitrary elements, and it must make definite predictions about the results of future observations.”

(Stephen Hawking in ‘A Brief History of Time’)

Theoretical advances in patient behavior change

Large literature, especially for:

• Smoking

• HIV prevention

Academic Literature on Changing Physician Behavior

• Education– Not very useful on its own

• Feedback (audit/feedback, academic detailing/outreach, reminders)

• Clinical Opinion Leaders / champions• Administrative Mandates• Incentives

Basic conditions/prerequisites for change include, according to many:

• Perceived consequences / positive expectancy• Response expectations/ response efficacy• Self efficacy• Behavioral capability / skills• Incentives/ Reinforcement/ punishment• Supportive environment & social norms

Rubinson L, et al. Why is it that internists do not follow guidelines for preventing intravascular catheter infections? Infect Control Hosp Epidemiol. 2005 Jun;26(6):525-33.

• Clinician experience and subspecialty, awareness of CDC guidelines, and external influences (eg, time to collect equipment) did not affect maximal barrier precautions adherence. The only

independent predictor of adherence was high outcome high outcome expectancy expectancy for the use of large sterile drapes (OR, 5.3; CI 95,

2.2-12.6). AvailabilityAvailability had the greatest influence on internists' selection of specific antiseptic agents, whereas cost was the least important determinant.

• CONCLUSIONS: Despite established efficacy, use of maximal barrier precautions and chlorhexidine gluconate is low among internists. Because improved adherence to these practices will require increased outcome expectancy for maximal barrier precautions and availability of chlorhexidine gluconate, targeting these areas through focused education and systems modifications is essential.

Cabana MD, Rushton JL, Rush AJ. Implementing practice guidelines for depression: applying a new framework to an old problem. Gen Hosp Psychiatry. 2002;24(1):35-42.

• Six primary barriers relate to providers (lack of awareness, lack of familiarity, lack of agreement, lack of self efficacy, lack of outcome expectancy, and inertia of previous practice). In addition, factors related to patient, guideline, and practice environment factors encompass external barriers to adherence.

• Different physicians and practice settings may encounter a variety of barriers, multifaceted interventions multifaceted interventions that are not focused exclusively on the physician tend to be most effective.

Maue SK, et al. Predicting physician guideline compliance: an assessment of motivators and perceived barriers. Am J Manag Care. 2004 Jun;10(6):383-91.

• Some variables, particularly perceived perceived barriers barriers to guideline implementation, predicted a provider's practice intentions and self-reported behavior.

Cabana MD, et al. Barriers pediatricians face when using asthma practice guidelines. Arch Pediatr Adolesc Med. 2000 Jul;154(7):685-93.

• Efforts to improve adherence to asthma guidelines should consider the range of barriers that pediatricians face, such as lack of awareness, familiarity, or agreement, and external barriers owing to environmental, guideline, or patient factors. In addition, this study documents barriers not previously considered, such as lack of self-efficacy, lack of outcome expectancy, and inertia of previous practice, that prevent adherence. Because type of recommendation and physician type of recommendation and physician demographics are related to which barriers are demographics are related to which barriers are prominent, prominent, interventions to improve NHLBI guideline adherence should be tailored to these factors.

Cochrane LJ, et al. Gaps between knowing and doing: understanding and assessing the barriers to optimal health care. J Contin Educ Health Prof. 2007 Spring;27(2):94-102. 

• Review of 256 studies

• While many studies are methodologically weak, there are indications that designs are becoming more aligned with the complexity of the health care environment. The review provides support for the need to examine multiple factors multiple factors within the knowledge-to-action process.”

Bloom BS. Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews. Int J Technol Assess Health Care. 2005 Summer;21(3):380-5.

• 26 reviews met inclusion criteria, that is, were either formal meta-analyses or other systematic reviews. Interactive Interactive techniques (audit/feedback, academic techniques (audit/feedback, academic detailing/outreach, and reminders) detailing/outreach, and reminders) are the most effective at simultaneously changing physician care and patient outcomes. Clinical practice guidelines and opinion leaders are less effective. Didactic presentations and distributing printed information only have little or no beneficial effect in changing physician practice.

• CONCLUSIONS: Even though the most-effective CME techniques have been proven, use of least-effective ones predominates.

Chaillet N, et al. Evidence-based strategies for implementing guidelines in obstetrics: a systematic review. Obstet Gynecol. 2006 Nov;108(5):1234-45. 

