Assignment 8 details:

Please see the following excerpt of a semi-structured interview transcript regarding pregnant women’s experiences with resources, such as social support, and stressors: PC_Respondent_28
The following interview guide was used for the entire interview.  The excerpt encompasses the first four questions in the interview guide: Interview guide

The goal of this qualitative study was to explore the salient resources that are believed to foster positive health outcomes by pregnant women from various socioeconomic levels. The study took place at a prenatal clinic in a rural Wisconsin town and largely comprised low socioeconomic status participants.

Using the “new comment” function under the “Review” tab on Microsoft Word, please conduct content analyses on the transcript to identify a priori and emerging themes regarding resources and stressors that the pregnant respondent has undergone thus far in her life and how these relate to her health. If you would like to manually mark up the transcript instead, please feel free to do so–just scan and submit your document. 

Once you have completed your analyses, please summarize your responses to the following four questions in a 1 page double spaced typed paper using 12-pt. Arial or Times Roman font. 

1) Please discuss the a priori codes that you employed during the open coding stage of your analysis.

2) Please discuss the exploratory codes that emerged during the open coding stage of your analysis.

3) Please discuss the emerging patterns and links you found during the axial and/or selective coding stages of your analysis. 

4) Please discuss the implications of your findings for Public Health research, policy or practice. 

***Please be sure to submit TWO documents for this assignment — the marked up document illustrating your analysis of the interview and your paper containing the responses to the above questions.

***Please refer to the PowerPoint lecture provided in Week 6, the supplemental readings provided in Weeks 6 and 7, and any additional resources you find when completing this assignment.

***Please note that there is NO right answer here–I am basically looking for thoughtful explanations for your selected codes.  The goal of the assignment is to practice qualitative data analysis and interpretation–this is a challenging task, but you will get better with practice 🙂 

Chapter 6, 7, and 8:
behavior change at the intrapersonal, interpersonal and environmental levels

Dr. Michael Reger

PUBH 520: Health Behavior and Health Promotion in Public Health

Hi everyone! This week, we will apply the ecological model even more and talk more specifically about behavior change at the individual, interpersonal and environmental levels.
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Questions of the WEEK
What are the major theories at the intrapersonal level?
What are two key learning behavior theories?
What are the key components of the A-B-C Model of Behavior Change?
What are some salient concepts/theories at the interpersonal level?
What are the key components of social network structure?
How do social networks influence behavior?
What are some social-influence-oriented interventions?
What are some different types of environments?
What are some environmental interventions that have been conducted to change three specific behaviors (diet, physical activity, HIV/AIDS prevention)?

Our questions of the week include:
What are the major theories at the intrapersonal level?
What are two key learning behavior theories?
What are the key components of the A-B-C Model of Behavior Change?
What are some salient concepts/theories at the interpersonal level?
What are the key components of social network structure?
How do social networks influence behavior?
What are some social-influence-oriented interventions?
What are some different types of environments?
What are some environmental interventions that have been conducted to change three specific behaviors (diet, physical activity, HIV/AIDS prevention)?

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Intrapersonal level theories
Health Belief Model
Transtheoretical Model/Stages of Change Theory
Theory of Planned Behavior
Social Cognitive Theory

First, we will start talking about behavior change models at the intrapersonal level, including:
Health Belief Model
Transtheoretical Model/Stages of Change Theory
Theory of Planned Behavior
Social Cognitive Theory
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Health belief model
Perceived susceptibility
Perceived severity
Perceived benefits
Perceived barriers
Cues to action
Self-efficacy

So, among intrapersonal level theories of behavior change, we start with the Health Belief Model.
The Health Belief Model was originally developed in the 1950s by the US Public Health service to figure out why people were not using the free mobile X-ray screening for TB. In short, the model describes how an individual’s perceptions affect the likelihood that he will take health-related action. The model has 6 components. To help you better understand the model, I will apply the model to an example of an obese 25-year old woman who is not interested in engaging in physical activity.
Perceived susceptibility: If a person believes they are at risk or susceptible to the disease or outcome. EX: “Heart disease only happens to old people or men…why should I care?’
Perceived severity: If a person thinks the outcome has serious consequences. Ex: “Heart disease rarely ends in heart attack and even then, can’t you just have surgery?”
Perceived benefits: If a person thinks there are benefits to the desired behavior. EX: “Exercising now and starting this lifestyle now will play a big part in lowering my risk of heart disease.”

Perceived barriers: If a person thinks the benefits outweigh the barriers. EX: “I don’t have time to exercise…I just started this new job! I can’t afford joining a gym!”
Cues to action: If a person is exposed to factors that prompt action. EX: “My aunt died from heart disease at age 50. so maybe I should think about exercising now…”
Self-efficacy: If a person believes he/she can successfully carry out the action. EX: “I believe I can stick to an exercise plan and lose weight.” Self-efficacy is particularly important, because it may vary by the complexity of the behavior as well as the context (e.g. it is easier to have self-efficacy in skipping dessert after dinner at home versus at one’s favorite restaurant).
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Transtheoretical model/Stages of change theory

