Monday, October 10, 2011

Efficacy expectations

I just sent an email to class titled, "Taping Lecture on Lecture." The nonsense of the statement reminded me of one of the most aggravating aspects of social science research: the lack of standardized language.

The last week in HBHE 600 was devoted to social cognitive theory, a model of learning that focuses on the role of self efficacy and outcome expectations and their dynamic interactions with environmental factors to shape behaviors. I remember being introduced to this theory in 2004, and struggling. More than most of the other theories we covered, SCT was one that I read about... and read more about... and kept reading because it has many moving parts and some of them just didn't sink in for. Part of the struggle was just the usual investment you have to make if you want to master anything. A lot of my person confusion, however, stemmed from imprecise language.

Some terms can mean too things

More specifically, the term "efficacy expectations" was used in class to refer to one's self efficacy to be able to perform a specific behavior in a specific situation. Simple, eh? Except a minority of academics used the term to refer to outcome expectations, as in "efficacy expectations were that medications would not lower blood pressure." Enough people, in fact, that I tried to convince myself that efficacy expectations were distinct from both self efficacy and outcome expectations. I think my confusion was forgivable: a lot of health behavior theories (e.g., Protection Motivation Theory, the Extended Parallel Process Model) include perceived response efficacy as key constructs, and it's a small step to morph that into the term, "efficacy expectation."

I raise this issue for two reasons. The first is simply to tell those of you who have tripped over the same confusion about lingo that I sympathize. I've seen other students with the exact same misunderstandings that I had, and I hope this posting helps to reduce that confusion.

The second issue is larger comment about social science more generally: I often wonder how the science advances without standardized language. My undergraduate education was as a biochemist, and you could generally make sense of any article you read, whether it be by someone in Canton, China or Canton, Ohio, because the metrics were standardized. In the social sciences, what does someone really mean when they say, "efficacy expectations?" Or "fear?" Or "perceived risk?" We have a gist-level understanding of what these terms represent, but the operationalization of them from situation to situation is often wildly different.

On the plus side, it's this lack of precision that makes social science interesting and challenging. The experienced practitioner knows enough not to get hung up on the minor differences between "fear" and "worry" when crafting an intervention, but is savvy enough to operationalize and label them appropriately during assessment and publication.

Thursday, September 29, 2011

Totato, totahto, and health behavior theories

It's the end of September, and we've just finished a lecture on the Theory of Reasoned Action and the Theory of Planned Behavior. It's time to pause and reflect on what we've covered to date.

Unless you're coming in with some training in psychology, you're probably thinking what I thought when I took this class long ago: are we just giving different names to the same things? What is the difference between perceived behavioral control and self-efficacy? Is an attitude really different from a belief? It's something I still struggle with from time to time.

Let's start with perceived behavioral control and self-efficacy. For the purposes of developing an intervention, assume they're the same (in fact, Fishbein or Azjen or maybe both asserted at a conference at some point that they were the same). From my perspective, though, self-efficacy is a part of perceived behavioral control. Self-efficacy is one's confidence in his/her ability to perform a specific behavior in a specific situation. Perceived behavioral control includes that in its definition, but also includes aspects like access and confidentiality (think enabling factors). Consider an outcome like intention to get the flu vaccine. You might have all the confidence in the world about your ability to handle the pain and ague associated with the shot. If you work and the shot’s only available during working hours, though, you might not have any intention to get it because you perceive that getting the vaccine is not under your control.

The differences between attitudes and perceived benefits/barriers is a little (but not much) cleaner. Attitudes are generally object-evaluation associations (or more relevantly, behavior-evaluation associations) that boil down to "good" or "bad." You say "swimming" and I think "yuck." You say "eating french fries" and I think "yum!" Perceived beliefs and barriers, on the other hand, have more of a this-is-what-the-behavior-achieves feel. Swimming makes me feel nauseous (perceived barrier), or eating french fries improves my mood (perceived benefit). What's the difference? An evaluation of the outcome. If I was bizarre, I might like to feel nauseous or might not want my mood improved.

An explanation that probably works better for class is to think of these theories as languages. When you're talking Health Belief Model, you say "perceived threat, perceived benefits, perceived barriers, and self-efficacy." When you're talking Theory of Planned Behavior, you say "attitudes about behavior, subjective norms, perceived behavioral control, and behavioral intention." You also operationalize your variables differently (extremely important nuances from an evaluation perspective), but I'll let y'all internalize those differences from your notes.

Hope that helps!

Sunday, September 25, 2011

Health Believing on a Sunday Night

Alas, another weekend is just about at an end. I thought I'd use the end of the week to reflect on what we covered in HBHE 600 last week, namely the Health Belief Model.

(everyone's favorite depiction of the Health Belief Model, even though self efficacy is missing...)