• Prospective identification of efficient strategies and barriers to change is necessary to achieve a better adaptation of intervention and to improve clinical practice guidelines implementation. In the field of obstetric care, multifaceted strategy based multifaceted strategy based on audit and feedback and facilitated by on audit and feedback and facilitated by local opinion leaders local opinion leaders is recommended to effectively change behaviors.

Predictive theories vs frameworks

• “More problematically, there are problems in the concepts underlying attempts to change professional behavior.” (p.107; from Grol)

• “…theories that identify modifiable predictors or explain how to change behavior are most likely to be useful in implementation research.” (p.108)

(Eccles et al. 2005)

• “Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another.”

(Cabana et al 1999)

• “It is amazing how little we know about how to induce behaviour change. Most of us accept this and are appropriately modest when we consider how effective we might be in convincing a family member to stop an irritating habit or a patient to quit smoking. But it is harder to accept when we are considering the need to change professional behaviour.”

(Flottorp & Oxman 2003)

“Cafeteria-style” theorizing

– “We did not rely on any specific theory of behaviour change, but we used elements from adult learning theories, theory of innovation, the transtheoretical model of behaviour change, and social influence theory. We used a pragmatic approach with a series of largely qualitative methods to identify barriers and tailor interventions to address these.” (Flottorp & Oxman 2003)

Bandura’s input was most instructive about the dangers of mixing constructs… in a cafeteria-style manner.

(Lent, Hackett, Brown, 1998)

But perhaps choosing from a menu makes sense -??

• To a large degree, how intervention programs are constructed is a reflection of the theory they are based on, whether overtly or implicitly

• Yet theoretical premises are often unmentioned or unexamined.

Challenges to considering THEORY -1

Challenges to choosing & using theory - 2

• No single theory is sufficient to meet the multiple challenges of a health problem– Various theories or models may be

appropriate at different times and for addressing different problems.

– Each theory addresses only part of the picture.

Challenges to choosing & using theory - 3

• Theory-based interventions have tended to draw on psychological explanations & mechanisms for behavior change

• Neglect of situational & social context, environment, and structural constraints

• Still shots – rarely moving pictures

• Our model is incomplete… we haven’t included the important roles that society & health care organizations play in providing and limiting resources for health services. Rather, our focus has been purposely on the decisions made by patients and their immediate health care providers, leaving the “bigger picture” for another discussion…

(Haynes, Devereaux, p.386)

• “Theory” may not be interesting to people who have previously been confused or over/under-whelmed by it

• Elitism of academic disciplines: each considers its own approach to theory is best

• Program planners and providers may regard theory as irrelevant to their work; they think that addressing a real-life problem in an efficient manner is not about theory.

Challenges to choosing & using theory - 4

• “Although these studies have been valuable in describing how medicine should be practiced, they have contributed less to an understanding of how it is practiced.”

(Eisenberg 2002, p.1028)

Challenges to choosing & using theory - 5

What makes “good” theory?

• NOT JUST Application & scientific merit– “a theory is a good theory if it satisfies two requirements: It must

accurately describe a large class of observations on the basis of a model that contains only a few arbitrary elements, and it must make definite predictions about the results of future observations.”

(Stephen Hawking in ‘A Brief History of Time’)

• Branding and persuasiveness– “Propaganda is of the essence” in theoretical arguments.

(Feyerabend, Against Method, p. 157)

“There is nothing so practical as a good theory.” But is that true?• Very few studies have employed theory in the design of

provider change interventions. Most studies have implicit theory but lack explicit theory.

• Few studies have tested theory. Most research has entailed practical, problem-centered studies.

• If theory is mentioned -- Many people employ a hodge-podge of theoretical constructs. (Is that OK?)

• What IS used frequently are conceptual and planning frameworks, e.g., PRECEDE-PROCEED; Social Marketing; Diffusion of Innovations

III. PLANNING/APPLICATION

“Theory-based intervention design starts with a comprehensive needs assessment” (R. Gonzales, last week)

• Ralph’s Roadmap for Designing Theory-Based Interventions– Needs Assessment– Understanding the Problem within a

Theoretical Framework– Designing Multifaceted Intervention within a

Theoretical Framework– …

Social Marketing Social Marketing offers a useful formative phase

• “Social marketing is a processprocess for influencing human behavior on a large scale, using marketing principles for the purpose of societal benefit rather than for commercial profit”

Bill Smith 1999

• = "the application of marketing technologiesmarketing technologies developed in the commercial sector to the solution of social problemssolution of social problems where the bottom line is behaviour changebehaviour change."

