On June 2, 2004, ETR's Lori Rolleri joined co-moderator Karen Glanz, PhD, MPH to discuss ways of translating health education and behavior theories into program activities and program evaluation plans. One hundred and sixty-two participants from across the United States and as far away as Australia and representing a variety of organizations and countries shared information, resources and common concerns and questions regarding health education and behavior theory.

Ms. Rolleri began the forum by introducing her co-moderator Karen Glanz, noting that she often relies on Dr. Glanz' book, Health Behavior and Health Education: Theory, Research and Practice in her work at ETR.

Dr. Glanz is currently a professor at the Rollins School of Public Health at Emory University in Atlanta. Her background is generally in health behavior/social psychology and health education, and more specifically, in content areas related to prevention of chronic diseases (tobacco control, dietary change, skin cancer prevention), early detection (e.g., colorectal cancer screening), and concerns of people at high-risk for disease. By way of introduction, Dr. Glanz added that she has spent many years teaching public health professionals across a broad spectrum of specialties, and she enjoys the challenge of applying theory to practical problems.

The forum discussion covered the basics of health education and behavior theory and also discussed concrete ways of incorporating theory into specific programs and settings. The forum's moderators fielded questions and offered information and advice on the following topics:

• The Development of Health Education Curricula
• Health Education Theory on a Community Level
• Implementation Issues
• The Influence of Social and Economic Factors on Health
• The Effectiveness of One-Time Only Presentations
• Full Implementation and Implementation with Fidelity
• Theory-Based Program Evaluation
• The KAB (Knowledge, Affective & Behavioral) Approach
• Health Education Theories versus Logic Models
• Theory of Reasoned Action
• Health Education Theories for Specific Programs
• Adolescent Sexual Risk Taking
• Increasing Partner Communication about Condom Use
• Coalition Building
• Latino Teen Tobacco Use
• Secondary Pregnancy Prevention
• Youth-Friendly Health Services
• Closing Remarks
• Resources

A participant asked co-moderator Karen Glanz if she recommends using a variety of theoretical underpinnings when creating health education curricula or if it is best to focus on only one or two. "It depends," Glanz replied. If you're creating curricula toward a specific focus and audience, it is useful to identify the most promising theoretical foundation(s) — one or two — and follow through consistently. However, if you're addressing different topics and/or different audiences, it's useful to step back and examine what's known about the audience and about the behavior(s) of central interest when you tackle the various topics/audiences.

This approach helps you keep more of an open mind and avoid creating "cookie cutter" programs. For example, a program for high school girls may differ significantly from what you'd do for an elementary school mixed-sex class. The goals, basis, and influences for these groups might warrant different theoretical underpinnings of the curricula.

Co-moderator Lori Rolleri added that in her experience of training to some of the evidence-based curricula to reduce adolescent sexual risk-taking, only a few theories are used to lay a foundation for the program. For example:

• Reducing the Risk is based on three health behavior theories: Social Learning Theory, Social Influence Theory and Cognitive-Behavioral Theory.
• Safer Choices is based on Social Cognitive Theory, Social Influences Theory, and Models of School Change.
• Making a Difference draws upon three theories: Social Cognitive Theory, Theory of Reasoned Action, and its extension, the Theory of Planned Behavior.
• Making Proud Choices draws upon three theories: Social Cognitive Theory, Theory of Reasoned Action, and its extension, the Theory of Planned Behavior.
• Focus on Kids is based on Protection Motivation Theory, (a social cognitive theory).
• Becoming a Responsible Teen (BART) is based on Social Learning Theory and Self-efficacy Theory.

A participant asked if education theory can help change health behavior on a community level as well as on an individual level and if it can inform the actions of state or local coalitions in the work they do. Co-moderator Karen Glanz commended the participant on asking a great question and stressed that it is an important one when it comes to public health issues, including adolescent pregnancy prevention.

Community-level factors shape individuals' (and groups') behavior and can either support or deter change. Theories of health behavior and health education (HBHE) can definitely inform the actions of coalitions and formal organizations (e.g., schools, health clinics). Glanz offered the following examples:

• Community organization: not a theory per se, but an application of a well developed set of concepts — most often emphasizing mobilization of groups for change and different approaches that may be useful for different situations.
• Theories of organizational change: especially interorganizational relations theory, which deals with how multiple organizations work together in coalitions.

Theories that focus on community-level factors and change usually are derived from the disciplines of sociology and organizational behavior. These theories are often less familiar to educators and/or people with psychological/counseling backgrounds but are definitely worth becoming familiar with.

Forum participant Jorge L. Figueroa, Ph.D. suggested reading up on the readiness to change model developed at the Tri-Ethnic Center at Colorado State University, which takes research approaches to changing individual behavior and applies them to community-based interventions. It is an excellent model that has been used with success in a variety of target areas (e.g., domestic violence, HIV, etc.), he said.

