The Temporal Shape of Behavior

Wayback Machine: I wrote this post in February 2010 and never finished it. I still think it's mildly interesting, so I'm tossing it up here as-is. The next class I'm taking - Intervention Design and Development to Reduce Health Disparities - I expect will take up the question of models of behavior change again. In the interim I (and my classes) have focused more on societal-level solutions to public health problems.

I just made up the terminology in the title of the post. I'm sure there's been thinking done on this question that I don't know about, probably in more than one field. And there's probably a real name for what I'm talking about! But for now -

Health behaviors vary widely in their "temporal shape," by which I mean things like duration, frequency, pattern, and schedule. For example, there are things like vaccination, which occur at most once or twice a year (for adults anyway). There are tests that should be done every few years or even just once a decade until you get past fifty or sixty. On the other end of the spectrum, there are behaviors like washing your hands or smoking, where the opportunity to do or abstain from the behavior presents itself multiple times each day. Healthy eating falls into this category - for food-secure people, each day presents multiple occasions of eating or choosing not to eat, as well as offering the choice between healthier and less-healthy foods. Exercise is an example where it runs the gamut, from multiple times per day for a few people, to never for others, with most people somewhere in between (it'd be interesting to see if that's a bell curve - I'd guess no). Some health behaviors are quite situational - for example, wearing sunscreen or taking other skin-safety measures (Although I think the actual recommendations are probably to wear sunscreen every day).  Or consider alcohol intake - this can run the gamut from frequent to infrequent, as well as varying on the magnitude axis - and you could even say its health value (positive/neutral or negative) switches somewhere in the middle.

The models of behavior that function on the individual level pay attention to an individual's thought processes or internal psychological states. Given the wide variety of temporal shapes of health behaviors, it seems we should be paying attention to the interaction of those characteristics with the models we're using. For example, take the Theory of Planned Behavior, which incorporates an individual's perception of the health outcomes of a behavior and their perception of the social norms regarding that behavior. For a frequently-repeated behavior such as eating, does the model describe the psychological state of a person immediately prior to or during eating on each occasion? Or does it describe a general state of mind, not in flux, that governs eating on any occasion?

The professor of my course has claimed that the Health Belief Model works quite well "on simple, one-time decisions such as vaccination." I'm curious to know more about that result and what other behaviors respond well to interventions based on that model. If they are all of that temporal shape, that can tell us something important about when to use and when not to use that theory.

These questions offer another lens through which to look at the Diffusion of Innovation theory.  At first blush, it is uninterested in the temporal shape of a behavior, since all that is required is that a behavior be contagious.  On the other hand, if a behavior occurs extremely sporadically, it's not going to be visible enough to catch on, even if it is the kind of thing where people are influenced by observing the actions of others.

Readin', Writin', and Procrastinatin'

Updates on Class

You know, if I didn't have class and classwork, I'd have a lot more time to blog about class. The semester is drawing to a close - I'm done with all the reading and am concentrating on my second paper.

My first paper was about cognitive dissonance and handwashing among health care workers, inspired in part by my first post in which I thought about behaviors that should not be affected by issues of access. At that point, inequity and inequality of access were a more major part of my understanding of poor health outcomes and unhealthy behaviors. During this semester, I've developed a more sophisticated and I think more accurate understanding of these issues.

What I ended up discussing in my paper, in part, was the idea that it is often difficult or impossible to know why it is that people fail to do healthly behaviors or participate in unhealthy behaviors. I proposed an intervention that attempts to circumvent this problem by making the health behavior a desirable activity for reasons unrelated to its health value, and instead tying it to a person's self-concept.*

Writing the paper was hard - it's been a few years since my last academic paper, and I really want to make a good impression in this class. I think I made a strong case within the confines of my chosen subject, but in truth the intervention I suggested probably isn't a very good idea. Oh well.

Now I'm very excited about the next paper, which is much longer. The assignment is to critique a public health intervention on the basis of the social/behavioral theories covered in class and propose changes to the intervention that would make it more effective. I've chosen to write about text4baby. Text4baby is a mobile-phone based intervention that aims to reduce the rates of premature birth and infant mortality by providing information to pregant women and new mothers via text message.  What's novel about this intervention is (pretty much only) the delivery method.  The aforementioned problems are worse among lower-income and minority women, and mobile phone use among those groups is higher than internet use. So the idea is to meet these women in a medium they use and are comfortable with, and provide them with helpful information that way. There are things I like about this intervention, but I also didn't find it too hard to come up with the required three criticisms. Well, I usually don't have a hard time being critical, so there's that, too.

*I'm using this term in the way it was used in the cognitive dissonance literature, which I don't think is very widely accepted. It's something like: a person's belief that s/he is moral, competent, and able to predict his/her own behavior.

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!)

Am Anfang

Before class today I popped up to the 12th floor library and checked out a book that At Your Cervix recommended, Midwifery and Childbirth in America by Judith Pence Rooks.  I'm a little nervous about my first birth-related book.  I have a bad habit of obsessing over a topic, then checking out a stack of books and never reading any of them - losing interest because the effort involved in continuing to learn is too great.  I'll keep you updated on progress.

In other news, class was fun.  This was the session I'd sat in on last semester, so the material was familiar.  We covered the Health Belief Model and the Theory of Reasoned Action, both in much simpler form than Wikipedia presents.  The professor is making the argument that most public health interventions are based on these or similar models, which are inaccurate representations of human behavior.  One of the texts for the class is Dan Ariely's Predictably Irrational, which I read after sitting in last semester.  I am definitely willing to buy that we should stop depending on human behavior to be rational.  What I haven't heard yet is an example of a successful intervention based on a model that takes this into account.

It also occurred to me to wonder if you get better results from these models for health behaviors that are less dependent on broad issues (socioeconomics, social inequity, lack of access, etc.).  The only example I can think of at the moment is hand-washing, say in the US, so we can assume the presence of clean water, bathrooms with soap in public places, and so forth.  Also assume with me for the moment that hand-washing habits are not greatly shaped by fundamental, underlying factors like those mentioned above.  Can you motivate people to adopt better hand-washing habits using one of the models above?  Is it that the models just completely don't capture behavior-related decision making, or is it that behavior-related decision making is usually so much more complicated and tied to all these other things?