The Health Belief Model is the first of many theories of health behavior that we cover in class. The guts of it are pretty straightforward: if I perceive a threat to my health, and I perceive benefits to a preventive behavior and don't perceive barriers, I'm likely to make the behavior change (and if you're using a more updated version of HBM, you also need to have confidence in your ability to do the behavior). It's a popular theory to use: freak people out, tell them what they can do to avoid the problem, and maximize their confidence to do the behavior and minimize their barriers to action and they're more likely to take preventive action. The seasoned practitioner might be nuanced about targeting a threat (e.g., if you want to get teenagers to brush their teeth, how much do you highlight the threat of cavities and how much do you hype the threat of bad breath?), highlighting the right benefits (the benefit that motivates me is the idea that my hygienist will finally praise my brushing), targeting the most important perceived barriers (I'm ashamed to admit that I often think that brushing my teeth takes too much time) and building confidence in the right skills. On the face of it all, it's seems simple to implement.

Or so it seems. We often default to HBM constructs because they're well proven correlates of behavior, even if the relationships between constructs may be more complicated that the base model depicts (e.g., benefits and barriers matter more when threat perceptions are high... except when threat perceptions are super high and people often prefer to avoid the topic altogether). But how do you change something like the perceived benefits of a behavior? Preaching benefits oftentimes gets people to go in exactly the wrong direction. Take my dad, for example. If you tell him that going to the eye doctor will slow the progression of his vision loss, he's going to tell you "the (add a few expletives here) eye doctor never helps!" You've got to bait the guy in a way that makes him think about the benefits himself. Something like:

Me - "How's your vision, dad?"
Dad - "Terrible."
Me - "Sorry to hear. Maybe there's something we can do?"
Dad - "Well, I suppose we could go see Dr. Bob."

My dad's the exception and not the rule on many things, but reactance is a common reaction to threats to personal freedom. We can actually cause people to perceive fewer benefits to preventive behaviors exactly by trying too hard to change them.

From a public health perspective, I don't think we should get too hung up on this issue and suddenly start creating reverse-psychology PSAs. There are lessons to be learned from the literature on motivational interviewing and "rolling with resistance," though, that might help if we found ways to implement those strategies at a population level...

Thursday, September 22, 2011

HBHE 600 Stuff: Behavior Modification and eating better

It's been a loooong time since I posted to this blog, but I'd made a promise to myself to keep the "fun stuff" to an absolute minimum until I felt comfortable about my dissertation progress. I have to admit that I'm still not feel great about my progress...

But the opportunity to use this blog in a way that might help with classwork is too big to waste.

To those of you from HBHE 600, welcome! It looks like I coerced some of you to jump onto my blog. Last Thursday, Jose gave you "homework" that amounts to developing a behavior modification plan. I thought I'd share my own!

My goal is to eat better. Somewhere in my late 20s, my weight became completely contingent upon what I was stuffing into my mouth. I'm sure many of you can relate to my prior weight management strategies: eat whatever, and exercise as much as you need to avoid accumulating too much chub. Admittedly, it wasn't a perfect strategy - my waistline slowly but relentlessly increased until some new equilibrium established itself at age 25. I attributed it to laziness rather than gluttony, though. But now, I can run for hours and it doesn't do a lot for me! I don't know if it's because my metabolism changed or because running more made me eat more. What I do know, though, is that if I want to stay healthy, I needed to devote more attention to what I'm chewing on.

I'm a pretty religious "tracker." I think a lot of us in graduate school are secretly fastidious about using Moleskins or charts to see how we're spending money, exercising, how productively we're writing, etc. My suggestion for those of you who are new to monitoring yourselves is to start with some sort of template, but modify and simplify until you get to something that works for you. It's easy for a tracker to spiral out of control, and it's important that you have a system that you can keep pace with. After many iterations, here's what I use myself:

I realize this is pretty difficult to read; and there's more than just eating on this. Let me point out some process points that work for me, and then some very apparent trends about my behavior:
  • For simplicity's sake, I just grade my diet on an A-F scale. I used to try to track the number of servings I ate, the number of calories, number of snacks... and never kept pace. Now, I just look at what happened and assign a gist grade. I think it's a fair assessment. It's a little depressing that I didn't do any "A-grade" eating over the last week.
  • I eat the same stuff every day. English muffins and soup every day of the working week? I don't like to spend time preparing food, so I eat whatever's handy, including what I stock at my desk.
  • I apparently like cheese and crackers more than I ever imagined.
  • My fruit intake is actually pretty good! There's work to be done on increasing veggies and reducing sodium and carbs, but I'm ok with the meals for now.
  • There's a lot of snacking going on. It's not reflected well on the sheet just how many snacks I put down, but it's a lot.
So with all that said and analyzed, let me set a revised, short-term goal: improve snacking. It sounds like a loosy-goosy goal, but let's be reasonable. Rather than cutting out snacks, let's aim for making them healthier. Later, we can cut them out. And now knowing that I'm an "eat-what's handy" kind of guy, this probably won't be too hard. Buy more healthy snacks (carrot bites, raisins) and stop buying cheese and crackers or making biscotti.