Co-moderator Karen Glanz agreed that understanding the social and economic influences on health is essential to identifying priority audiences and their needs, and understanding their circumstances. But she agreed that these influences are not easily changed and often cannot be changed by things in our typical "tool kit." She sees three possible implications for action for those who work in health education programs:

1. Exploring & understanding more. The fact that we have little empirical information about the relative effects of social and individual determinants of behavior (and choices, attitudes, etc.) makes this an area where research is needed — both qualitative and quantitative. Glanz added that the questions that strike her as important are: Why do some people "escape" the hazards they are subject to from their social/economic environments? How much do family factors, personality characteristics, (formal) education, etc. matter relative to the external social factors?
2. Adapting health education programs to be sure we aren't suggesting too much "swimming upstream" for clients or participants. This means taking the social environments into consideration — addressing them — and trying to find solutions even without social change occurring.
3. Becoming advocates for social change — in small and large ways. This can be done by engaging youth (and/or families) in empowerment type programs, where they have a chance to make decisions and try to affect political/economic realities. It can also be done more directly by political participation through local government, professional associations or organizations such as schools, community centers, etc.

Co-moderator Lori Rolleri agreed that poverty, in particular, is a strong determinant of adolescent sexual risk-taking. However, most community-based organizations working with financial resources cannot significantly impact poverty in their communities. A significant impact on poverty would most likely come from broader policy changes. She added that high unemployment rates, high crime rates and low parental education/income are also examples of social determinants related to adolescent sexual risk-taking.

Rolleri encouraged participants wanting to learn more on this topic to order a publication by ETR's Doug Kirby, Ph.D. In "Emerging Answers: Research Finding on Programs to Reduce Teen Pregnancy," Kirby reviews hundreds of research studies on the risk and protective factors related to adolescent sexual risk-taking. Rolleri also recommended another ReCAPP piece in Theories and Approaches by Kirby on the risk and protective factors related to adolescent sexual risk taking. Also, ReCAPP's on-line course on developing BDI logic models takes the learner through a step-by-step process in selecting risk and protective factors, with consideration to both impact and feasibility for change.

A community educator who is often asked to provide one-time only presentations in schools on contraception, STIs or HIV, wondered about the efficacy of these presentations and whether they can possibly lead to any change in behavior or attitude. She asked those who have been in the field for a long time whether they thought she was just spinning her wheels and whether she should focus on a more long-term training process outside of school programs.

In response, co-moderator Lori Rolleri mentioned Doug Kirby's list of 10 common characteristics of effective programs, a list which evolved from extensive studies of both effective and ineffective sexuality education programs. Included in this list is: "Effective programs lasted a sufficient length of time to complete important activities adequately." More specifically, effective programs tended to fall into two categories: those that lasted 14 or more hours and those that lasted a fewer number of hours (around 5 hours) but were implemented in small group settings with a leader for each group.

Co-moderator Karen Glanz noted that the same findings have been reported for other topics too (like drug education, tobacco use prevention, etc.) and admitted that one-time presentations usually are limited in their impact. She cautioned, however, that one has to take into account the reality and constraints that we face so often in mainstream education settings — so many topics vying for limited time.

Is a little of something better than nothing? Glanz tends to think that a well-crafted single presentation can engage the learners' interest (create awareness-motivation), and possibly correct misconceptions (increase knowledge). It can also be a gateway for people who need it to get more education or skill training. In summary, given the choice about how to run programs, she would definitely opt for more versus less contact time. But if the choice is nothing or a one-time presentation, Glanz suggested making the most of the time and being sure to offer some contacts or follow-up for people who may need or want more.

Rolleri added that a one-time program may not lead to behavior change (e.g., increase condom use), but it might lead to a change in knowledge (e.g., how to use a condom correctly, locations in the community where condoms are available) and/or change in attitude. (e.g., "Now that I've touched a condom in today's workshop, I don't think they are so 'gross.'") These are definitely steps in the right direction.

A participant added that one-time interventions could also move people along the stages of change. Glanz agreed. Participant Jorge Figueroa also agreed. Although it's difficult to get any hard data, he thinks the work (even when limited) is worth doing. There are cumulative effects of people being exposed to the information. There may be secondary benefits that don't directly reduce risk behaviors (e.g., finding out where to get tested, get condoms, etc). There is also the benefit of desensitizing youth to sexual issues and helping them feel more comfortable about seeking information or revealing risk behaviors.

A participant said that her project finds it challenging to get accurate evaluation data about significant outcomes when the schools in which they are implementing their health education program will not allow it to be implemented with fidelity — that is, the full number of sessions and/or shorter (time) sessions. She asked whether it is better to give what one can in health education, knowing it is not the optimal way a program was designed to be delivered, or nothing at all.