• It involves: "the analysis, planning, execution and evaluation of programs designed to influence the voluntary behaviourvoluntary behaviour of target audiencestarget audiences to improve their personal welfare and that of society."

Alan Andreasan

Social marketing

• IS AUDIENCE CENTERED– SM researches the audience to find out what

segments make sense to target, and what they believe, perceive as norms, want, fear, and need

• IS CONCERNED WITH “UPSTREAM” AND “EXTERNAL” (STRUCTURAL & SYSTEM) FACTORS– Change those first if you can

• EASILY LINKS WITH CHANGE THEORIES• IS COMMITTED TO GOOD MESSAGE DESIGN

Change theories – key domains for SocMarktg

PERCEIVED

ADVANTAGESe.g., positive expectancies;

predisposing factors (aware, know, agree); acceptability,

compatibility, low complexity

PERCEIVED

CONSEQUENCESe.g., outcome expectancies; perceived severity of threat;

personal susceptibility to neg. & pos. consequences

PERCEIVED

SOCIAL NORMSe.g., normative beliefs about

what peers and persons whose opinion matters to you

believe

SELF-EFFICACYe.g., confidence in

behavioural capability/skills and sense of control

regardless of complexity or difficulty of situations

SYSTEM / STRUCTURAL FACILITATORS

e.g., clarity of what is “ideal”;“cues” to do XYZ; easy information flow & access within & across

reference groups; a clear institutional policy;

feedback with data; champions; opp’ties to observe, to try, & to be

rewarded

Do I know about & value it?

Who matters to me? Do they endorse it & do it? Are they paying attention?

What bad or good things happen if I do it or don’t? What do I have to give

up? What do I get in exchange?

Is it easy to do?Do I have the confidence & skills to do it whatever the circumstances?

Also: segmentation & stage

Steps/Principles in Social Marketing

• Do theory-informed, empirical, formative research to understand the problem, the context, and who the players are, what they do & think, & what matters to them.

• Figure out what you can do or offer the key players that makes XYZ easy and important from their perspective.

• Apply the highest structural/system action possible first.• Develop and deliver messages to persuade players that

by doing XYZ they will get benefits that they want.

What kinds of messages are most likely to reach the audience, be memorable, be actionable, and actually make a difference?

Messages should • establish a CConnection• promise a RReward• inspire AAction, and

• stick in MMemory

Here is Katya Andresen’s recommendation, from her new book, Robin Hood Marketing: Stealing Corporate Savvy to Sell Just Causes

CRAMCRAM

Found googling images for <“hand washing” hospital>

Is it memorable?

Will people notice it?

Will they remember it?

Will they read the small print?

Will they act on it?

Does the msg resonate with a benefit that people want?

WILL HE REACH 20? billboard

SM - What Makes an Effective Campaign?

• Conducting Formative Research – garnering feedback from and about the target audience on the behavior under study, initial versions of campaign messages, &campaign channels under consideration for use.

• Using Theory – employing a behavioral theory as a conceptual guide

• Segmenting Audiences – dividing audiences into one or more homogenous groups for purposes of targeting campaign messages.

• Effective Message Design – using message design theory & formative research to create msgs thought to be effective w particular audience segments.

• Effective Channel Placement – strategically placing messages in appropriate channels (e.g., TV, radio, print media) widely viewed by the target audience, in order to ensure high exposure to campaign messages.

• Process Evaluation – following campaign implementation closely to ensure that a campaign plan is effectively put into action, as well as making “mid-course corrections” where necessary.

• Outcome Evaluation – where possible, employing a sensitive outcome evaluation design that allows firm causal conclusions regarding the impact of the campaign to be made.

Formative research

• OBJECTIVE = increase daily physical activity [sustained brisk walk or more] to a minimum of 30 minutes a day, 5 times a wk

• AUDIENCE SEGMENTATION = including “staging” participants– Seminar students – healthcare providers

• THEORY: 3 basic constructs + structural/environ’l factors• DOER – NONDOER ANALYSIS

OTHER OPTIONS -- Spending 30 quality min/day with your childOR -Handwashing before seeing every patient

From AED, Comparing Doers and Non-Doers: A Rapid Assessment Tool for Social Marketing Programs, 1998.

