Health Problem Behavior Change Jan 3rd 2025

This is a good documents for Health financing

1. Module: Health and Communication Unit: Health Promotion and Behavior Change Prof. NYIRAZINYOYE Laetitia ( MSc , PhD) & Michael Habtu (MSc, PhD) January 2024

2. LEARNING OUTCOMES Explain the foundation of behaviour change Understand and determine social determinants of health Discuss the role of Health Communication / Health Education in the process of addressing health issues Describe Health Promotion strategies and approaches Apply BBC theories and develop a HP strategy to a specific Public Health problem 2

3. Course plan Day 1 (03/01/2023) Introduction to Health Education and Promotion Social Determinants of Health Introduction of group assignments … applying health promotion models Topics Group 1: Hypertention Group 2: Soil-Transimitted Diseases Group 3: TB Group 4: Malaria 3

4. Course plan……. Day 2 & wekend (05 -7/01/2023): Group assignments (home work ) Desk review of theories and models appllied for behaviour change Application of Behavior change theories to the Health issues assigned to each group in the littérature. Group assignment Introduction writing Day 4 (08/01/2023) Health promotion strategies Health Promotion related Measurement and Design: Research and Practice Day 5 & 6 (9th &10 th , January 2023) Group assignments : HP strategy development Day 7 (11 th , January 2023) In class presentation and discussion (30 minutes for each group) Course wrap up 4

5. In 4 groups:  Read provided materials  Discuss the Behavior change theories and their application to your assigned topic  Develop a Health Promotion strategy applied to the group assigned topic

6. Materials Ottawa Charter for health promotion. First International Conference on Health Promotion, Ottawa, Canada. 21 Nov 1986. Theory at a Glance A Guide For Health Promotion Practice: A Guide For Health Promotion Practice (Second Edition ). Barbara K. Rimer and Dr. Karen Glanz Health behavior theory for public health. Ralph DiClemente , Laura Salazar , Richard Crosby. 2 nd Edition. 2018 6

7. Instructions for group Presentations Prepare a 15-slides power point group presentation Title slide (max. 1) Overview of each theory : (1 slide each ) Stages of Change Theory or the T r a n s t h e o r et i c a l M o d el) Social Learning Theory (SLT) Community Organizational Theory (COT) Discuss theorie’s components for your topic (max. 2) Discuss limitations of each theory (max. 2) Present your group HP strategy (max 4 slides) Describe your resaerch methods to evaluating your group strategy (3 slides) NB: 1. Use of pictures , tables and figures is encouraged ! 2. All members have to present ( marking will be done on individual basis) 7

8. Grades 1) Attendance: 10% 2) Groups point group presentations ( individually ) : 20% 3) CAT (short multipe choice exam ) date TBD: 30% 4) Final Paper - HP Strategy ( narrartive report) to be submitted End of Feb , 2024: 40% 8

9. I. INTRODUCTION TO HEALTH PROMOTION AND HEALTH EDUCATION (Key Concepts) 9

10. Key concepts 1. Health Education: Health Education is an array (set) of procedures and strategies aiming at informing the individual / community on a health issue in order to help / support him / her in behaviour change process meaning in changing a behaviour at risk for Health ( a negative behaviour ) and in adopting a positive behaviour or in maintaining a good behaviour for Health. 10

11. Key concepts 2. Health Promotion: Health promotion is defined in the Ottawa Charter for Health Promotion (1986) as the process of enabling people to increase control over, and to improve, their health. == The Ottawa Charter identifies the prerequisites for individuals and communities to attain optimal health outcomes such as peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice and equity. 11

12. Key concepts 2. Health Promotion (cont’d) == The fact that the ultimate outcome of effective health promotion interventions is a healthy and productive generation makes it a socially justifiable investment that leads to improved social and economic development. ==Health Promotion is an array of interventions aiming at improving health status of the community. 12

13. Health Promotion Means Changing Behavior at Multiple Levels A Individual: knowledge, attitudes, beliefs, personality B Interpersonal: family, friends, peers C Community: social networks, standards, norms D Institutional: rules, policies, informal structures E Public Policy: local policies related to healthy practices

14. II. SOCIAL DETERMINANTS OF HEALTH 14

15. What are the social determinants of health? The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by: (Structural factors): Unequal distribution of power, income, goods, and services, globally and nationally, (Individual level factors): Consequent unfairness in the immediate, visible circumstances of peoples lives –their access to health care, schools, education, conditions of work/leisure, homes, communities, towns, or cities– and their chances of leading a flourishing life. This Unequal distribution of health- damaging experiences is not in any sense a ‘natural’ phenomenon…. but is the result of a toxic combination of poor social policies and programs, unfair economic arrangements, and bad politics.