Now let’s talk about the Transtheoretical Model, or the Stages of Change Theory
An important part of this model is that people go through stages when making behavior change, rather than making a lot of changes at one time. Again, I will use the example of an obese 25-year old woman who is not interested in engaging in physical activity.
So we start with:
Precontemplation: This is when it is not even in the individual’s radar that they need to make any changes in their behavior. Action: Try to determine what the right time would be for the individual would be ready to change. ex: Let her know casually that there is a worksite wellness program. Maybe the right time to bring it up is when the she complains that she get out of breath when she walks from the parking lot to the office.
Contemplation: The individual actively thinks about the health risk and what they need to do to reduce their risk. However, he/she doesn’t actually plan any behavior change. Action: Highlight some of the short-term benefits of exercise, rather than long term benefits (preventing chronic disease)—maybe being able to walk without getting out of breath, being introduced to a new fun sport/social activity with worksite wellness, losing weight, feeling better and having more energy, stress relief. Also, make sure you record the baseline info (how much does she exercise now—ask her to keep a log for 1-2 weeks of current activity)
Preparation: This is when the individual actually makes a plan for change and sets a timetable. Actions: Help her develop some feasible, measurable goals—exercise 15 min a day on treadmill, twice a week…try this out for 1 month and then increase intensity. Also, help her avoid things that may get in the way of the behavior—e.g. eating a heavy meal and then feeling sleepy, not getting enough sleep the night before. Also, offer other support like peer support through the worksite wellness program.
Action: The person actually makes a MEANINGFUL behavior change, but there is a chance he/she may relapse to old habits. Action: Give positive reinforcement for change (incentives/prizes for participating in worksite wellness program or losing certain amount of weight), give positive feedback and support and also know that she may get frustrated and stop exercising. Also emphasize social support/peer support and take things one day at a time
Maintenance: The person basically incorporates the desired behavior into permanent lifestyle change. If they are working on stopping a negative behavior (e.g. smoking), we would want him/her to attain termination of the behavior completely. Action: Reinforce methods for exercising—e.g. how she can continue exercising regularly after worksite wellness program ends; what kinds of things should she keep avoiding that keep her from exercising; what kind of social support does she need to keep exercising (e.g. exercise buddy)?
Further, we have to keep in mind that individuals may not progress through the stages in a linear fashion; people may move in and out of various stages and relapse to previous stages. We also need to think about one’s readiness to change and how it is related to the type of behavior we are trying to change. For example, quitting smoking is pretty clear-cut, but trying to lose weight is multidimensional. Therefore, one may be ready to reduce caloric intake but not ready to exercise regularly.
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Precontemplation

Actions: Prognosticate

Contemplation

Actions: Motivate change

Preparation

Actions: Plan change

Action

Maintenance

Actions: Reinforce change

Actions: Maintain change in order to reach termination

Theory of planned behavior

Then, we have the Theory of Planned Behavior—this is the idea that behavior is basically determined by intention. And what is intention influenced by? One’s attitudes about the behavior, beliefs about whether people important to him approve or disapprove of the behavior, and belief about how much control he has over performing the behavior.
Attitudes toward behavior is determined by behavioral beliefs (exercising at a younger age will prevent heart disease in the long run) and evaluation of behavioral outcomes (I don’t want to get heart disease).
Subjective norm is determined by normative beliefs (my family and friends would approve of me exercising) and motivation to comply (I care about what other people think…).
Perceived behavioral control is determined by control beliefs (beliefs pertaining to facilitators or impediments to engaging in desired behavior—e.g. “I hate getting all sweaty when I exercise, and I hate when my heart races”; “Having an affordable gym nearby is convenient so that I can stop by after work to exercise”) and perceived power (perception of how easy or difficult it is to engage in behavior given the facilitators and impediments—e.g. “The gym is affordable and on the way home from work, and I can start slow with the exercise so that my heart just doesn’t start racing and so I don’t feel uncomfortable”).
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BEHAVIOR

Behavioral intention

Attitude toward behavior

Subjective norm

Perceived behavioral control

Behavioral beliefs

Evaluation of behavioral outcomes

Normative beliefs

Perceived power

Control beliefs

Motivation to comply

Social cognitive theory
Self-efficacy
Observational learning (modeling)
Expectations
Expectancies
Emotional arousal
Behavioral capability
Reinforcement
Locus of control

Reciprocal Determinism

The final intrapersonal theory we will discuss is the Social Cognitive Theory, which originates from Social Learning Theory and basically focuses on the interactions between individuals and their systems as a way to promote behavior change. Basically, it states that changing behaviors requires us to understand cognitive and personal factors (knowledge, skills, attitudes), environment cues or events (peer influence, family support, neighborhood characteristics, work and school environment) and then the interaction between these things.
So it basically uses this concept of reciprocal determinism, which means that there are interrelationships between person-related factors, their social environment, and the health behavior. And if you change one thing, you can essentially change them all somehow. So if you change someone’s attitudes about exercise, they may exercise and then this may get them to start hanging out with healthier peers or they may become role models for their families or friends to also change their exercise behavior
So the social cog theory involves 8 factors:
Self-efficacy – person related factor, belief is one’s ability to take action—I CAN adopt an exercise program
Observational learning (modeling): learning by watching others in their social environment—my co-worker Michelle has started exercising regularly and has kept up with it for a year
Expectations – likely outcome of a certain disease – Exercising will help me lose weight, relieve stress, meet new people, and have good long-term health
Expectancies – the value placed on the outcome of the behavior—losing weight and relieving stress are really important so that I can look and feel better
Emotional arousal – emotional reaction to a situation—when I exercise, I feel better—endorphins are released
Behavioral capability – knowledge and skills needed to engage in the behavior – I need to see what affordable exercise programs there are in my area, or I need to find out where there are available walking or biking trails in my area, I need to learn the best type of exercise I should do to lose weight quickly
Reinforcement – rewards or punishments for performing a behavior—When I don’t exercise, I am too lazy to hang out with my friends; when I do exercise, I look more attractive and am more energetic and people want to be around me
Locus of control – belief of personal power over events – Only I can make myself exercise; I have control over my own actions
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Behavior

Environment

Person

Learning theories
Classical conditioning
Operant conditioning

Now that we have discussed how people may change their behavior at the intrapersonal level, we also need to consider the ways in which people tend to learn. There are two key learning theories, which you have probably heard of before: classical conditioning and operant conditioning.
Classical conditioning: This was first discovered by Ivan Pavlov and explains the process of frequently pairing a stimulus with an emotional or behavioral response. For example, the act of smoking can be paired with feelings of relaxation after repeated “smoke breaks” in which the person steps outside a hectic office to have a cigarette. Therefore, when a person feels stressed or wants to take a break, the first thing that may come to mind is smoking.
Operant conditioning: This is learning that occurs as a result of rewards or punishment for behavior. When a person performs a certain behavior that results in a positive consequence (reward), he or she will be more likely to do the behavior again. This is called reinforcement, or the process of increasing or decreasing a specific behavior using a system of consequences. For example, when someone goes one week without smoking, positive reinforcement would be putting all the money they saved not buying cigarettes to go shopping for something fun at the end of the week. This positive reinforcement may make it more likely for the person to stick to their smoking cessation program.
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A-b-c Model
Antecedents
Identify triggers for behavior
Behavior
Consequences
Identify consequences that increase, maintain, or terminate behavior
Behavior Change
Interventions to modify antecedents
Interventions to modify consequences
Basic Behavioral and Social Science Research (b-BSSR)

