[MUSIC] In the previous lectures, we have talked about different theoretical models that are intended to help predict or understand behavior, based on looking at behavior as a dependent variable. Intermediate variables, such as beliefs, attitude, skills, self efficacy. And independent variables such as demographic characteristics. At this point, we want to consider what are known as process models that help us understand the stages, or steps, that people go through in order to adopt a new behavior or to change their behavior. We'll start off by looking at three different types of process models that have been developed over the years, but the basic concept under them is the same. The idea that people don't just change on and off like a light switch, but that they go through various processes of thinking, considering, trying, and doing, before they adopt a new behavior. The first theory we'll look at is field theory, or unfreezing, refreezing behavior by Kurt Lewin. We'll also look at the stages of change or transtheoretical model that has been popular by Prochaska. And we'll also look at the process of adoption of innovations, which is also known as diffusion theory, that's been propounded since the 1950s, especially in the field of agriculture extension, by people like Everett Rogers. One of the earliest process models was developed as part of field theory or force field theory by Kurt Lewin. And starts with the concept that people need to consciously recognize that an existing behavior may no longer be functional, or useful, or yield positive results or that a new behavior might be needed. This is known as unfreezing. A person releasing him or herself from previous habits, and being willing to consider new behaviors and new ideas. A person may be feeling lethargic, not satisfied with his or her state of health and think that something is needed. A person may receive information over the media from friends about the dangers of smoking or the importance of a new dietary pattern. These kinds of issues can help people recognize that a change may be needed. Subsequent to that, the person must evaluate the change. What are the implications of changing diet? What would be involved in eating the new foods? What do they cost? Where are they available? Person gathers information tries to understand the implications of changing. As you can recall from the drawings of force field analysis, the forces are driving or restraining efforts to reach a goal. And so the third stage or third step in the unfreezing refreezing model is goal setting, making a conscious decision, a commitment to change. After making this decision, the next step would be action or trial, performing the new behavior, seeing what it's like, assessing the benefits, the problems. The person may want to stop smoking, but may still encounter stressful situations that may drive them to want to try to smoke again. The person may want to adopt a new diet, but find it's difficult to prepare the foods. The mother may want to prepare a salt-sugar solution if her child has diarrhea, and yet she cannot always find sugar available when she needs it. So it's important for the person to see if the new behavior is feasible in his or her economic and social environment. Assuming that the person tries the new behavior and the results are positive and encouraging, then the person may re-freeze that new behavior as a normal, routine part of his or her life. And continue that behavior until some other stimulus comes along that questions the value of that behavior. The transtheoretical model or stages of change was developed by Prochaska and starts one step ahead of unfreezing, refreezing starts. This model recognizes that, for the most part, people exist in a state of precontemplation, where they do not perceive that they have a particular problem. Therefore, they have no intention of changing their behavior because they do not perceive a need. At some point they may receive information, they may experience some symptoms that make them question their present behavior, their present condition. And therefore they may be receptive to some new ideas and start contemplating, actively thinking about a new behavior, what would be involved. People will want to gather information, advice from people who have tried it before, weighing the pros and cons. At a point they may make a decision to try to the behavior and would start preparing, gathering more information. What are the actual steps in preparing the salt sugar solution? Buying enough salt and sugar to keep on hand in case the child has diarrhea, etc. Getting the resources, learning the skills, to carry out this behavior. And at a point begin action, actually carrying out the behavior, eating more fiber foods, eating less meat in the diet. And of course, the action phase. If this is carried out for two, three weeks, months, the person has tried it and feels satisfied with the results, then the person will have entered what is known as the maintenance phase. Maintaining that new behavior or refreezing, as the case may be in the field theory. Another important component of the transtheoretical model is the recognition that people may relapse. A person may have been taking hypertensive medication for some years. The person may feel fine. Maybe the person doesn't have as much money as before, and says, well, I'm feeling fine, why should I continue to spend on drugs every week? And they may stop, they may go back to the pre-contemplation stage, and think I really don't have problems. Maybe they even believe they're cured. It's important to recognize this movement back and forth among the different stages. People may get simply to the stage of just trying the action and feel that it's not appropriate for them and abandon it. People may, as suggested, try the behavior for three or four years and still relapse. So this idea of behavior as a process, thinking, decision-making, planning, action, evaluation, and refreezing that new behavior into a normal part of the routine is important to recognize. And people are at different stages, not everybody attending a clinic for hypertensive patient, not everybody who is enrolled in a program is at the same stage. Part of the reason for this is that there are different factors operating on each person to propel him or her forward in the change process or restraining him or her from making progress in changing behavior. And this is why it's important to consider both theoretical and transtheoretical process models together. The theories can help us understand those factors, those variables that may, at each stage, restrain or drive a person forward. The next slide shows such an analysis. As seen in the slide for understanding the transtheoretical model would be the stages of change for bed net use. At the precontemplation stage, a family, an individual, may not have even heard of nets, or if they've heard of them they don't think that they are relevant to their needs. So they have no consideration, no thoughts about buying a net. At the contemplation stage, they may be considering nuisances of insects, people may have been complaining, someone may have bought a net and be talking about it. They may have heard some advice when they attended the clinic, there may have been a jingle on the radio, and so they're starting to think about it. They're seeking information, asking people for advice. Have you ever seen it? Have you tried it? What do you think about it? At the next stage, preparation, they may be trying to find out where the nets are sold. Or they may be getting some more information on what they need in their home, in terms of hanging the net. If they have a bed, what kind of poles are necessary, or can they tie it from the rafters. Do they need to take in consideration if they're using a sleeping mat and how it will work in their house? They