16. THE SOCIAL DETERMINANTS OF HEALTH The greatest share of population health problems is attributed to the social and economic conditions in which people live their daily live Effective policy to tackle health challenges must therefore address the underlying social conditions that make disadvantaged people more vulnerable This emphasizes the need to focus on the “causes of the causes”

17. What are the social determinants of health? . https://www.gov.uk/government/publications/health-profile-for-england/chapter-6-social-determinants-of-health

18. To clarify these processes, WHO set the Commission on the Social Determinants of Health The Final Report of the WHO Commission on the Social Determinants of Health (CSDH 2008) declared that the poor health of the poor, the social gradient in health observed within countries, and the marked health inequities between countries are caused by: …. (available at: https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1 Structural factors: unequal distribution of power, income, goods and services, globally and nationally Individual level factors: consequent unfairness in the immediate, visible circumstances of peoples lives – their access to health care, schools, work opportunities, leisure, decent homes, social groups, etc , and their chances of leading a flourishing life 18

19. Contd Highlights the role of health across all government sectors and the need for policies to protect health (health in all policies) Calls for an “open” health sector : environment, water, sanitation, education, trade, transport housing, social policy, etc

20. Theories and Applications 20

21. Theories and their applications at the individual (intrapersonal), interpersonal, and community levels of the ecological perspective. Three key concepts cut across these theories: 1. Behavior is mediated by cognitions; that is, what people know and think affects how they act. 2. Knowledge is necessary for, but not sufficient to produce, most behavior changes. 3. Perceptions, motivations, skills, and the social environment are key influences on behavior. 21

22. What Is Theory? /Model? A theory is a set of concepts, definitions, and propositions that explain or predict these events or situations by illustrating the relationships between variables. They are, by nature, abstract, and don’t have a specified content or topic area. Like empty coffee cups, theories have shapes and boundaries, but nothing inside. They become useful when filled with practical topics, goals, and problems . Models may draw on a number of theories to help understand a particular problem in a certain setting or context. . It's commonly used to describe, or even simplify, the process of translating research into practice. Framework describes (but doesn't explain) factors believed to influence an outcome. 22

23. How Can Theory Help Plan Effective Programs? Theory gives planners tools for moving beyond intuition to design and evaluate health behavior and health promotion interventions based on understanding of behavior. It helps them to step back and consider the larger picture. Like an artist, a program planner who grounds health interventions in theory creates innovative ways to address specific circumstances. He or she does not depend on a “paint-by­ numbers” approach, but uses a range of behavior theories, skillfully applying them to develop unique, tailored solutions to problems 23

24. Explanatory Theory and Change Theory Explanatory theory describes the reasons why a problem exists. It guides the search for factors that contribute to a problem (e.g., a lack of knowledge, self-efficacy, social support, or resources), and can be changed. Examples of explanatory theories include the Health Belief Model, the Theory of Planned Behavior, and the Precaution Adoption Process Model. 24

25. Explanatory Theory and Change Theory (2) Change theory guides the development of health interventions. It spells out concepts that can be translated into program messages and strategies, and offers a basis for program evaluation. Change theory helps program planners to be explicit about their assumptions for why a program will work. Examples of change theories include Community Organization and Diffusion of Innovations. 25

26. Fitting Theory to the Field of Practice A useful theory makes assumptions about a behavior, health problem, target population, or environment that are: (1) Logical; (2) Consistent with everyday observations; (3) Similar to those used in previous successful programs; and (4)Supported by past research in the same area or related ideas. No single theory dominates health education and promotion, nor should it; the problems, behaviors, populations, cultures, and contexts of public health practice are broad and varied. Some theories focus on individuals as the unit of change. Others examine change within families, institutions, communities, or cultures. Adequately addressing an issue may require more than one theory, and no one theory is suitable for all cases. Effective practice depends on using theories and strategies that are appropriate to a situation. 26