• These 3 determinants are … almost always a good place to start, if you have limited resources. – perceived consequencesperceived consequences– self-efficacyself-efficacy– social normssocial norms

• Within each of these, distinguish which are structural/ environmental factors and which are cognitive & interactional factors

• The Doer Non-Doer rapid assessment tool translates these determinants into a set of simple questions.

• Helps you determine differences between these groups

• What do the players know & understand about what’s expected [the target behavior]? Do they accept it? What advantages & consequences do they perceive?

• Do they have the self-efficacy to do it right? (confidence & skills, in complex situations)

• Are there social norms that support & reinforce the behaviors? (& Who is paying attention? Who matters?)

Theory in a Doer – NonDoer Analysis

• Perceived consequencesPerceived consequences– Knowledge, attitudes– Pros/cons, risk perception, decisional balance

• Self-efficacySelf-efficacy– Do I have not just the skills but also the confidence to

do XYZ in complex situations?

• Social normsSocial norms– Is this the kind of thing a person like my peers and I

do? Does it matter to people who are important to me?

The perceived consequences questions

• Question No. 2: What do you see as the advantages or good things that would happen if …XYZ…?

• Question No. 3: What do you see as the disadvantages or bad things that would happen if …XYZ…?

The self-efficacy questions

• Question No. 4: What makes it difficult or impossible for you to …XYZ…?

• Question No. 5: What makes it easier for you to …XYZ…?

The social norm questions

• Question No. 6: Who (individuals or groups) do you think would object or disapprove if you …XYZ…?

• Question No. 7: Who (individual or groups) do you think would approve if you …XYZ…?

• Question No. 8: Which of these individuals or groups in either of the two questions above is most important to you?

1. Do you get at least 30 minutes of exercise (a sustained brisk walk or more] a day, at least 5 days a week?

2. What do you see as the advantages or good things that would happen if you got exercise 5 days each week?

3. What do you see as the disadvantages or bad things that would happen if you got exercise 5 days each week?

4. What makes it difficult or impossible for you to get exercise 5 days every week?

5. What makes it easier for you to get exercise 5 days/wk?

6. Who do you think would object or disapprove if you get exercise 5 days every week?

7. Who do you think would approve?

8. Which of these individuals or groups in either of the two questions above is most important to you?

DOER – NON-DOER QUESTIONS TO ASKDOER – NON-DOER QUESTIONS TO ASK

Social marketing exercise summary

FINDINGS DOER NON-DOER

Ask: For what % of the doers is X an issue, and for what % of the non-doers is X an issue?

Social marketing exercise summaryFINDINGS DO NO-DO IMPLICATIONS

ADVANTAGES:

DISADVANTAGES:

FACILITATORS/ EASY:

BARRIERS / HARDER:

WHO APPROVES:

WHO DISAPPROVES:

PERCEIVED PERCEIVED CONSEQUENCESCONSEQUENCES

SELF EFFICACY SELF EFFICACY

SOCIAL NORMS SOCIAL NORMS

Social marketing exercise – Example

FINDINGS DO NON-DO

IMPLICA-TIONS

ADV - More energy 60% 20%

ADV - Feeling good 70% 45%

ADV – Appearance 50% 60%

DISADV - Stress of doing it 40% 60%

DISADV - Time, takes up time 70% 80%

DISADV - Injury, soreness, pain 60% 20%

EASIER: - Enabler (Ipods, weather, car, shower) 70% 40%

EASIER: - Time, having the 30% 80%

EASIER: - Social interaction 50% 50%

Social marketing exercise summaryFINDINGS DO NO-DO IMPLICATIONS

ADV:ADV:

ADV:ADV:

ADV:ADV:

DISADV:

DISADV:

DISADV:

FACIL:FACIL:

FACIL:FACIL:

FACIL:FACIL:

BARR:

BARR:

BARR:

Social marketing exercise summaryFINDINGS DO NO-DO IMPLICATIONS

APPROVES:APPROVES:

APPROVES:APPROVES:

APPROVES:APPROVES:

DISAPPROVES:

DISAPPROVES:

DISAPPROVES:

What do you do with this diagnostic information?

• First see if there are “umbrella” approaches – e.g., structural, systems, organization-based interventions - to addressing contextual, environmental barriers & facilitators

• Then assess the cognitive & interactional factors– Employ constructs from theoretical domains or a

“name-brand” theory

• Design multi-faceted approaches to address the factors that differentiate doers & non-doers

Pressing need for improvement -- but no clear path for how to do it