may be looking for the money to buy the net, making sure that they have the money together, and then, in the process, they would actually go and purchase the net. So they're now prepared to use it. At the action stage, of course, they'd hang it over their bed, sleeping mat, and they would actually sleep under it for every night for some weeks. At some point, after having used the net, correctly, regularly, making sure that they're sleeping under it, that they don't go outside on the front porch or under the tree and sleep in the evening when the mosquitos are biting. That they actually have used it every night for several months, maybe up to a year. One could say they have maintained this behavior through thick or thin. Even when the dry season comes and it's warmer, they're still using it. So they've maintained that behavior. But it may happen that some people, during this dry season when it is hotter, they may say well, there are not many mosquitoes around. Let me not worry about it, and they would relapse and go back to sleeping without using a net. The next example, as seen in the slide concerning whether a motorcycle taxi driver in a Nigerian town would decide to wear a motorcycle helmet to protect himself. At the pre-contemplation stage, the person may not have experienced an accident himself, may believe accidents are due only to fate. And this would restrain or keep the person at a pre-contemplative level. On the driving side, maybe there had been a public awareness campaign. Maybe law enforcement had been stepped up. Maybe a close friend had had an accident and had serious injuries because of not wearing a helmet, in which case the person may start contemplating or thinking about wearing a helmet. The person may move ahead from contemplation, if he or she has a desire to learn the consequences, information is easily available. On the other hand, if it's difficult to obtain a copy of the highway code that spells out the laws, if you can't find an expert, someone to provide information and details about the types of helmets and how they work, the change may stop at that point. Assuming the person decides to take action, this action may be encouraged or reinforced by what parents of the motorcycle driver have to say. The person is married, maybe the wife would encourage to try to continue the action to take it. On the other hand, other drivers, friends will say it's just a matter of fate, why are you wasting your money? The helmet may be expensive, it may not be available in a small town when they have to go to the big city to buy it. Assuming that the positive driving forces have encouraged the person to maintain action for some time, enter the maintenance phase. They may continue to wear the helmet if they get praise from their relatives, if their passengers praise them for trying to be more safe. On the other hand, after some time they may experience that the helmet is hot, that the straps irritate their neck, and maybe the police are no longer enforcing the laws and there's lack of reinforcement. And then they may stop wearing it and relapse back to the pre-contemplation stage. We can use our theoretical models more specifically in making this kind of analysis. We can look at the issue of contemplation and we can say does held belief model tell us something about perceived threat that may encourage the person to take action. In terms of maintaining and taking the action, the social learning theory tell us that the person feels confident to carry out the behavior, that the person has other people to observe carrying out the behavior correctly. So we can use the two types of models, two types of constructs together to help plan programs. Because, again, as was mentioned, the people in community or the client group of people, the people may be at different stages, and would need different kinds of educational inputs to help them move to the next stage. The graph in the next slide is also accompanied by an article in your readings. That show that through interviews and questionnaires we can determine that in our broader population we can find that there are people at different stages. And they would require different educational interventions, because the factors that are influencing their remaining act or moving to the next stage would be different. This shows the issue of using condom, and it differentiates between different groups of men, men whose other sexual partners are men, men whose other partners are women, etc., and finding out with those in a particular community, where is each group. So not only do we have different people at different stages, who would need different educational interventions, but we have people with different characteristics that are at different stages. The people whose primary partner is a man were found more to be at the contemplative stage, etc. So I think it's important that we gather information about the community before designing programs. Because people will need different levels of information at the contemplation stage, resources and skills at the preparation stage, and social reinforcement at the action and maintenance stage. Another example of measuring the stages, occurred when we were looking at the reproductive health needs and interests of out-of-school adolescents in southwestern Nigeria. A number of children, at least in the rural communities, up to half may drop out of school after primary school or somewhere along in secondary school. Start taking up work as an apprentice, a tailor, mechanic, or go out and do farming, or trading, selling things in the market. And these people do not benefit from any formal reproductive health education, the little that there is in the schools. They're busy during the day. They may not even hear any programs going on on radio, or any other activities organized for youth. And we framed questions, have they ever heard of condoms, have they thought about using them, have they sought information, have they actually purchased, have they used them? So we had to frame questions that would've applied to each of the stages. And so the graph that you can see shows how many young people were at each stage of change. Most of the young people and these, again, were between the ages of 10 and 19, in the adolescent age range, had not even contemplated using condoms. A few had contemplated, fewer still made preparations action. Very, very few were using condoms regularly during sexual intercourse. And a number had used them at one time, but were no longer using them. Again, these are only the young people in that age group that we interviewed, who reported that they were sexually active. One thing that the chart shows that's very important, is that there are important differences in subgroups within this population. That urban young people were more likely to have prepared or taken action to use condoms, males more likely than women. So again, if programs are going to be developed, health education programs, they need to be adapted to these different groups. Because by being at different stages, as we've mentioned before, there are concerns that factors such as self-efficacy may be more important at certain stages. Attitudes toward the behavior may be more important at others. For example, those who have contemplated but decided not to, it may be the attitude toward the behavior or the social norms that is holding them back. And we need to find that out and address those needs for that group, maybe at the action stage or the preparation stage, at self efficacy, they're not certain. Farther along, it may be the partner or their friends are not supporting it and so they relapse. So we need to identify those factors, and recognizing, again, that we have four distinct subgroups in the population and being at different stages they would have different factors influencing their behavior.