27. III. BEHAVIOR CHANGE THEORIES USED IN HEALTH PROMOTION 27

28. T h e o r y/ M o d e l S u m m a r y K e y C o n c e p t s In d i vi d ual H e a l t h b el i e f m o d e l E. g. F o r p e o p l e t o a d o p t rec o m m e nd e d p h y sic a l a cti v i t y b e h a v i o r s , t h ei r p e r ce i v e d t h r e a t o f d i s e a s e ( a n d i t s s e v er i ty ) a n d b e n e f i t s o f a ctio n m u s t o u t w e i gh t h e i r p e r c e i v e d b a r ri e r s t o a ct i o n. Per c ei v e d s u s ce p t i b i l i t y Per c ei v e d s e v e r i t y Per c ei v e d b e n ef i t s o f a ctio n Per c ei v e d ba r r i er s t o a ctio n C u e s t o a ct i o n S e l f - eff i c a c y S t a g e s o f c hange (t r a n s t h e o r et i c a l m o d el ) I n a d o p t i n g h e a lt hy b e h a v ior s ( e . g . , r e gu l a r p h y sic a l a cti v i t y ) o r el i m i n a ti ng u n h e a lt h y o n e s ( e . g . , w a t c h i n g t e l e v i sio n ) , p e o p l e p r o g r es s t h r o u g h fi ve l e v e l s r e la t e d t o t h e i r re a d i n e s s t o c ha n g e — p r e-c o n t e m p l a t i o n , c o n t e m p l a t i o n, p r e pa r a t i o n, a ct i o n , a nd m a i n t e n a n ce . At e a c h st a g e , d if f e r e nt i n t e r v e n t i o n s t r a t e g i e s w i l l h el p p eo p l e p r o g r es s t o t he n e x t s t a g e . P r e -c o n te m p la t i o n C o n t e m p l a t i o n P r e pa r a t i o n A ct i o n M a i n t e n a n c e 28

29. H e a l t h b el i e f m o d e l 29

30. HEALTH BELIEF MODEL

31. Example ….HBM High blood pressure screening campaigns often identify people who are at high risk for heart disease and stroke, but who say they have not experienced any symptoms. Because they don’t feel sick, they may not follow instructions to take prescribed medicine or lose weight. The HBM can be useful for developing strategies to deal with noncompliance in such situations. According to the HBM, asymptomatic people may not follow a prescribed treatment regimen unless they accept that, though they have no symptoms, they do in fact have hypertension ( perceived susceptibility ). They must understand that hypertension can lead to heart attacks and strokes ( perceived severity ). Taking prescribed medication or following a recommended weight loss program will reduce the risks ( perceived benefits ) without negative side effects or excessive difficulty ( perceived barriers ). Print materials, reminder letters, or pill calendars might encourage people to consistently follow their doctors’ recommendations ( cues to action ). For those who have, in the past, had a hard time losing weight or maintaining weight loss, a behavioral contract might help establish achievable, short-term goals to build confidence (self-efficacy). 31

32. STAGES OF CHANGE THEORY 5. MAINTENANCE: practice required for the new behavior to be consistently maintained, incorporated into the repertoire of behaviors available to a person at any one time 4. ACTION: people make changes, acting on previous decisions, experience, information, new skills, and motivations for making the change 3. PREPARATION: person prepares to undertake the desired change - requires gathering information, finding out how to achieve the change, ascertaining skills necessary, deciding when change should take place - may include talking with others to see how they feel about the likely change, considering impact change will have and who will be affected. 2. CONTEMPLATION: something happens to prompt the person to start thinking about change - perhaps hearing that someone has made changes - or something else has changed - resulting in the need for further change 1. PRECONTEMPLATION: changing a behaviour has not been considered; person might not realize that change is possible or that it might be of interest to them. RELAPSE: at any point in the change process, the individual could relapse to the old behavior. The factors that contribute to relapse are complex and contextual.

33. Example ….stages of change theory Suppose a large company hires a health educator to plan a smoking cessation program for its employees who smoke (200 people) but only 50 joined the program By asking a few simple questions, the health educator can assess what stages of contemplation potential program participants are in. For example: Are you interested in trying to quit smoking? (Pre-contemplation) Are you thinking about quitting smoking soon? (Contemplation) Are you ready to plan how you will quit smoking? (Preparation) Are you in the process of trying to quit smoking? (Action) Are you trying to stay smoke-free? (Maintenance) 33

34. HUMAN BEHAVIOR CHANGE 2. Interpersonal-level health behavior models examine the individual existing within social environments Social Learning Theory The prem­ise of SLT is that people are influenced by, and are influential in, their social environments.

