While injuries are preventable, they continue to be a leading cause of mortality, morbidity and disability in Alberta. In Alberta in 2010:

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Christopher Roger Shelton
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1 BEHAVIOUR CHANGE Introduction This edition of the Injury Prevention Cenrtre s (IPC) Injury Examiner reflects key concepts from prevailing behaviour change theories and models and applies them to injury prevention. You may use this document as a guide to strengthen injury prevention efforts within your community. The Issue While injuries are preventable, they continue to be a leading cause of mortality, morbidity and disability in Alberta. In Alberta in 2010: 1,781 Albertans died from injuries; more than 4 injury deaths per day. 58,846 Albertans were admitted to hospital due to injuries; more than 161 injury admissions per day. 435,191 Albertans visited emergency departments due to injuries; 1,192 injury visits per day. 1 Changing individuals behaviour is key to reducing the incidence of injury. Facilitating behaviour change in individuals can be achieved through a combination of measures including education, opportunity (like easily accessible safety equipment), policy/enforcement and engineering so long as they reflect the target population s social and policy contexts. You can learn about your target audience s social and policy contexts by getting answers to questions like: What is the target population s perception of the injury problem and of resources and organizations in their environment? How important is the injury issue to the Individual and to their circle of influencers? What resources are available to address this injury problem? What are the characteristics of the community that enable or inhibit the prevention of this injury? What is the political climate to take action and sustain measures to prevent this injury? 2 Intervention levels To facilitate change in a target audience, longitudinal research increasingly supports a multi-level, well-coordinated and integrated approach implementing interventions at several levels of influence simultaneously rather than focusing solely on one intervention level. 3 The Ecological Model for Health Promotion 4 categorizes health promotion interventions into five, classic levels of implementation: Intrapersonal factors - interventions at this level strive to change individuals knowledge, attitudes/beliefs, skills and/or intentions around a defined behaviour. Strategies may also focus on changing individuals perceived or actual barriers to adopting a defined behaviour. An example of an intervention at this level would be educating youth about bike-related head injury and the benefits of bike helmets and providing them with access to free or less costly bicycle helmets. Interpersonal process - interventions target individuals social groups and influential contacts like their family, healthcare providers, work colleagues, etc. Interpersonal approaches focus on changing the norms/practices within existing groups, facilitating membership to other groups, creating alternative networks and/or decreasing desirability of membership to certain groups in order to facilitate the

2 adoption of a defined behaviour in individuals. An example of an intervention at this level would be educating parents about the importance of wearing bike helmets and providing them with methods and/or resources to encourage helmet use in their youth. Institutional factors - interventions introduce or facilitate change in programs, systems and policies in organizations like healthcare settings, schools, work settings, etc. to support the adoption of a defined behaviour in individuals. An example of an intervention at this level would be having organized youth biking events or venues make helmets mandatory for participation. Community factors - interventions facilitate collaboration between public, private and non-profit organizations, development of coalitions and advocacy groups, common messaging or practice among multiple organizations, engagement of media and/or empowerment of disadvantaged populations to support the adoption of a defined behaviour in individuals. An example of an intervention at this level would be engaging local media outlets to do stories on bike-related head injury and the benefits of bike helmets. Another intervention example would be engaging a variety of public, non-profit and private community organizations to jointly promote and present consistent bike helmet safety and use messages. Public policy - interventions develop, promote and advocate local, provincial and national policies and laws and enforcement to support the adoption of a defined behaviour in individuals. An example of an intervention at this level would be provincial legislation requiring minors to wear bicycle helmets. Another intervention example would be having local enforcement officials increase enforcement efforts and/or hand out prizes to youth complying with legislation. 4