Co-moderator Karen Glanz faces the same challenges and frustrations when trying to do a well-controlled research evaluation. She offered the following suggestions for sorting out the implementation-effect link on an evaluation:

• Be sure to get good implementation tracking information — both what was implemented and how much. (If teachers, rather than outside staff, conduct the program, they need to be given "permission" to be honest about the implementation, however it goes).
• Analyze the data from a "dose-response" point of view — does higher implementation lead to better outcomes? The statistical capability may depend on how many groups are in the evaluation, but it should at least give the evaluator a sense of how "quantity of implementation" relates to the results.

Co-moderator Lori Rolleri examined the question of why schools are not implementing the program with fidelity. She posed the following questions:

• Is it a staff training issue? Are the pieces being cut out from the curriculum a reflection of teacher discomfort with teaching methods or content?
• Was there buy-in from key stakeholders about the curriculum from the beginning?
• Do key stakeholders believe in the program? Or are they doing it because they have to have something?
• Was there some careful thought put into the adaptations that were made to the curriculum — i.e., was any analysis done to the key components of the program and was an effort made not to compromise these components?

She also wondered if anyone had talked to the developer to see if the adaptations seemed like acceptable practice.

Noting that all program development should include an evaluation plan, a participant asked co-moderator Karen Glanz to comment on using theory to guide an evaluation of a program. As an evaluator, the participant said, it makes her job easier to help assess why a program may not have worked if it was designed around a particular theory because she can determine if there was a failure of theory or, if the theory was sound, a failure of implementation. Of course, if the program was a success, it builds credibility for using the selected theory in future program planning.

Glanz began her response by encouraging all the participants to take the participant's points to heart and to build in measures of intermediate outcomes and/or mediating factors in their program designs as well. She also suggested some resources for guiding theory-based program evaluation (listed under Resources). Co-moderator Lori Rolleri added that studying BDI Logic Models would also be helpful.

A participant noted that one often talks about "Knowledge" (cognitive, facts, information), "Affective" (emotional, values, attitudes) and "Behavioral" (skills) learning domains in sexuality education and that educational efforts should address all three domains. She asked where this framework comes from and whether it is rooted in social learning theory.

Co-moderator Karen Glanz is reluctant to credit one person or source for the KAB theory since it has been put forth by many different authors. The KAB approach has been around as long as she can remember and is familiar to a lot of health education topics, in addition to sexuality education. In fact, a quick Medline search produced over 13,000 citations. Glanz tends to think of this approach as more of a "typology" than a theory. Although in a simplistic way, it implies a theory (that knowledge precedes attitudes and they precede behavior), we know that behavior is much more complex than this framework suggests. Still, this set of three categories of concepts is useful since in most behaviors (and most curricula), we need to attend to each of these areas in order to make a difference.

Co-moderator Lori Rolleri asked Glanz to discuss what "intermediate outcomes and/or mediating factors" are and how they relate to theory and program evaluation. The intermediate outcomes or mediating factors are those things that reflect the theoretical basis for the program, Glanz said. If, for example, you are basing a program on Theory of Planned Behavior and one "intermediate goal" is to increase a person's sense of perceived control over condom use, then you would want to devise a measure of perceived control — not just measure the behavior outcome (condom use).

A mediating factor is a more technical term for something that is believed to lead to the outcome. If, for example, you think that people don't see unprotected sex as risky (for pregnancy, for STDs), and your theory (say, Protection Motivation Theory) would lead to giving a lot of graphic illustrations of the risk that comes from unprotected sex, you would expect to see a rise in perceived risk and an increase in condom use as a result of that rise in perceived risk.

Co-moderator Lori Rolleri asked Dr. Glanz to explain how a theory becomes a "recognized" theory. In particular, what was the process that Bandura undertook to get social learning theory recognized, how were his theories "tested," and are health behavior theories always 100% true?

A participant quickly responded that no theory is 100%, and Glanz agreed. If something is 100%, it's a law, like the law of gravity. Theory, on the other hand, deals with probabilities. The broader scientific terminology refers to something abstract that explains a range of phenomena and can be tested — either to be supported or refuted.

A participant commented that in her state, teen pregnancy prevention programs are asked to create and use BDI logic models to guide program development, implementation, and evaluation. They do not actually talk much about "theory" per se. She has come to the conclusion that a good BDI logic model is similar to a "theory" but is situation specific, in that it identifies specific determinants instead of broader, more general constructs. How, she asked, is a logic model like or unlike a theory?

Rolleri responded by saying that when a program planner develops a logic model (BDI or another framework), he or she is in a way proposing an informed (but not necessarily proven) theory. As an example, if she chose to focus on six of the risk and protective factors (highlighted by Kirby in "Emerging Answers") related to delaying the onset of sexual intercourse in her logic model, she is proposing the theory that if we can change these six risk and protective behaviors, we can get to the desired behavior of delaying sex.

