Optimism Day

Today in class we finally started covering theories about behavior that the professor thinks work.  Not to say (and he hasn't) that all the previous ones were worthless.  But now, we're into the good stuff.

First up was Diffusion of Innovation.  Having honed my skills in Paint this last week, I decided to make a wee graphlet for illustration:

Along the x-axis is time, and along the y-axis, for our purposes, is the percentage of people who have adopted the health behavior.  The appeal of this theory, as compared to the others we've talked about, is that it makes no claims about the mental states, motivations, or decisions of individuals.  It doesn't care whether behavior is (ir)rational or (un)planned.  Instead, it reflects the process of behavior adoption and consensus within a community or other group of people.¹

The first thing that occurred to me is that the "levers" aren't obvious like they are in, say, the Health Belief Model.  By this, I mean it's not clear what this model of behavior would lead you to do for a public health intervention.  The whole point is that individuals' behavior changes due to a kind of snowball of influence effect.  What are you going to do, seed the system with health nuts?  Send out plants into the community to hang out performing healthy behaviors?

Well, kind of.  Apparently the idea really is to have opinion leaders, or influential members of the community, act as so-called early-adopters of the behavior.  Then you hope that people will mimic their behavior, and so on iteratively, starting the upward curve of the graph above.

I understand how this might work with a very public behavior or choice, such as a fashion trend.  What I don't understand is how this is supposed to work with something like eating more fruits and vegetables, or condom usage.  The idea seems to be 'show, don't tell,' but many health behaviors just aren't amenable to public display.  Some are, like exercise, but many aren't.

And if the idea is to have the opinion leader try to convince people to adopt the behavior, well, then we're back to square one with just telling people how to act.  An in-group member might hold more sway, but frankly we just spent weeks becoming un-convinced that telling people how to act was at all effective, so I'm skeptical.

Another thing is problematic about this model to me.  I don't think that the loss of agency entailed is all twinkles and sparkle-stars.  I am fairly comfortable with demoting rational, chosen behavior to a lower place than Western thought in general wants it to be.  But the fact remains that people do have agency, and furthermore, people who are products of Western cultures believe that they are rational actors.  I don't think we can ignore that.  For example, what does this model give, say, a woman who has tried and tried to lose weight unsuccessfully?  It tells us/her that there isn't anything she can do.  Maybe if her friends at work all go crazy for spinning, and her neighbors all start growing vegetable gardens, she's got a shot.  But in her mind, the locus of control is herself, and she can't do it.

1 When I showed my brother the syllabus for this class, he said it seemed kind of Malcolm Gladwell-y, which was a good call. There were major props to The Tipping Point today.

Behavior Change

In class, we have been talking about behavior change - specifically, theories or models that purport to explain or describe the processes people go through when changing or when planning behaviors.  The presentation thus far has been along the lines of "look at these theories of behavior change," then "look at how comically inept they are at describing what we see happening in the real world."

There are two main flaws in these theories/models that are lightning rods for criticism in class and in the readings.  First, many of the theories operate on the level of a given individual's behavior, seemingly without the realization that behavior does not happen in a vacuum.  These theories overlook, or include only tokenly, interpersonal influences on behavior, as well as even wider factors such as institutional barriers to access and the like.

The second main flaw is that many of the theories assume that behavior is rational, like I mentioned.  What I mean by rational here is something along the lines of the product of thoughtful analysis.  It is simply not the case that a person thoughtfully analyzes the pros and cons of a given behavior, then proceeds to act in the maximally healthy/efficient/correct/productive/recommended manner.  Really, all the stages of that putative process - starting from the assumption that each action or health behavior has been preceded by a contemplative moment - are vulnerable to influence from the real world.

Sure, maybe you can model that.  Maybe it would look like this?  But then, what do you do with this model? What does it tell you?  How do you use it to create an appropriate intervention?

Two more things:

1.  One of the readings (finally) had some pointers on creating good, working interventions.  I made the following notes:
* Good public health isn't always about a novel product, slogan, or campaign.  Sometimes, it is about facilitating a good match between existing tools and a population.
* Educating or dispensing information isn't sufficient, but it is necessary.  Sometimes (not always) a lack of good information is a barrier.
* The interaction of access issues and self-efficacy.  A resource may be inaccessible or extremely difficult to access.  Or it may be moderately difficult to access and a person may have low self-efficacy on the issue of access.  A robust intervention addresses this issue as well as the health issue at the heart of the intervention.

2.  I have been trying to think of other areas where people are interested in changing other people's behavior.  Here's a list of some that I've thought of:
*Advertising/marketing (obvy)
*Education/schools
*Religious organizations (both in exhorting congregations to behave in a certain way, and in proselytizing)
*Motivational speakers
*Rehab centers of many stripes
*Jails (Is this true? Do modern incarceration systems attempt to rehabilitate people? I'm clueless!)