I realize that something like recording the "duration of my behavior" isn't explicit in my tracker; nor are perceptions and feelings. Don't omit them yourselves. I've learned to adjust for the former when I assign myself a grade; and the latter figures both into my "sleep" column (through experience, I've noticed a huge correlation between the number of hours I'm sleeping each night and my diet) and in my "notes" column.

It'll be interesting to see how this pans out. I've been bad in the past in adhering to my modified diets, but there's quite a bit more at stake now that I have a little man who's 8 months old. In the long run, he's counting on me to 'be there.' More immediately, he seems to mimic whatever I do (and eat!), and I'm in the process of getting life insurance; so there are large and immediate financial implications to eating well (may be too late to alter my immediate rating, but there are still big incentives to drop some weight).

I'll blog more going forward to keep those of you who are interested in the loop about how I'm doing on my goals. More relevantly, I'll try to discuss this in the context of the health behavior theories we're addressing in class, so check back in from time to time.

Good luck to y'all on your own goals!

Wednesday, March 30, 2011

Blog Hiatus

I'm sure my audience isn't too large right now, but I apologize to those who are interested because the space has been - and will continue to be - quiet for a while. I am focusing on moving my dissertation forward. Alas, I have managed the process poorly and naively over the years. I'll make that the theme of my next posting...

Which will come only after I've made a substantial step forward. Focus, middle aged grasshopper!

Thursday, February 24, 2011

Microsoft and the Star Trek Economy

I'm currently neglecting my wife and kid while my laptop finishes downloading and installing Windows 7 Service Pack 1. If it finishes the last 4% in the next five minutes, I'll be able to catch the 5:59 bus home. The smart money is wagered against me.

The wait has given me time to monologue about Microsoft. I am increasingly orbiting further away from its gravitational pull. Firefox long ago supplanted Internet Explorer as my browser of choice. I gave up on my Hotmail account a month or two ago. I use OpenOffice rather than Office 2007/2010 on a number of computers. I even installed the Ubuntu operating system rather than Windows when I salvaged an old laptop. I've found that I can easily live without Microsoft.

I'm worried that I'm helping to destroy a good thing.

You can despise the muscle-flexing that Microsoft used to establish its hegemony in the computer world, and you can doubly despise how Microsoft incessantly installs patches and add-ons and whoosy-whats-its to all of its products. You also have to admit that Microsoft Windows and Office have been pretty useful over the years. I came of age when PCs moved from novelties to essentials, and I credit much of the evolution to the way Microsoft got everyone onto the same system. It reminds me of old history lessons about how marauding armies of yore helped standardize communication by forcing people to speak their language. They may have spread smallpox and slaughtered innocents, but they also got everyone speaking the same language. Microsoft spread Windowsox and Officesox for money, and by doing so revolutionized the way almost everyone does business.

But now there are comparable options that are free. You can save the $140 and buy another mp3 player or whatever. Is that a good thing in the long run? The freeware world confuses me because I don't understand how it is sustainable. In any economy, you exchange goods and services for goods and services, with money as the grease to that transaction. I make pies, you make cakes, and we can both have pies and cakes if we're willing to trade. Now, programmers make pies, and they get back... good feelings? I'm left feeling the same way I did in the late '90s, when everyone quit their jobs to work for internet startups. You'd ask your buddy to explain his business plan, and he's say something about, "Well, we don't make money now, but once we get enough subscribers, we'll make money from advertising." The plan worked for very few of them. Very few, despite the time they put in and the good that came of it. Most have transitioned to more traditional jobs like marketing, lawyering, and real estating. Maybe they were motivated by self-interested hopes of becoming millionaires, but what they produced was pretty damn useful to the collective. Some of my college roommates helped to pioneer online job recruiting, for example. I'm old enough to know what a web-free job search was like. It stank, and it made who you knew much more important that what you knew. In a very real way, Crimson Solutions (the original name of their company) helped to revolutionize how you get a job. I don't really know how much they all made from their venture, but it wasn't much, in my opinion, in relation to the amount of effort they put in and the amount of good that came of it. Their story made me apprehensive.