35. T h e o r y/ M o d e l S u m m a r y K e y C o n c e p t s In t e r p e r s o nal Le v e l S o c i a l l ea rn i ng/ s o c i a l c o gn it i v e t h e o ry The theory suggests that humans learn behaviors by observing others and choosing which behaviors to imitate . Behaviors that are rewarded are more likely to be repeated, whereas behaviors that are punished are less likely to be repeated. S e l f - eff i c a cy R ec i p r oc a l d et e r m i n i s m B e ha v i or a l c a p a b i l it y Ou tc o m e e x p e ct a t i o n s Ob se r v a t i o nal le ar n i ng T h e o ry o f r e a s on e d a c ti o n Suggests that a person's behavior is determined by their intention to perform the behavior and that this intention is, in turn, a function of their attitude toward the behavior and subjective norms A t tit u d e to w a r d t h e b e h a v i o r • Ou tc o m e ex p ect a t i o ns • V a l ue o f o u t c o m e ex p e ct a ti o ns S u b j e ct i ve n or m s • B e li e f s o f o t h e r s • D e s ir e t o c o m p l y w i t h ot h e r s T h e o ry o f p l a n n e d b e h a v i o r Assumes that individuals act rationally, according to their attitudes, subjective norms, and perceived behavioral control. . A t tit u d e to w a r d t h e b e h a v i o r • Ou tc o m e ex p ect a t i o n s • V a l ue o f o u t c o m e ex p e ct a ti o ns S u b j e ct i ve n or m s • B e li e f s o f o t h e r s • D e s ir e t o c o m p l y w i t h ot h e r s Per c ei v e d b e hav i or a l c o n tro l 35

36. SOCIAL LEARNING THEORY Concept Definition Application Reciprocal Determinism Behavior changes result from interaction between person and environment, change is biderectional Involve the individual & relevant others, work to change the environment, if warranted Behavior Captability Knowledge and skills to influence behavior Provide information and training about action Expectations Beliefs about likely results of action Incorporate information about likely results of action in advice Self-efficacy Confidence in ability to take action and persist in action Point out strengths, use persuasion and encouragement approach behavior change in small steps Observational learning Beliefs based on observing others like self and/or visible physical results Point out others’ experience, physical changes, identify role models to emulate Reinforcement Responses to a person’s behavior that increase or decrease the chances of recurrence Provide incentives, rewards, praise, encourage self-reward, decrease possibility of negative responses that deter + changes

37. Example …. Social Learning Theory A university in a rural area develops a church-based intervention to help congregation members change their habits to meet cancer risk reduction guidelines ( behavior ). Many members of the church have low incomes, are overweight, rarely exercise, eat foods that are high in sugar and fat, and are uninsured ( personal factors ). Because of their rural location, they often must drive long distances to attend church, visit health clinics, or buy groceries ( environment ). The program offers classes that teach healthy cooking and exercise skills ( behavioral capability ). Participants learn how eating a healthy diet and exercising will benefit them ( expectations ). Health advisors create contracts with participants, setting incremental goals ( self-efficac y). Respected congregation members serve as role models ( observational learning ). Participants receive T-shirts, recipe books, and other incentives, and are taught to reward themselves by making time to relax ( reinforcement ). As church members learn about healthy lifestyles, they bring healthier foods to church, reinforcing their healthy habits ( reciprocal determinism ). 37

38. Theory of Reasoned Action and Theory of Planned Behavior 38

39. Example …TPB/TRA Surveillance data show that young, acculturated women are more likely to get Pap tests than those who are older and less acculturated. A health department decides to implement a cervical cancer screening program targeting older women. In planning the campaign, practitioners want to conduct a survey to learn what beliefs, attitudes, and intentions in this population are associated with seeking a Pap test. They design the survey to gauge: when the women received their last Pap test ( behavior ); how likely they are to seek a Pap test ( intention ); attitudes about getting a Pap test ( attitude ); whether or not “most people who are important to me” would want them to get a Pap test ( subjective norm ); and whether or not getting a Pap test is something that is “under my control” ( perceived behavioral control ). 39

