The comment I received from a student about the 'theory' class in social marketing spoke for not only students, but I expect many professionals.
This was the first behavioral theory class that I have enjoyed in a very long time. While learning about the theories was repetitive, I felt like I learned a more useful way to apply them to interventions. This was a nice break from prior classes that examined behavioral theory. The other enjoyable aspect of this particular session is that we learned about theories that were developed recently... and not in the 1950's.
What is a given for most social marketing and health communications programs is that they are based on theories from long ago and/or far away from the topic at hand. When I have done research into what theories people use in public health programs, practitioners can describe (maybe) one or two, and academics describe their own (developing your own theory must be a prerequisite for tenure now). That some authors want to impose a single theory on social marketers borders on malpractice.
People in the advertising and public relations worlds who work on social marketing projects don’t even know what a theory is – unless they have been in the game for a while. They want you to believe that their past ‘experiences’ give them a better feel for what will work with an audience than any textbook. What they often fail to intuit is that these ‘experiences’ form their own naïve or folk psychological theories. The difference between their theories and the ones in the textbooks? About several dozen to several thousand research studies validating them (and some will still argue ‘what do the researchers know! I do this for a living!’ Walk widely around them.).
Theories are helpful AND harmful for several reasons:
- Explains how or why things are related
- Guides you to what’s important
- What questions to ask
- What you should do about it
- How you should measure success
In other words, the theory you use – whether old, new or personal – frames the way you look at a problem, try to understand it, go about solving it and attempt to measure it (for example, not one epidemiological survey has ever give me a clue about HOW to change risk behaviors, only that it needed to be done for certain population groups).
I was recently called into a family planning project at the beginning (thankfully) to help develop an overall approach and strategy. The initial discussion included something like ‘We are going to use a theory-driven approach, you know, theory of reasoned action and stages of change, to enroll more women in our services.” At one level I appreciated the nod to the conscious and deliberate use of theoretical models from the outset, but I also shuddered at the choices.
Let’s take the first one today.
Nothing wrong with TRA, if you want to use a theory that even one of its originators has moved beyond. This is, what the student above referred to, as theory from the 1950s (well, not quite that long ago, but you get the idea). It is the canon for behavior change academics, one that must (?) be passed down to the graduate students of today for it’s historical importance – although, unfortunately, most of those instructors I expect still believe it to be operational. OK, now some reality for the TRA and TPB folks (and if you have to look those up, don’t worry, it means you are less susceptible to their influences).
The integrative theory proposed by Fishbein & Yser, I will say from the outset, has its detractors in the academic realm, mostly, I gather, because it includes too much. However, among the practitioners I have worked with, they find it a very useful and comprehensible road map for thinking about a variety of public health problems.
The integrative theory incorporates elements of 3 widely used theories in behavior change and communication interventions: the health belief model, social cognitive theory and theory of reasoned action. In this model, whether a specific behavior is performed depends upon (1) if one intends to engage in that behavior - which you can see depends on a whole lot of things, (2) if they have the requisite skills and abilities to perform the behavior, and (3) if there are no environmental constraints (broadly defined) to performing the behavior. Those are 3 pretty big IFs that research and social marketing efforts need to address.
Here’s an example of how the model was used in the strategic planning document for the family planning program:
To improve the likelihood of engaging in family planning behaviors then, we must first look at what environmental constraints may be preventing women from engaging in them and act on those (or help people overcome them).
Among the constraints identified in the audience research are the few facilities available in rural counties, busy clinic staff that makes local outreach and promotion efforts difficult, making time in their busy schedules for setting clinic appointments, and difficulties using the centralized referral service.
Second, we need to assess if the person has the necessary skills to access and effectively use family planning methods over time.
Here we found that not understanding the eligibility criteria (due to confusing messaging and low literacy skills) and non-adherence with birth control methods over time (discontinuing pills or missing doses, reports of broken condoms leading to unwanted pregnancies) were the most common problems reported by research participants.
However, if the person does have not strong intentions to perform the behavior, we need to look at changing (1) attitudes towards performing the behavior, (2) perceived norms about performing the behavior, and/or (3) the person’s perceived self-efficacy, or confidence in being able to perform the behavior.
Among the determinants of these intentions we found that conservative community values can play an important role in reducing conversations and public education activities around family planning. We heard few comments related to negative personal, peer or social attitudes towards their personally using birth control. Indeed, there were generally favorable attitudes about delaying pregnancy until the woman had graduated from school, had a steady job and boyfriend and otherwise was ‘ready’ to raise a child. We did not hear much about women believing they were not susceptible to becoming pregnant (though other research informs us that this is the most common reason from women to discontinue using contraceptives). There was also evidence that women do talk with each other about birth control, though no common times or places were discovered that might guide communication strategy.
Now some people will ask ‘what about…?’ And if you think that’s an important variable to consider, first make sure your audience does too. While I am not going to defend this particular theory as all-encompassing (that is why there will be a second installment to this topic), what you can take away from this is: the theory you use helps you to focus in thinking about the issue, asking relevant questions of your audience and forming program strategies that are both theoretically- and research-driven.