The incentives to create the things I want most, like good software and good music, seem to be fewer and fewer while the incentives to create things I don't want, like another mp3 player, haven't changed. I know I'm airing a tired idea. I know economics is about supply and demand, not about effort or actual good or productivity or any of that other idealistic stuff. I know all progress is scary; and that this will all work itself out in the long run because, well, because life goes on and it has to work itself out. Because programmers and artists and everyone else have no choice but to get something for their services. I keep hoping, though, that we're finally at the cusp of the Star Trek economy. If you're a Next Generation Trekkie like me, you know that the intrepid explorers of the USS Enterprise worked for goodwill's sake, that money was a thing of the past. I suppose you can get away with fantasy stuff like that on TV, where everyone knows their place and stays busy and feels appreciated and eats. What's standing in our way of having the Star Trek economy... today? It seems like we have the means, productivity-wise. Is it pride? Greed? Logistics? It it simply that one kind of supply - the material kind - is limited and another - the software/art kind - is limitless? How close are we to a functional replicator of the Star Trek sort?

I love the freeware world and I admire the principles behind it, but I don't understand how it will sustain unless other goods and services also become free; and it doesn't seem like Exxon-Mobil or Con-Agra will be moving in that direction any time soon. Until the Start Trek economy becomes a reality, do I have an obligation to even this equation and buy Microsoft? What's the right thing to do in the long run?

Addendum: It's 2:40 pm three days after I started this post, and Service Pack 1 is finally done installing. I'm starting to think that the right thing to do is to teach myself how to program and to contribute some sort of application...

Tuesday, February 22, 2011

The Biggest Little Study

I finished putting together a presentation for the 2011 American College of Medical Genetics Annual Meeting and reviewing some interview notes, both about some work we called the "Recontact Study." They'll probably be the finishing touches on the biggest little study I'll ever work on.

Here's the short story of what we did: some melanoma patients donated DNA back in the early 2000s to help identify genes for the disease. Usually, that's the end of the story for patients, and if researchers use the DNA to discover a mutation, it doesn't really matter for you because you're not going to hear about it. Is that ethical? There's a lot of debate on the issue, but little of it is based on any real data. Key questions that hadn't been addressed include whether people even want this information, how they respond to disclosure, and what burdens does disclosure put on researchers. We developed a pilot disclosure protocol and tried to address those very questions and more.

In a nutshell, people wanted the information, they responded very well to disclosure, and it was expensive and time-consuming for the research team (big caveat: because of the unknowns, we erred on being 'safe'). If you're interested, you can read peer-reviewed articles about our study here and here. What's shocking to me is that we squeezed two publications, a couple conference presentations, and some press coverage out of a study that ultimately only included 19 people.

Trust me, I'm not apologizing for the study at all. It was two year's worth of work on my end alone, and I wasn't the one who provided the genetic counseling. There are a lot of studies out there that enroll lots of participants and end up with no publications in the end. That's science (even social science!): you try things out and oftentimes they fizzle. And if they fizzle, nobody's going to want to hear your story unless you're writing about something people care about. Fortunately, we had the opposite scenario - we got good data about a subject people care about (two subjects really: melanoma genetic testing and disclosure of individual research results).

Which finally brings me to the point of this posting: what should an academic study? Stuff you care about, or stuff other people care about? Professors always tell their students to focus on the former, but it's a recipe for career dissatisfaction for people like me who want their work to be important. Am I the only one yawning when someone starts into a presentation about how physicians can improve care by using more personal pronouns? Don't we have 50 million Americans who don't even have health insurance? I realize one shouldn't always cater to the flavor-of-the-day topic, but the vehemence of many academics' beliefs that they should be funded to study whatever's on their minds constantly surprises me and is one of the reasons I think that academia suffers from a critical lack of self awareness.

Thursday, February 17, 2011

Entering the blogosphere

Welcome to my initial blog attempt! I'm sure there are a few of you who are wondering why I would make this leap. I have long thought that maintaining an interesting blog requires discipline that would be better exerted on career advancement or marital bliss. Or parenting. Or teaching myself Chinese or piano or programming in R or just about anything else. Everyone has a few interesting things to say, but can one maintain an 'interesting' pace for months? Years? Most blogs I've seen start out well, but lose my interest as the postings take on a "must... post...... something........" feel. I avoided the blogoverse because I worried that I'd reveal to the world that I fundamentally have only ten to twelve interesting threads.

So what changed? Frankly, I am feeling a sense of grandeur that I haven't felt in years. Those who run the world have a healthy arrogance and a vigor that allows them to shape how things should be, not just follow through on how things are being done. I am starting to believe, again, that Kurt's way is a better way. More importantly, I am simply happier. A number of personal failings, climaxing in the death of my mother, sent me into a deep depression that has only recently lifted. I'll save those thoughts for another day, but the short of it is that I'm pretty sure I'll feel good about myself even if I can't keep pace on this blog.

So let's see where this goes, and maybe I'll learn some new tricks along the way!