40. C o m m uni t y L ev e l Theories T h e o r y/ M o d e l S u m m a r y K e y C o n c e p t s C o m m u n i t y o r g a n i z a t i o n m o d e l P u b l i c h e al t h w o r ker s h e l p co m m un it i e s i d e n t i f y h e a lt h a nd soc i a l p r o b l e m s , a n d t h e y p l a n a nd i m p l e m e nt str a t e g i e s t o a d d r e s s t h es e p r o b l e m s . A ct i v e c o m m u n it y p a r t ic i pa ti o n i s e s s e n t i a l . L o c al i t y d e v e l o p m e n t ( civic associations, consumer cooperatives or neighborhood councils) S o c i a l p l a n n i ng ( such as housing, education, health, women’s development etc. ) S o c i a l a ct i o n (  based on social justice, democracy, redistribution of power, and decision-making ) D i ff u s i o n o f i nn ov a t i o n s Th e o r y Peo p l e , or g a n i z a tio n s , o r s ociet i e s a d o pt n e w i d e a s , p r o d u cts , o r b e hav i o r s a t d if f e r e nt r a t es , a n d t he r a t e o f a d o p t i o n i s a ff e ct e d b y s o m e p r e d i ct a b l e f a c t o r s . Relative Advantage - The degree the innovation is seen as better than the idea, program, or product it replaces. Compatibility - How consistent the innovation is with the values, experiences, and needs of the potential adopters. Complexity - How difficult the innovation is to understand or use. Triability - The extent to which the innovation can be tested or experimented with before a commitment to adopt is made. Observability - The extent to which the innovation provides tangible results. 40

41. III. HEALTH PROMOTION STRATEGIES

42. KEY HP STRATEGIES The Ottawa Charter identifies three basic strategies for health promotion: 1. Empowerment Of Individuals & Communities For Health Action – Enabling ) 2. Support For Creation Of Conducive Environments – (Mediation) 3. Advocacy For Health

43. Three basic strategies … Advocate – political , economic, social, cultural, environmental, behavioural and biological factors can all favour or harm health. Health promotion aims to make these conditions favourable , through advocacy for health . Enable – health promotion focuses on achieving equity in health. This includes a secure foundation in a supportive environment, access to information, life skills and opportunities to make healthy choices . This must apply equally to women and men . Mediate – the prerequisites and prospects for health cannot be ensured by the health sector alone. Health promotion demands coordinated action by all concerned, including governments, health and other social and economic sectors, non-government and voluntary organisations , local authorities, industry and the media . 43

44. Empowerment Taking action to empower individuals and communities for health action. Seeks to strengthen people’s health knowledge and skills they require to: Prevent disease Promote health Protect behavior that is favourable to health. Seeks to assist people to change un-healthy attitudes and behaviour

45. Empowerment - METHODS Methods used to implement empowerment actions: Health education Social mobilization: The process of bringing together all societal and personal influences to raise awareness of and demand for health care, assist in the delivery of resources and services, and cultivate sustainable individual and community involvement. IEC BCC: involves the development and implementation of communication messages, communication activities and a supportive environment needed to promote and sustain behavior change. Participatory community development techniques But all this process must be based on the specific context of a given setting or community

46. Conducive environment Mediating between different interests in society in pursuit of health Involves reconciling different interest of individuals, communities, and other sectors to promote and protect health

47. Conducive environment - METHODS Methods used to implement the creation of a conducive environment for health actions: Legislation … act or laws ( e.g : Affordable Care  Act ) Policy development (health supportive public policies)… distance to HF, smoking in public Reorientation of organization Negotiation Changing: Structures Services

48. Advocacy as an HPR Strategy Advocacy to create the essential conditions for health - refers to combination of individual and social actions designed to : Gain political commitment Policy support Social acceptance System support For a health goal or program.

49. Advocacy - METHODS Methods used to implement advocacy actions: Lobby Social marketing or marketing for good: is  a strategy that promotes positive societal transformation by focusing on influencing individuals' actions or ways of life rather than just selling an item or service. IEC Community mobilization Use of media

50. HEALTH PROMOTION: APPROACHES The Three Health Promotion Approaches: ISSUES – BASED APPROACH: – Addressing specific diseases , risk factors and the determinants (Diabetes, Violence, Injuries, nutrition, smoking, alcohol) POPULATION – BASED APPROACH: (Young people, women, elderly, displaced persons) SETTINGS BASED APPROACH : (school, community, workplace, cities, hospitals etc.)