Glanz agreed that a logic model is a way of making the assumptions behind program strategies/methods explicit; and this is the essence of applying theory. But the logic model is more of an "operationalization" — or application — of a theory. By way of comparison, Glanz explained that theories have concepts, or constructs, and variables are the operational (specific, measurable) forms of constructs. The variables can be traced back to a theory, but they are an application for a given situation or problem. Some people call this the "theory of implementation" that is specific to a program. However, linking "theory" with program specifics leads to some foggy semantic areas, Glanz said, since one of the key features of theory is its abstractness and its generalizability. Glanz likes the term "logic model" since it encourages one to work out the details logically and focus on causal pathways.

One participant, who created a male involvement program called Male Advocates for Responsible Sexuality (MARS) based on constructs from the Theory of Reasoned Action and Diffusion of Innovation Theory, asked about the Expanded Theory of Reasoned Action (TRA). She had learned about it in graduate school and knew it includes constructs of habit, facilitating conditions, and affect. She asked Dr. Glanz why she had omitted the expanded theory of reasoned action in her book and if she knew of any teen pregnancy prevention programs that have used this theory.

Glanz replied that there are some limited references to the Expanded TRA, and even one citation by Montano (the chapter author) and Taplin (1991). There is also some discussion about how "facilitating conditions" — referred to as a concept from Triandis (p. 76, HBHE 3rd edition) — is similar to Perceived Control in Theory of Planned Behavior. Also, there is some discussion and a figure (Figure 7.1) depicting the Integrative Model that Fishbein put forward in an article in 2000, in the "Perspectives" chapter by Barbara Rimer, in the 2002 (3rd) edition of her book. She concluded that the Expanded TRA pre-dated the wider publication and use of Theory of Planned Behavior, and that is why her book (on the recommendation of the chapter authors) doesn't go into the Expanded TRA.

Co-moderator Lori Rolleri added that the curricula Making Proud Choices and Making a Difference both use Theory of Reasoned Action, but she is not sure if they use Expanded Theory of Reasoned Action.

Glanz added that she is not aware of any teen pregnancy prevention programs that used the Expanded Theory of Reasoned Action.

Lori Rolleri invited forum participants to ask co-moderator Karen Glanz questions about programs they are adapting or developing and the theories used to guide their development. For example, if a group is developing a program with the behavioral objective of "increasing partner communication about condom use," they might want to ask Glanz about what theories might help inform/guide/map the program activities/strategies they are planning.

The first participant to follow up on Rolleri's suggestion asked which health education/behavior theories are most relevant to adolescent sexual risk-taking behavior and how are they connected. There are two often-used theories applied to adolescent sexual risk taking: Theory of Planned Behavior (TPB), and Social Cognitive Theory (SCT), Glanz said. She described them as follows:

TPB has a couple of constructs that seem very applicable — especially those related to "subjective norms" (belief about whether most people approve or disapprove of the behavior) and "behavioral intentions." The former relates to peer influence and also partner influence/pressure; the latter relates to the notion that people may "intend" to behave a certain way but may change their behaviors when confronted with a situation.

SCT has several relevant key constructs, including behavioral capability (skills), self-efficacy (self-confidence in a given situation), and the idea of reciprocal determinism — being influenced by the [social] environment but also being able to influence others.

The participant also asked which theories can be taken from the disciplines of psychology (or other related disciplines) that might help adolescent reproductive health professionals. Glanz thinks both TPB and SCT (above) are relevant, but there are certainly others. There are several useful counseling models — for example, client-centered counseling — which might be relevant (i.e., drawing out people's thoughts and helping them reach conclusions that they will be committed to). She cautioned, however, that it would depend on the situation, such as whether one is dealing with motivated or troubled youth. The latter might need different and possibly more "directive" approaches. Similarly, individually-oriented counseling sessions might call for different approaches and models than what's most suitable for a class or group session.

Noting that she agrees with all of Glanz's suggestions, Rolleri provided information on where to find practical information about the theories Glanz mentioned as well as some others. (See Resources.)

A participant from Adelaide, Australia shared her experience with creating and evaluating multimedia teen pregnancy prevention interventions that were based on learning theory. One CD ROM-based program aimed at young men included role play scenarios in which they had to face the consequences of fatherhood and make some choices. The choices were presented through Social Information Processing Theory. She cautioned that this kind of intervention can't stand alone and needs to be embedded in the right sort of interactive school curriculum. Glanz commented that the program sounds very creative and provides a great example of a new kind of option with current communication technologies.

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• Secondary Pregnancy Prevention
  Another Chance: Preventing Additional Births to Teen Mothers by Lorraine Lerman, Dr P.H. To order, visit: www.teenpregnancy.org/

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