Further, we know that theories of behavior change provide proposed explanations and models of health behavior, but the disciplines of basic behavioral and social science contribute more empirically based proposals for mechanisms and processes of behavior change. Thus, the NIH has adopted a basic Behavioral and Social Science Research (b-BSSR) to incorporate basic sciences for more effective clinical and PH interventions. The classic model of intervention using b-BSSR approach is the Antecedent-Behavior-Consequence (A-B-C) model. Based on basic behavior science of behavioral conditioning, learning and motivation, this model emphasizes causal relationships between antecedents, consequences and behaviors.
Antecedents come before the behavior of interest and serve as triggers for that behavior. These triggers may be environmental (e.g. for eating unhealthy food, they could be advertisements, sales on unhealthy food), sensory (e.g. smell of food, appetite), emotional (e.g. boredom, loneliness, depression, happiness), intrapersonal (e.g. belief state), or interpersonal/social (e.g. friends going out to eat).
Consequences that follow a behavior serves as a reinforcement, which increases or maintains the behavior that follows. Here is where positive reinforcement or rewards come in. Reinforcement can also be negative, which means you remove an aversive stimuli after the desired behavior (e.g. reducing insurance premium after smoking cessation). Also, punishments can be used if the person does not do the desired behavior (e.g. increasing the insurance premium if failing to quit smoking).
Basically, the figure shows us that we can work to change behavior by developing interventions to modify the antecedents/triggers of behavior or interventions to modify the consequences of behavior. In turn, all of these interventions are, of course, informed by b-BSSR.
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Interpersonal level concepts
Social Cognitive Theory
Social identities
Social Comparison Theory
Diffusion of Innovations Theory
Social capital

Now’s let’s shift gears and talk about some salient concepts and theories at the interpersonal level. We know that the opinions, thoughts, behaviors, advice, and support of those around us—including peers, family members, friends, coworkers, sex partners, health professionals, and others—influence our behavior and ultimately, our health. Concepts/theories at the interpersonal level include:
Social Cognitive Theory: This theory is applicable at both the individual and interpersonal levels as it contains components from both of these levels. I have already gone over this theory in this lecture. At the interpersonal level, the components of modeling and reinforcement given by members of one’s social networks (e.g. praise, membership into certain social group, etc.) are relevant. Also, the backbone to the SCT is reciprocal determinism, which is the dynamic interaction between the individual and the environment in which they continually influence each other (adjustments in the environment cause changes in the individual and their behaviors, and the adoption of new behaviors can cause changes in the environment and the individual).
Social identities
Social Comparison Theory
Diffusion of Innovations Theory
Social capital
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Social identities

Further, we have found that social identities may have powerful influences on behavior. When individuals identify with a group, the collective group concept becomes part of their self-concept. Then, the self is redefined and the individual’s behaviors become more like the group’s goals and actions. Therefore, if you can change the group norm to engage in a healthier behavior, then individuals within the group may be more motivated to adopt this behavior as part of their social identity. Social identity may be linked to membership in groups, neighborhoods, professions, sports teams, ethnic identity, and behaviors.
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Collective group concepts (goals and actions)

Self-concept

Social comparison theory

Next, it has been proposed that an individual’s attitudes and behaviors are influenced by reference groups, which are clusters of people that serve as reference points for behaviors and attitudes. People look to other people in their social environment as a guide to what constitutes appropriate behavior. According to the Social Comparison Theory, individuals not only look at the behaviors of others as a guide, they also COMPARE their own behaviors to those of others. In other words, through observing others’ behaviors and comparing their own actions, norms about which behaviors are appropriate for a given social environment emerge. Also, the most important reference group is one’s social network. For example, adolescents are more likely to smoke if their peers also smoke and especially if an important social network member (best friend, boyfriend, girlfriend) smokes.
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Individual Attitudes and Behaviors regarding smoking, eating and exercising

Reference group for smoking behavior

Reference group for eating behavior

Reference group for exercising behavior

Diffusion of innovations Theory

Next, we have the Diffusion of Innovations Theory. The diffusion of innovations theory is a widely used theory of behavior change at the population level. This theory focuses on how to promote a new idea or practice (an innovation) in a population—the theory includes the innovation itself, the communication channels used to get information about the innovation to the population, the time it takes to adopt the innovation, and the social system in which this all takes place.
Innovation: This is an idea, practice, or object that is new or perceived as new by your target audience (E.g. the HPV vaccine for teens). Things to consider with an innovation are its relative advantage (the extent to which it is better than the idea, practice, or product it is trying to replace), compatibility (it aligns with the values, past experiences, and needs of target audience), complexity (how much difficulty will the target audience have in using it?), trialability (the degree to which it can be experimented on target audience), and observability (the degree to which it can be observed by potential adopters and those around them).
Communication channels: These are the means by which information is shared between two or more people. Mass media channels (e.g. TV) can share information on a large scale, whereas interpersonal channels (e.g. face-to-face meeting) can share information on a smaller scale. Mass media channels are important to create public awareness about an issue or to convey small pieces of information about an innovation. Interpersonal channels are better for persuading individuals to actually adopt the innovation.
Time: This entails three key concepts, including the innovation-decision process, adopter categories, and rate of adoption. The innovation-decision process is the process by which individuals gain information about the innovation and decide whether or not to adopt it. This process has 5 steps, including knowledge (learning new information about the innovation—e.g. there is a new HPV vaccine available, HPV is one of the most common STDs out there and can lead to cervical cancer; cervical cancer can be fatal once you get it but may be easily prevented by using HPV vaccine); persuasion (forming a favorable or unfavorable attitude about innovation–e.g. positive: getting my 15-yr old daughter the HPV vaccine will help prevent her from getting cervical cancer in the future; negative: getting my 15-yr old daughter the HPV vaccine will make her think I’m okay with her having sex at this age); decision (deciding whether or not to adopt the innovation–e.g. Deciding to take daughter to get vaccine); Implementation (Initiating use of the innovation; e.g. The mother takes her daughter to get the vaccine); and confirmation (either continued adoption or rejection of innovation, later adoption or discontinuation of adoption–e.g. The mother can decide whether or not to take her younger kids to get the vaccine when they become teenagers). Further, adopter categories are the five categories based on time of adoption of an intervention, including innovators, early adopters, early majority, late majority, and laggards. The majority of adopters tend to be early majority (34%) and late majority adopters (34%), and the innovators only make up 2.5% of all adopters of the innovation. Finally, the rate of adoption is how fast the innovation occurs over time. Usually, there will be an S-shaped curve if you graph this out—In the beginning, there will be a few innovators, followed gradually by other adopter categories until only a few laggards remain.
Social systems: This entails sets of interrelated units, such as members of a community, group, or organization that work towards a common goal or set of objectives. There are certain factors that can facilitate or hinder the adoption of an innovation in a social structure, including homophily (the tendency of people to join with others who are similar to them in some way), system norms (set behavioral patterns that are characteristic of a certain group), and opinion leaders and change agents (popular members of a community who can influence others into adopting or rejecting the innovation).