51. 1. Issues – Based Approach Addressing a particular Health related issue/problem – tackling risk factors/modifiable & behavioural , & s ocio-economic & cultural determinants of health Examples: Diet and physical activity (DPAS) NCD CD SRH Alcohol/tobacco Mental health Violence & injuries

52. Issues – Based Approach (cont’d) ADDRESSING RISK FACTORS/BEHAVIOURAL E.G: Smoking Harmful use of alcohol Reluctance to use Insecticide-treated nets (ITNs) Reluctance to use condoms Reluctance to use contraception Reluctance to vaccination Drink-Driving Violence & GBV Drug use Delayed/late health care seeking Bad nutrition and physical inactivity

53. Issues – Based Approach (cont’d) CHANGES IN SOCIO-ECONOMIC STRUCTURES EXAMPLES: Social Less active physical activity (transport, TV, house technology, etc) Economic Higher availability of cheap processed foods (high fat, high carb .) Biological Preference for fats and sugar Cultural Social status, worry of disease, protection against disease (babies) Political-macroeconomic Overproduction of foods, competition, lobbies, interest to several economic sectors

54. 2. Population – Based Approach: Population based approaches principles: 1- use population based data 2- HP actions are geared towards shaping the selected population group overall health status

55. Population – Based Approach (cont’d) Examples of population groups: Students Community Teachers Health workers Adolescent and Young People Health volunteers Women Disadvantaged groups Men Adults Clients Elderly Prisoners Military

56. 3. Settings Based Approach (cont’d) The settings approach: an ecological perspective Individuals are inseparable from environment or settings where they live, work and play; The interaction is continuous and reciprocal; Health outcome is produced by these settings; Historical continuity threatens behavior change success

57. Health Promotion as an Integrative Response Addressing issues/problems in a combined manner Combining approaches/methods Bringing together various actors Integration refers to: Process-Knowledge and skills development, policies and legislation, and resource mobilization and referral Methods-health education, community, mobilization and advocacy Players-Government, various sectors, civil society and academia

58. Example: addressing causes of the causes” 58

59. IV. Measurement and Design Related to Theoretically Based Health Promotion, Research, and Practice 59

60. Introduction (1) Theories are useful in that they advance our understanding of the specific individual and environmental factors that greatly influence various health behaviors. Application of theory greatly depends on having sound measurement instruments for the theoretical constructs. Without the proper measurement tools, we can never be certain as to whether certain theories should be supported, confirmed , or swept into the theory dust bin . Although the measurement tools we use in health-promotion research and practice are qualitatively different from the sophisticated devices used by physicists, there are similarities. 60

61. Introduction (2) For example , we hold our measurement tools up to similar standards (e.g., physics is concerned with accuracy and precision , while health promotion is concerned with validity and reliability ). Just like physicists who attempt to measure particles or phenomena that are seemingly intangible, health promotion researchers also measure properties or characteristics of individuals, systems, and communities that are seemingly intangible , such as perceptions, attitudes, or norms. Testing theories (i.e., theoretical propositions) requires measuring constructs accurately, correctly, and in a scientific manner before the strength of their relationships can be tested. A fundamental challenge involves measuring intangibles (i.e., nonphysical entities that are nonetheless believed to exist). Self-efficacy, for example, is a fairly robust element in most of the individual-level behavioral theories. 61

62. History of Measurement of Intangibles 62

63. From Constructs to Variables (1) The public health theories have various psychological constructs, such as attitudes, as well as knowledge, abilities, and, of course, behavior. For example, attitudes form the basis of the theory of reasoned action and self-efficacy is at the core of social cognitive theory. B ecause much of what we do in public health research and practice is to examine how individuals, systems, and communities differ, we are interested in measuring constructs and behaviors that can take on more than one value which is a variable . In general, variables can be classified into one of two types: qualitative and quantitative. Qualitative variables use a nominal metric, whereas quantitative variables use ordinal, interval, and ratio . 63