3 Theory guided questions to facilitate intervention development Dr. Martin Fishbein 5 developed an integrated model drawing from Health Belief Model, Social Cognitive Theory, Theory or Reasoned Action and Theory of Planned Behaviour. To apply this model, he offers a list of questions for you to ask members of your target audience about injury preventing behaviour that is being promoted (i.e. bike helmet use, medication storage in homes, strength/balance exercise participation for fallprevention, protective glove use in specific contexts, etc.). Ideally, the questions should be posed to both target audience members that don t and do engage in the desired behaviour. Responses collected from this process can help you identify an intervention or let you know if the intervention that you ve already proposed is appropriate. The following is a cursory list of Dr. Fishbein s questions: Current behaviour measures: In the last X months how often did you perform behaviour X while in context ABC (never to all the time)? Intention measures: What is the likelihood that you will perform behaviour X while in context ABC in the next N months (unlikely to likely)? Attitude measures: My performing behaviour X is: bad to good; unpleasant to pleasant. What makes it bad/good; unpleasant/pleasant? Subjective norm: Most people who are important to me think I should perform behaviour X (unlikely to likely). Think of the people who are most important to you. How many of them do you think have performed behaviour X? If you re not sure, make your best guess (none to all). Perceived control and self-efficacy: My performing behaviour X is up to me/not up to me. My performing behaviour X is under my control/not under my control. Would [environmental or situational factor A] make it easy or difficult for you to perform behaviour X (easy to difficult)? How often is [environmental or situational factor A] present when you try to perform behaviour X (0/10 times to 10/10 times)? Refer to Harborview Injury Prevention & Research Center s Behavioral Approaches to Injury Control Conference Proceedings for more details about Dr. Fishbein s questions - hiprc/pdf/behavior%20conference%20%20manuel%20final.pdf

4 Learn more about theories and frameworks to guide intervention development Theory provides insight into how and when changes can be achieved in individuals and organizations. Using theories and frameworks to inform the content and process of an intervention increases the likelihood of positive outcomes. 6 There is no single theory that captures all factors influencing human behaviour and organizational/policy change; consequently, it is ideal to have a general understanding of a broad range of different theories and how they can be applied to various contexts and situations. 7 On the next page there a list of theories with links to details that have been categorized into the five classic levels of implementation. Conclusion Facilitating behaviour change in a target audience is a challenging endeavor which requires a comprehensive, multilevel approach. Fortunately, there are theories and models that can provide guidance in the development of interventions to better ensure a successful outcome. Intrapersonal Interpersonal Organizational/Community Public Policy Health Belief Model Social Cognitive Theory Community Organization and Coalitions Theory Community-Building Models Theory of Reasoned Action / Social Networks and Social Diffusion of Innovations Theory Policy Windows Theory Theory of Planned Behaviour Support Theories Transtheoretical Model and Stages Diffusion of Innovations Theory Organizational Change Theories Large Leaps Theory of Change Goal-Setting Theory Resilience Theory Social Marketing Authoritative Parenting Model Social Marketing Community Mobilization Theory

5 References 1. Injury Prevention Centre (formerly ACICR). Injuries in Alberta [Internet] [Cited 2014 March 3]. Available from 2. Canadian Collaborating Centres on Injury Prevention. Canadian Injury Prevention Curriculum (2 nd Edition). Toronto, ON: SMARTRISK; Breinbauer C, Maddaleno M. Youth: Choices and Change Promoting Healthy Behaviors in Adolescents. Washington, D.C: Pan American Health Organization; McLeroy KR, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Health Education & Behavior 1988;15(4): Fishbein M. Models of Health Behavior. Behavioral Approaches to Injury Control Conference Proceedings. Seattle WA: Harborview Injury Prevention & Research Center; Nutbeam D, Harris E, Wise M. Theory in a Nutshell: A practical guide to health promotion theories 3rdEdition. Australia: McGraw-Hill; French J, Blair-Stevens C, McVey D, Merritt R. Social Marketing and Public Health Theory and Practice. New York: Oxford University Press; 2011.

The Injury Alberta Report, 2011

The Injury Alberta Report, 2011 By 2015 480 Lives Saved 30% Fewer Injury Hospital Admissions $700 Million in Healthcare Costs Saved Injury Alberta is an initiative led by graduate students with the School