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Innovation

Communication channels

Time

Social systems

Social capital

Next, we have the concept of social capital, which has been conceptualized as a phenomenon that links individuals together through their collective actions and enables them to access resources through processes of trust, cooperation, bonding, and formation and perpetuation of social norms. Social capital is basically formed from the norms of reciprocity (helping each other out) and mutual trust (trusting each other) in a social network. Resources flow through networks, based on who is in the network and the roles that they occupy, and resources may be provided directly by close networks or indirectly through secondary or tertiary members. Numerous studies have shown that having greater social capital has been linked to better physical and mental health and the reduction of disease. There are two key dimensions to social capital:
Bonding social capital: Relationships among people who share similarities (belonging to same family, organization or neighborhood). This reinforces group identity.
Bridging social capital: Relationships among people who are not similar but have shared associations or goals (e.g. relationships among work colleagues or members of different religious institutions).
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Social capital
Norms of reciprocity and mutual trust in social network

Bonding social capital

Bridging social capital

Social network structure

Further, at the interpersonal level, we really focus on the importance of social networks in influencing behavior. A social network is a set of individuals who are connected by relationships. Social network members may be directly or indirectly linked by behaviors, emotions, group memberships, social position, physical settings, or a specific type of interaction (drug sharing, sexual contact, etc.) There are two types of social networks:
Egocentric networks: One individual who is the focal individual, along with his/her social ties. Eg. Egocentric networks for students may be there friends, family members, partners, neighbors, mentors, and classmates.
Sociometric networks: These link individuals (or nodes) and may be considered bonded groups. For example, if we took a class roster, we could if there are friendships between classmates (with 1’s) and lack of friendships between classmates (with 0’s). A pictorial example of a sociometric network is Fig. 7.1 on Page 106 in your textbook.
Further, social network structure refers to who is in the network and what relationships exist among members. Components of social network structure include:
Network size: # of network members
Direction of relationship: unidirectional or bidirectional
Multiplexity: Number of relationships between focal individual (ego) and a network member. This is measured by the # of network members named in two or more functional or relational network domains
Density: Proportion of individuals within a network who are linked to each other divided by the number of possible links.
Centrality: Individuals within the network with the highest numbers of direct and indirect ties.
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Social network: Egocentric or Sociometric

Network size

Density

Centrality

Direction of relationship

Multiplexity

Social network functions

Now that we have described the components of social networks, let us discuss HOW social networks may shape behavior:
As a source of social support and resources: Social network members may provide social support to each other, and social support has been highly associated with positive health outcomes. Social support is intangible or tangible resources offered by one person to another, such as emotional, informational, financial, and material support. Social support may be either perceived or enacted. Perceived social support is the individual’s perception of the type and amount of support he/she is receiving from social network members. On the other hand, enacted social support is support that has been actually provided by social network members. Perceived support is often important for psychological wellbeing, whereas exacted support is often important for caregiving relationships. Interestingly, social support from social networks is particularly important for low-SES individuals as these networks often provide resources that are necessary for basis survival.
As a source of interpersonal conflict: While social networks can support much-need social support, they can also be a source of conflict. Stress caused by problematic social networks have been shown to have a greater impact on health outcomes compared to supportive networks, though in a negative sense,of course.
As a source of social norms: Social networks also influence behavior through the creation and enforcement of norms. There are collective norms and perceived norms. Collective norms are established by the group or social systems. On the other hand, perceived norms are the norms as the individual perceives them. For example, college drinking may not the norm, but students may perceive it as being the norm and therefore engage in this behavior. Also, perceived norms can be descriptive or injunctive. Descriptive norms are our perception of the behaviors practiced by others in our social environment, whereas injunctive norms are our perception of the behaviors, attitudes, and beliefs that are considered appropriate or acceptable in a social group.
Overall, both egocentric and sociometric networks have been used to learn how diseases spread through a social network. For example, there is a strong relationship between egocentric network factors and substance use and HIV-risk behaviors among the very poor populations in the US and internationally. Network characteristics (network size, composition and density, or how close members are to each other) have been linked to HIV-risk behaviors, such as sharing injection equipment, drug use cessation, having multiple sexual partners, same sex partners or unprotected sex, exchanging sex for money and age mixing of sex partners (having sex with partners who are much older or younger).
An application of the use of sociometric networks is the longitudinal Framingham Heart Study, which examined sociometric social network factors and changes in various health issues such as obesity, smoking, depression, happiness, and alcohol use. They found that participants were substantially more likely to drink heavily if a person they are directly related to also drank heavily. This effect was even observed within three degrees of separation (friend of a friend of a friend). In terms of happiness, they found that happiness was clustered within networks—members of social networks who were surrounded by happy people were more likely to be happy in the future.