64. From Constructs to Variables (2) For example, self-efficacy is typically measured using an ordinal metric by presenting statements theoretically related to the characteristic, followed by potential responses, which represent various levels of self-efficacy. An item from a self-efficacy measure could be the following statement: “I can solve most problems if I invest the necessary effort.” The presentation of this statement is followed by asking respondents to pick the best response from the following responses: 1 (definitely not true), 2 (somewhat untrue), 3 (neither untrue nor true), 4 (somewhat true), and 5 (exactly true). Because equal distance between these five ordered response options cannot be ascertained, this example constitutes using an ordinal metric for measuring self-efficacy. 64

65. From Constructs to Variables (3) Another example of a ratio measure would be a knowledge test. Knowledge has been identified as necessary, but not sufficient, to affect behavioral change. Knowledge of the risks and benefits of engaging in a certain behavior serves as the precondition for change. Thus , knowledge of various health issues is an important construct to assess. 65 Do you agree or disagree with this statement about health behavior: “Knowledge is enough to change behavior”? Why do you agree or disagree?

66. Developing Measurement Tools for Theoretical Constructs (1) 66

67. Developing Measurement Tools for Theoretical Constructs (2) For each specific construct, an operational definition is required. For example, an operational definition could be: “attitudes toward the flu vaccine will be measured using the scale developed by Montano .” If a tool exists, then we would simply state the name of the measurement tool as our operational definition; however, if a tool does not exist, then one must be developed most of the time a scale or index . 67

68. Constructing Scales and Indices S c a l es and i nd ic es are c o m po si te m ea s ures that u s e m u l t i p l e • i te m s to c o ll e c t i nfor m at i on about then u s ed to rank i nd i v i dua ls . a c on s tru c t. The s e i te m s are • E x a m p l es of sc a l e s : – – Depre ssi on sc a l e An x i ety sc a l e • E x a m p l es of i nd ic e s : – – S oci o-E c ono m i c Status i ndex Con s u m er pr ic e i ndex Rosenberg Self-Esteem Scale self-efficacy to refuse sexual intercourse scale A scale is a cluster of items (questions) that taps into a single domain of behavior, attitudes, or feelings. An index is a set of items (questions) that structures or focuses multiple yet distinctly related aspects of a dimension or domain of behavior, attitudes, or feelings into a single indicator or score.

69. G r aphi c a l Pr e s entatio n o f R elation s bet w een It em s and Construct for Scales and Indices • S c ale : e e D epre ss ion e • I nde x : So c ial E c ono m ic S t a t us 4 O cc upa t ion I n c o m e Edu c a t ion Sui c idal I dea t ion Sleeple s s F eeling s ad

70. W h y S c ale s an d I ndi c e s ? M ost soc i al pheno m enon of i n t e r est a r e m u l t i -d i m ens i onal cons tr uc t s and cannot be m easu r ed by a s i ng l e ques t i on , f or e x a m p l e: – W ell - being – V iolen c e W hen a s i ng l e ques t i on i s used, t he i n f o rm a t i on m ay not be ve r y r e li ab l e because peop l e m ay have d i ff e r ent r esponses t o a pa rt i cu l ar i dea i n t he ques t i on. The va r i a t i on of one ques t i on m ay not be enough t o d i ff e r en t i a t e i nd i v i du a l s. S ca l es and i nd i ces a ll ow r esea r che r s t o f ocus on l a r ge t heo r e t i cal cons tr uc t s r a t her t han i nd i v i dual e m p i r i cal i nd i ca t o r . 5

71. S i m ilar i tie s an d D ifference s be t w ee n S ca l e s an d Ind i ces B o t h tr y t o m easu r e a co m pos i t e cons tr uct or cons tr uc t s. B o t h r ecogn i ze t hat t he cons tr uct or cons tr uc t s have m u l t i p l e - d i m ens i onal a ttr i bu t es. B o t h use m u l t i p l e i t e m s t o cap t u r e t hese a ttr i bu t es. B o t h can app l y va r i ous m easu r e m ent l eve l s ( i . e . , no m i na l , o r d i na l , i n t e r va l , and r a t i o) t o t he i t e m s. B o t h a r e co m pos i t e m easu r es as t hey bo t h agg r ega t e t he i n f o rm a t i on fr om m u l t i p l e i t e m s. B o t h use t he w e i gh t ed sum of t he i t e m s t o ass i gn a sco r e t o i nd i v i dua l s. T he sco r e t hat an i nd i v i dual has on an i ndex or a sca l e i nd i ca t es h i s / her pos i t i on r e l a t i ve t o t hose of o t her peop l e . D iff erences: S ca l e cons i s t s of e ff ect i nd i ca t o r , but i ndex i nc l udes causal i nd i ca t o r s S ca l es a r e a lw a y s used t o g i ve sco r es at i nd i v i dual l eve l . H o w eve r , i nd i ces cou l d be used t o g i ve sco r es at bo t h i nd i v i dual and agg r ega t e l eve l s. M any d i scuss i ons on t he r e li ab ili t y and va li d i t y of t he sca l es, but f ew d i scuss i ons on t hose of i nd i ces. 6 S i m il ar iti e s :