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Source of social support and resources

Source of interpersonal conflict

Source of social norms

social-influence-oriented interventions

Now that we have learned more about the structure and functions of social networks, let’s discuss different types of social-influence-oriented interventions. There are two types of such interventions:
Interventions that alter social norms: These interventions focus on changing individual perceptions of their referent group norms. These interventions are often implemented on a community-wide scales and may use multimedia campaigns like billboards, radio and TV. One behavior that this type of intervention has impacted is smoking—in the past, smoking was seen as glamorous (e.g. in Mad Men), and now it is considered social unacceptable. Further, we know that college students often overestimate how much their peers drink alcohol, and this leads to them drinking more. In one particular intervention, they had students use wireless keypads to indicate how much they thought their peers drank and how much they drank…these responses were instantly displayed on an overhead screen in order to correct this misperception.
Peer-based interventions: The goal of peer-based interventions is to use social networks as a way to disseminate information and resources about health promotion and disease prevention. There are two types of peer-based interventions:
Popular Opinion Leader Model: Popular opinion leaders are individuals with high centrality (having a high number of direct and indirect ties or being a person whom resources tend to flow through) or those who are rated by network members as important sources of health information or advice. Once these individuals are identified in a social network, we then train them to disseminate health-related information, promote various health messages, and model health behaviors to fellow network members. This approach has been really effective in HIV risk reduction among gay men in urban settings. Bartenders were identified as popular opinion leaders and were trained to disseminate HIV prevention information to bar patrons.
– Network Oriented Peer Educator Model: This model is based on the assumption that individuals in all positions and that many members of the network can be trained in leadership, communication, and social influence skills. An example of this is the HIV/AIDS prevention intervention (SHEILD) used in Baltimore, in which current and former drug users were trained to conduct HIV prevention outreach to people in their social networks and communities.

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Interventions that alter social norms

Changing individual perceptions of their referent group norms

Peer-based interventions

Popular Opinion Leader Model

Network Oriented Peer Educator Model

Types of environments

Now that we have discussed behavior change at the intrapersonal and interpersonal levels, let us discuss behavior change at the environmental level. Environmental influences (especially those from the social environment) are often less tangible and are less often the target of interventions due to this. However, environmental interventions often deliver “more bang for the buck” because negative environments tend to drive multiple unhealthy behaviors. Therefore, even modest interventions at the environmental level may address multiple behaviors (e.g. adding walking trails to a community may help people increase their physical activity and then be motivated to be healthier in general—eat healthier foods, drink more water, and also walking trails may encourage people in the community meet or form walking groups and therefore build more social cohesion and social capital).
So, first, let us think about what we mean by environment. There are four types of environments:
Geographic: Comprises residential space of individuals and location of home within their neighborhood, city and region; also their activity space (where they work, go to school, shop, and spend leisure time); Also includes the travel routes taken to get to activity spaces and home (e.g. car, bus, train, highways, etc.).
Social environment Extends beyond geographic environment and includes things such as culture (including popular culture), religion, social norms, social networks, modes of communication (TV, social media, etc.), etc….
Compositional: The composition of the community is the aggregate description of individual characteristics (e.g. percentage of people in a community who have a college education)
Contextual: This extends beyond compositional environment and assigns qualities/characteristics to the whole neighborhood/community—e.g. being a low-SES neighborhood, etc. The contextual environment is especially important because social context (neighborhood characteristics, etc.) affect individual health, over and above the individual’s characteristics. For example, even if a person is highly educated but lives in a low SES-neighborhood, they are still more likely to have a lower quality of life. On the other hand, even if the individual is lower SES and lives in a higher-SES neighborhood, this may be protective because they can still access the shared resources of the neighborhoods (e.g. access to higher quality healthcare, stores with nutritious foods, and clean and safe physical activity spaces).
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Geographic environment

Social environment

Contextual environment

Compositional environment

Types of environmental interventions

Finally, let us discuss some environmental interventions that have been conducted to change three specific behaviors:
Diet: Most interventions aimed at changing people’s eating behaviors have been at the individual level. However, we need to keep in mind that the social environment influences what, how, when, and how much we eat. For example, factors such as food cost, access to supermarkets and other food sources, prevalence of fast food restaurants, culture and social influence all contribute to our food-related behaviors. Environmental interventions can be developed in a variety of settings, including schools, work sites, and community retail stores to address these aspects of the social environmental and improve food-related behaviors. Interventions that address food availability or information in place at the area where food is being purchased have shown success in positively impacting food choices. Food availability interventions increase the availability of healthy foods and may even decrease the availability of unhealthy food. Further, information provided at the point of purchase, such as nutritional content, cost comparisons, and promotion of healthful selections, can help people choose healthier foods. The book provides some great examples of environmental interventions to influence eating behaviors on pgs. 125-126.
Physical activity: The built environment is the part of the physical environment that has been modified by humans. It includes transportation systems, land use, public resources (parks), zoning regulations, and buildings (schools, homes, workplaces). Inadequate access to exercise facilities such as safe recreational parks and sideways may lead to physical inactivity. Also, perceived neighborhood safety, social support and social capital all impact one’s likelihood of engaging in physical activity as well. Environmental intervention to increase physical activity levels include strategies such as informational approaches (point-of-decision prompts to use stairs instead of elevators) and behavioral and social approaches (school-based physical education, social support interventions). One popular type of environmental intervention to increase physical activity is the development of walking groups in the community. You can see some examples of walking interventions on pgs. 127-128 in your textbook.
HIV/AIDS prevention: Here, we will discuss the use of economic incentives as a means of improving health-related behaviors in low-resource populations. These incentives are meant to change the economic dynamics at the group level (families, villages) and because these interventions tie economic incentives to specific behaviors, they serve to change the behavioral norms among cultures and societies; therefore, they may change behaviors among people not directly funded. There are different types of economic incentives used:
– Microcredit interventions: These offer very small loans to impoverished individuals who would otherwise lack the collateral to borrow from banks. They create the capacity for group problem solving and empowerment in settings where borrowers, such as women, may not have previously had opportunities to work with their own economic incentives.
– Microfinance interventions: These go one step further than microcredit and are often coupled with other methods to improve people’s financial wellbeing (insurance, savings programs, and business training). Additional interventions along with financial assistance often include literacy and education or targeted interventions for health and nutrition education. A great example of how microfinance has been applied to HIV/AIDS prevention is the Sonagachi Project in India, which my colleague Dallas Swendeman from UCLA led. This project was geared toward female sex workers and used four strategies among the intervention group to help empower women: community mobilization, microfinance, rights-based framing and advocacy. They also used a control group , who received standard STD care, condom promotion, and peer education. The effects of the intervention included disclosure of profession and reframing of sex work as valid work, more positive thoughts about the future, desire for education, increased social support and interpersonal networks, financial savings and skills in both condom negotiation and refusing undesirable transactions.
– Conditional cash transfer: These provide direct payments rather than loans, and these payments are tied to the achievement of certain behaviors or goals. The idea behind this is to break the intergenerational cycle of poverty in families and so for example, mothers would be paid for their children’s school attendance, well-child medical visits, or nutrition-based behaviors, and then it is hoped that the child will become a healthy adult with maximum earning potential who can give back to the family.
 
19

Diet

Focus on increasing healthy food availability and providing nutrition information at place where food is purchased

Physical Activity

Focus on enhancing built environment to increase opportunities to engage in physical activity

HIV/AIDS Prevention

Use of economic incentives (microcredit, microfinance, and conditional cash transfer) to change behavior in low-resource settings

Focus on modifying social environment to promote physical activity

PC_Respondent_28

Interviewer/Interviewee

Interviewer:
Like I said earlier, I’m interested in learning about the types of things that have helped women get through stressful times and achieved good health. Good health can include many things. It could mean your good overall health, having a healthy pregnancy, having a healthy baby, good physical health, good mental health, any number of things.

To start with, I would just like to know a little bit about the people in your life. Can you tell me—and this could be your partner, your family members, your friends, a support group, coworkers—who gives you support on a regular basis?

Interviewee:
My mom is my biggest supporter, I think. She’s been there throughout. My first two pregnancies was kind of rough. The father wasn’t helpful. He was in and out of jail. My mom was always there for me. I think if I wouldn’t have had my mom and I’d be pregnant again, I think I’d be lost. I might’ve probably wouldn’t even have gone through this pregnancy this time. I’m a single mom, so raising a baby by myself can—with two older kids is probably the biggest stressor, plus working a full-time job and paying bills full-time myself. I give my mom the most respect, and she’s been probably my biggest stress reliever.

Interviewer:
Okay. Great.

Does she lives close to you?

Interviewee:
Yeah.

She lives about five minutes away, so—

Interviewer:
Oh, that’s helpful.

Interviewee:
– and it’s just—she’s a phone call away. She’s not working right now, so she—it helps.

Interviewer:
Okay. How old are your other children?

Interviewee:
I have a six-year-old and a nine-year-old.

Interviewer:
Oh, okay, so a little bit older?

Interviewee:
Yeah. My six-year-old will be seven in November. Her birthday’s actually [personal information removed] and I’m due November 7th.

Interviewer:
[Cross talk 01:43].

Interviewee:
I’m hoping it doesn’t fall on her birthday.

Interviewer:
Right, so she’ll not feel as special anymore. [Laughter]. I understand.

Interviewee:
Mm-hmm.

Interviewer:
When you talk about your mom supporting you, tell me specifically how she supports you?

Interviewee:
If I’m ever in need of anything, toilet paper or milk or certain days I work and daycare’s not open—she’ll come take my kids.

Interviewer:
Okay, so childcare.

Interviewee:
If she feels that I’m having a stressor, she’ll take my kids overnight for me so I can have a night to myself. We go out to eat. She calls me on a daily basis so I have somebody to talk to. She listens to everything. She gives me criticism, but like a normal mom. She supports in any way that she can, basically.

Interviewer:
Okay. Does she help you financially?

Interviewee:
Yeah. She helps me pay my—she helps me with my bills. She helps me if I need to borrow money for—say I’m short on rent or whatnot, she’ll help me with that, and then I help her back. We go back and forth with one another, and it’s—financially, emotionally, physically, mentally—my mom is my supporter.

Interviewer:
All sorts of support?

Interviewee:
Yeah.

Interviewer:
Financial support, like you said, helping you with tasks like childcare and some of that?

Interviewee:
Yeah.

Interviewer:
Then the emotional support and giving you advice when you need it?

Interviewee:
Yeah.

Interviewer:
Okay. Do you have anyone else that you count on, like friends or other family?

Interviewee:
There are moments in time where—my spouse.

Interviewer:
Your spouse? Okay.

Interviewee:
Yeah. He’s a supporter, too, but he’s also a stressor.

Interviewer:
You said you were a single mom, so—

Interviewee:
Yeah.

Interviewer:
– is that your ex-husband?

Interviewee:
I’m not married. It’s the father of this child.

Interviewer:
So it’d be your partner? Okay.

Interviewee:
Yeah.

Interviewer:
My other father of my child—I don’t—there’s no communication. We have a seven or ten-year restraining order against one another.

Interviewee:
Okay.

That was for your other children?

Interviewer:
Yeah, for my other two kids.

Interviewee:
Okay.

Interviewer:
This one, we have our moments, so if I need his support, he’s there to talk to me, but he also has another daughter that he has to take care of. It’s—I don’t know. Hopefully, after this baby’s born, it’ll be a little bit different. I’m just taking it day by day with him, but mainly, the person that I always run to or go to is my mom.

Interviewee:
Your mom? Okay.

Interviewer:
Just because she’s most dependable. My other siblings and family members—they have their own stuff that they have to deal with. I don’t wanna put my stress or my pain or my agony on them and make them ten times worse. They have their own families and everything. I know my mom’s my mom, so any [inaudible 04:33] in time, she’ll be my number one supporter.

Interviewee:
Right.

I understand.

Interviewer:
I’d rather go to her than burden somebody else.

Interviewee:
Okay. Are your siblings and your other family also close by?

Interviewer:
Oh, we’re all close. We’re real close. Me and my brothers—we talk every day. Me and my sister—we talk about once or twice a week. Her sons and my daughters play together all the time. They’re like best friends.

Interviewee:
Oh, so you have playdates? Okay.

Interviewer:
Yeah.

No, our families are real close. We’re very family oriented. We all stick together, so anytime we can have a grill out or a cookout or just birthday parties or going to the beach—it’s not just me, my mom, and my kids. It’s me, my mom, my sister, her kids, my brother, and my brother just found out that he’s gonna be having a baby, so—

Interviewee:
Oh, wow. Congratulations. Great.

Interviewer:
– now we got more talking about that, so my mom’s gonna have two grandkids in the next year.

Interviewee:
Nice, so you have sort of a network in your family?

Interviewer:
Yes. It’s one big network. It’s not just seeing them once a year. It’s seeing them five to eight times a month, basically.

Interviewee:
Okay. Good. We talked a little bit about childcare, like you get—you said your kids go to daycare, but your mom helps with that—emotional support, which you get from mostly your mom, and then financial support which your—does your partner help with that at all?