72. Con s t r u c t io n o f Sc ales D e V elli s , R obe r t ( 2011) S c ale D e v elopmen t : Theo r y and A ppli c a t ions D e t e r mine c lea r ly w hat c on s t r u c t y ou w ant t o mea s u r e Gene r a t e an i t em pool D e t e r mine t he f o r mat f or mea s u r e m ent H a v e t he ini t ial i t em pool r e v ie w ed by e x pe r t s C on s ider in c lu s ion of v alida t ion i t ems A dmini s t er i t ems t o a de v elopment s ample Ev alua t e t he i t ems Op t imi z e sc ale leng t hs 7

73. Common Likert-Type Response Scales Used in the Social Sciences 73

74. Con s t r u c t io n o f I ndi c es B abb i e, E . ( 2010) s ugge s ted the fo ll o w i ng s teps of c on s t r u c t i ng an i ndex 1. S e l e c t po ssi b l e i te m s    De ci de how gene r al or s pe ci f i c y our v a r i ab l e w il l be S e l e c t i te m s w i th h i gh fa c e v a li d i ty Choo s e i te m s that m ea s u r e one d im en si on of the c on s t r u c t 2. E x am i ne emp i r ic al r e l at i ons  E x am i ne the emp i r ic al r e l at i ons among the i te m s y ou w is h to i n cl ude i n the i ndex 3. Sc o r e the i ndex – – – W hat the sc o r e r ange of i ndex i s W hat sc o r es a r e a ssi gned to r e s pon s es of the i tem Is the r e an adequate number of c a s es at ea c h po i nt i n the i ndex 4. V a li date the i ndex – – Item ana l y si s T he a ss o ci at i on bet w een th i s i ndex and other r e l ated mea s u r es 8

75. Reliability and Validity In health-promotion research, r eliability indicates the extent to which the scale or index consistently measures the same way each time it is used under the same condition with the same subjects. Validity refers to the extent to which the scale or index measures what it is supposed to measure. As is true in physics, a measurement used in health promotion could be highly reliable, yet not be a valid measure of the construct. 75

76. Ways of estimating the reliability of a measure Test–retest reliability: Apply the test at two different time points. The degree to which the two measurements are related to each other is called test-retest reliability Inter-item reliability : Apply only when you have multiple itemsto measure a single concept. In Statistics, we use Cronbach’s Alpha to measure inter-item reliability Reliability can also be estimated using a technique called the split-half method . Inter-observer reliability: When more than one observer to rate the same people, events, or places 76

77. Ways of estimating the validity of a measure Two of the most elementary techniques are face validity and content validity . Face validity: Experts decide if the scale “appears” to measure the construct . Content validity, on the other hand, experts decide if the items of a scale are relevant and representative of the range of possible items to measure the construct Another method or technique for determining construct validity is called factor analysis which is a statistical technique ( exploratory factor analysis) for assessing the underlying dimensions of a construct, if in fact they exist, and for refining the measure. Factor analysis is commonly used in the development stage of a new measure. 77

78. W ay s o f A ggrega t in g Ite ms Sc a l e sc o r es Ite m s c ont r i bute d i ffe r ent l y to the l atent fa c to r s unde r l y i ng the s e i te m s S um sc o r es a r e obta i ned by w e i ght i ng and agg r egat i ng i tem sc o r es together Index sc o r es Ite m s c ont r i bute d i ffe r ent l y to the i ndex ( or c omponent) sc o r e s . Index ( or c omponent) sc o r es a r e obta i ned by w e i ght i ng and agg r egat i ng i tem sc o r es together 24