Interviewer:
Yeah. He helps when he can. Right now, he’s going through a child support battle.

Interviewee:
Okay. With the other? Okay.

Interviewer:
Yeah, so right now, the money that he does make basically goes to child support, and then whatever he has left—it’s going towards what we need.

Interviewee:
Do you feel you could count on him for financial support when it comes to your child, at least?

Interviewer:
Yeah. When it comes to my child, yes. He’s a good father. I’m not stating that. His number-one priority is his kids, so he puts them first before anything else, and then he’ll put whatever else needs to be—he wants to make sure that—‘cause his other daughter doesn’t live with him, so he wants to make sure that he is able to support her and that she has everything she needs, knowing that if she needed somebody to fall back on, he’s there. He gives me the same support like that. It’s just when it comes to my emotional or my stressor or physical or anything like that, I just feel that that’s between a mother and a daughter to talk about.

Interviewee:
Sure. I understand. Right. Okay. You talked a little bit about this already, but I wanted to know a little bit more about your community. Community, again, can mean many different things. It can mean your neighborhood, your extended family that we talked about, members of—like a church, a religious institution. First of all, what do you consider your community to be?

Interviewer:
My community is my family. I have close friends. We don’t see or talk to each other on a daily basis like me and my best friend, which is the aunt of my child, but whenever—I guess she could be a supporter, too, but whenever I need her and she’s available, she’s there. I’m a Baptist, so I don’t really go to church every Sunday, but on holidays, Easter, Thanksgiving, Christmas. My daughters really wanna go back, so we’re thinking about going back. Part of my community would be my family at work.

Interviewee:
Your extended family—oh, at work? Okay. Sure, your coworkers.

Interviewer:
Yeah. They can see when I’m stressed out or whatnot, and they’ll just sit down and be, like, “Hey. How are you?” I’ll be, like, “[Groaning noise].”

Interviewee:
You kinda have someone to just kind of vent to or talk to?

Interviewer:
Yeah. Basically, I have a lot of people I can vent to, so my community is just everybody that’s around me. I’m a very friendly and outgoing—I guess you could say I’m outspoken, too. I’m not blunt to the point where I’m gonna be rude to somebody—

Interviewee:
Right.

Interviewer:
– but I’m not gonna keep something back and hold it. I’m gonna be, like, “This is my opinion on this. I’m sorry if you take it the wrong way, but that’s my community is everybody around me.” It’s not just one certain set thing. It’s just whoever’s around me. I consider you a friend, and then my family is my main—

Interviewee:
Your main source of—

Interviewer:
Yeah.

Interviewee:
Okay. How ‘bout neighbors?

Interviewer:
My neighbors are old.

Interviewee:
Okay.

Interviewer:
They’re nice. They give the girls Christmas presents and Easter baskets and Valentine’s cards.

Interviewee:
There’s some interaction? Okay.

Interviewer:
Yeah.

Interviewee:
Our backyard is my girls’ playground where we live—we live three blocks away from the school, so a lot of people in my area—they’re really older, and then you get closer to the school, and then there’s the kids.

Interviewer:
The young families? Okay.

Interviewee:
I live on a main street. The closest thing to me is a bar.

Interviewer:
Okay.

Interviewee:
That’s not really community friendly.

Interviewer:
Kid-friendly, yeah. The backyard probably helps them a lot. Okay. That’s a good support.

Interviewee:
Or the school. The school is a good supporter, too—good community helper. They do a lot of summer activities. Tonight, they’re doing the back-to-school event where they help kids with backpacks and school supplies and clothes and food and music.

Interviewer:
That’s great. That’s been an important support to you, to your children, you would say?

Interviewee:
Yeah.

Interviewer:
It sounds like you kind of have a close relationship with your school, with their teachers?

Interviewee:
My nine-year-old has ADHD, so that’s also a stressor on me because—

Interviewer:
Sure.

Interviewee:
– she has her mood swings. The school’s a really good help with finding the right resources, after-school help, during-school help. If she has a bad day, the social worker’s there. Social workers are a good part of my community too. They help me out with if I ever needed any funding or anything or help with clothing or whatnot, they’re in that, too.

Interviewer:
Is she on a medication?

Interviewee:
I take her off for the summer. I’m actually, after my doctor’s appointment, I gotta go set up an appointment for her and my other daughter.

Interviewer:
Yeah. That must be hard.

Interviewee:
They have to do physicals before school.

Interviewer:
Right. Right. Okay. Does the social worker sort of help with that process, too?

Interviewee:
[Cross talk 10:54]. Yeah. They communicate with the doctors and everything to make sure that—she was on Concerta, 36 milligrams, but I took her off of that. It just didn’t seem like it was working anymore, so this year, we’re gonna try something different, and they wanted her to—they want her to start two weeks before school starts so it’s in her system.

Interviewer:
Okay, so then she kinda gets—right.

Interviewee:
When we go back two weeks, we can let the teachers know, “She’s been on it for two weeks. [Cross talk 11:22]. We’re gonna do another month’s study to see how well it goes and then we’ll proceed from there.” Mainly, it’s her attention—her attention span last year was ten seconds. Unless she’s very, very interested in that, then she’s right there. I’ve noticed that it’s changed, that she’s more into arts and music.

Interviewer:
Okay, so that’s sort of more attractive to her?

Interviewee:
Yeah.

Interviewer:
Okay. Great. We talked a little bit about your mom, and we talked about your extended family, and we talked about the school being a support, and then you mentioned that you go to church sometimes. Are members of your church also—

Interviewee:
Actually, I work with a member of my church. She’s known me since I was six, seven years old. They’ve seen me grow up, and now they’re seeing my kids grow up and everything. They don’t pressure or anything. My church isn’t like a type of church where they pressure you into being a supporter of God and everything like that, ‘cause I have my beliefs and my disbeliefs. They respect that. I think I just wanna do it for my kids. They like going. They like learning about him.

Interviewer:
Okay, like a community? Okay.

Interviewee:
Yeah. They have Sunday school and everything like that.

Interviewer:
Do they go to Sunday school? Okay.

Interviewee:
We’re gonna be starting, actually, ‘cause I just now got my Sundays off.

Interviewer:
Okay. Great.

Interviewee:
Oh, good. She’s moving.

Interviewer:
I understand.

[Laughter]. You’re having a girl. That’s nice.

Interviewee:
Yeah. She didn’t move yesterday but maybe twice, so it made me nervous.

Interviewer:
Oh, I understand. Yeah.

Interviewee:
I’m just sitting there. I’m, like, “Oh, my God.”

Interviewer:
I think it’s still a little early where—for them to move all the time.

Interviewee:
Mine constant. It’s just this last week has been a really big—it’s been hard. I think I’m got the early baby blues. I just want her out.

Interviewer:
I understand.

Interviewee:
I’m having more heartburn and more anxiety and everything. I think she’s grown more hair or getting big. I feel like I’m running out of space.

Interviewer:
[Laughter]. Yeah. I understand. I understand that. Actually, you’re kinda bringing us to our next point. Let me just finish up on this point. Members of your church—how else do they support you? Do they come over?

Interviewee:
No, nothing like that. I haven’t been attending that much for them to know where I live or anything like that.

Interviewer:
Okay, so you go there, basically?

Interviewee:
Yeah. I keep church separate from home.

Interviewer:
Okay. Tell me a little bit about—is faith important to you, personally?

Interviewee:
My faith and what I believe is important to me. What other people believe—I’m not judgmental, so I keep my faith to myself. I believe there’s a God. I believe that there is a Heaven and there is Hell. I believe that people are destined to go where they need to go where they need to go to. I’m not gonna sit there and preach to them about it. If they wanna sit and talk about it, I’m not gonna be judgmental. I’ll listen. Atheists have their rights to their own beliefs. Catholics have their rights to their own beliefs. I’m not gonna sit there. I’ll listen. I’ll attend your church. I’ll see how it is, but I’m not gonna judge you about it. That’s not me.

Interviewer:
Okay. We’ll come back to your faith a little bit later. You kind of just touched on this, but can you tell me about an especially stressful or difficult time that has had a negative impact on your health? You mentioned that your past two pregnancies were tough. What did you mean by that?

Interviewee:
My other daughter’s father was very abusive, so physically, mentally, and emotionally. For five years, it was really rough for me. I was the only supporter. I was the only one working. I was the only one paying bills. I was the only one taking care of the kids, cleaning the house, cooking, everything. I was a single parent. Even though he was there, I was still doing it all.

I was working two full-time jobs being seven months pregnant, working from 4:00 a.m. to 6:00 p.m. at night. That was my stressor there. After five years, once my youngest daughter hit two months, I couldn’t take it anymore. I’m, like, “You know what?” He went to jail for domestic abuse—felony domestic abuse and attempted murder on an unborn child. I went through that, and then I just—for the next—well, let’s see. We’ve been together for a year so for the next five years, I’ve been doing it on my own.

I’ve had my supporters. I have my best friend. She was helping me when I was living in Milwaukee, and then I moved back up here ‘cause my grandfather passed away. My grandma, she’s now in the first stages of Alzheimer’s dementia, so I want her to get to know my kids. I don’t want them to miss out on growing up with their cousins or their aunts and uncles.

Interviewer:
Right, the extended family. Right.

Interviewee:
No one lives down in Milwaukee but my aunt, and she has her—she doesn’t have any kids or anything, so I rarely ever saw her. Being up here, I can see my family more. Plus, the environment that Milwaukee was was a lot of stress and everything with the violence and the drugs and—

Interviewer:
Okay, and it’s a big city and traffic.

Interviewee:
Correct. Getting from one place to another without a car—living expenses out there was outrageous. I loved growing up here, and my kids enjoy it, so I’d rather keep them where they’re more comfortable, ‘cause right now, my main means of—my life is around them. It’s not about me anymore. It’s about my kids.

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Interviewguide

PREAMBLE: I am interested in learning about the types of things that have helped women get

through stressful times and achieve good health. Good health can include many things, such as

good overall health, having healthy pregnancies and babies, good physical health, good mental

health, etc.

1) First, I would like to know about the people in your life. This could be your partner, family

member(s), friend(s), support group, co-worker(s), etc. Who gives you support on a

regular basis?

Probes: In which kind of situations are these people helpful? If she mentions her family,

ask if her family lives near her. At the end, also probe to ask if there is anyone else they

would like to mention.

2) Now, I would like to know more about your community. Community can mean different

things to you, such as your neighborhood, your extended family, members of your

religious institution, etc. How does your community support you?

3) Now, please tell me about an especially stressful or difficult time that had a negative

impact on your health.

Probe: Again, health can include many things, such as overall health, having healthy

pregnancies and babies, physical health, mental health, etc.

4) What helped you through this stress?

Probes: What kinds of things did you count on to help you to deal with this stress? At the

end, also probe to ask if there is anyone/anything else they would like to mention.

5) What are the personal strengths that you bring to stressful or difficult situations (if not

mentioned earlier)?

6) Now that we have talked about the different types of things that have helped you in your

life, what do you think is the most important thing to help you achieve good health?

AFTER THE QUALITATIVE PORTION, ASK THE FOLLOWING QUANTITATIVE QUESTIONS:

1) What is your age?

2) Which one of these groups best describes your racial background?

White, Black, Asian/Pacific Islander, Spanish or Hispanic, or other

3) What is the highest year of school you completed?

Less than high school, high school diploma or GED, some college/associate degree,

bachelor’s degree, master’s degree or more

4) If you don’t mind telling me, what is your approximate annual household income?

Less than $20,000, $20,000-$39,000, $40,000-$59,000, $60,000-$79,000, $80,000-

$99,000, more than $100,000

5) Are you employed? If so, what do you do?

6) What is your current marital status?

Married, separated/divorced, widowed, single/never married, or cohabiting

7) Where were you born?

8) If not born in the US, how long have you lived in the US?

9) How many times have you given birth before?

10) If you have been pregnant before, have you experienced any of the following outcomes?

Miscarriage, pregnancy complication (e.g. preeclampsia/gestational hypertension,

gestational diabetes, premature rupture of membranes, bacterial vaginosis, fetal growth

restriction, bladder or kidney infection), stillbirth, preterm delivery, low birthweight baby,

small-for-gestational age

11) Do you have any current medical conditions? Examples: high blood pressure, diabetes,

anemia, etc.