the importance of context in understanding behavior and ... · understanding behavior and ... of...

Society of Behavioral Medicine 2007

The Importance of Context in Understanding Behavior and

Promoting Health

Edwin B. FisherDepartment of Health Behavior and Health Education

School of Public HealthThe University of North Carolina at Chapel Hill

[email protected]

Interactionand

Moderationin All Things!

Overview: The Importance of Context

• SBM’s Links with Behaviorism• Social Ecological Perspectives• How to Study Influences of Environments• Genetics as Model for Effects of Context• Multilevel Analysis• Implications for Research• How We Think About Contexts

Behavioral Medicine’s Links with Behaviorism

• First meeting of SBM at annual meeting of the Association for the Advancement of Behavior Therapy

• 1st and 3rd Presidents – Stewart Agras and Gene Abel – leaders in Behavior Therapy

• Neil Miller– Dollard & Miller: Personality & Psychotherapy

(1950)– Early leader of SBM

Intervention Roots in Behavior Therapy

• Biofeedback• Stress management interventions featuring

relaxation and active coping with stressors

• Weight management (e.g. Stuart)

• Smoking cessation (e.g., Lichtenstein)

• Self control– Mahoney & Thoresen: Self-control: Power to the

person (1974).– Thoresen & Mahoney: Behavioral Self Control (1974)

• Contingency management, e.g., Geller’s approaches to auto safety

Misunderstanding Behaviorism

Behaviorism does not:– View complex behavior as simple aggregate of

stimulus-response associations– View behavior as response only to the current

stimuli present.Fundamental point of behaviorism:

– Behavior is learned– Current behavior is integration of past

experience with similar situations

Behaviorism is fundamentally historical, fundamentally directed to how

1. Past Experience

2. Governs the Impacts of the Present

Unambiguous Threats• Teacher scolding you when others were the

troublemakers• Storekeeper turns sign from “Come on in,

We’re Open” to “Sorry Closed” just as he sees you approaching through the glass door.

Past Experience Governs Impacts of Present

Example: How We Respond ToAmbiguous Stimuli

Ambiguous Threat

Mr. Stubbs the Geometry Teacher• Going to give back the tests.• But first, there’s been cheating and if I find out

who....• Hands back grades.• Billy, who had been concerned, gets good grade,

is pleased.• Ok, class dismissed.• Oh, Billy, could you wait a minute. I want to

talk with you.• Sure Mr. Stubbs, but what’s this all about?• Just wait. I’ll be with you in a minute.

Lower socioeconomic status confers:• More experience with negative

outcomes • In ambiguous situations:

– Greater likelihood of negative outcomes

– Greater sense of perceived threat

Low SES and Past Experience

Influence of Past Experience/SES on Response to Threat

Chen et al. Child Development 2004 75: 1039-1052

Perceptionof Threat

Low ParentalEduc & Occup

β = .43

β = .09 Perceptionof Threat


Unambiguous Negative Video

Ambiguous Video

Perceptionof Threat

Ambiguous Video

SES, Perception of Threat, and CVD Risk

Heart RateDBP


Chen et al. Child Development 2004 75: 1039-1052


• SBM’s Links with Behaviorism

• Social Ecological Perspectives• How to Study Influences of Environments• Genetics as Model for Effects of Context• Multilevel Analysis• Implications for Research• How We Think About Contexts

(Assuring the Public Health in the 21st Century, IOM, 2002)

Social-Ecological Model

Over the life span

Marmot and the Causes of Causes

CountryGNP per capita (US $s)

LifeExpectancy

USA $34,000 76.9 yearsGreece $17,000 78.1 yearsCosta Rica < $10,000 77.9 yearsCuba < $10,000 76.5 years

Social Determinants• Stress, Early life circumstances, Social exclusion, Work,

Unemployment, Social support, Addiction

Marmot The Lancet 2005 365:1099-1104

Disparities from Material conditions, Income poverty

Diabetes Initiative of the Robert Wood Johnson Foundation

Fourteen programs demonstrating feasibility of self management as part of quality care in real-world primary care and community settings

diabetesinitiative.org

Core Concept:Resources & Support for Self Management• Individualized assessment, including

consideration of individual’s perspectives, cultural factors

• Collaborative goal setting• Building skills

Diabetes specific skillsSelf-management skillsIncludes skills for “Healthy Coping” and dealing with

negative emotions• Continuity of quality clinical care• Follow-up and support• Community resources

Tri-Level Model of Self Management and Chronic Care

Organization & System

e.g., Chronic Care Model

Implementatione.g, Resources & Supports for Self Management

Impactse.g., AADE 7Self-Care Behaviors

Clinical Status & Quality of Life

CommunityResources and Policies

DeliverySystem Design

DecisionSupport

ClinicalInformation

Systems

Health SystemOrganization of Health Care

Self Management

SupportInformal

Social Networks

CommunityOrganizations

Individualized Assessment

Collaborative Goal Setting

Skills Instruction

Ongoing Follow Up

and Support

Community Resources

Continuity of Quality

Clinical Care

Individualized Assessment

Collaborative Goal Setting

Skills Instruction

Ongoing Follow Up

and Support

Community Resources

Continuity of Quality

Clinical Care

Problem Solving

Taking MedicationMonitoring

BeingActive

Healthy Eating

Healthy Coping

Reducing Risks

Problem Solving

Taking MedicationMonitoring

BeingActive

Healthy Eating

Healthy Coping

Reducing Risks

Families

Worksites

BuiltEnvironment

Professors at SUNY at Stony Brook

Gerald Davison and Stuart ValinsComplex social influences that surround and contribute to behavior influence

Howard RachlinHow to understand complex human behavior from a rigorous, positivistic perspective

Robin WinklerToken economies Behavioral economics

Leonard Krasner & Leonard Ullmann

Krasner & Ullmann Behavior Influence and Personality: The Social Matrix of Human Action (1973)Models of psychopathology products of social influences of professional and science establishments

Krasner Environmental Design and Human Behavior (1980)“Community Mental health and Environmental Design”“Environmental Design in Alternative Societies: The People’s Republic of China,”

Krasner & Ullmann Research in behavior modification. 1965.

Ullmann & Krasner Case studies in behavior modification. 1965.

Behavioral & Ecological SimilaritiesBehaviorism:• History and experience of individual guides behaviorEcological perspective:• Social, organizational layers as architecture of

experienceShare• Experiences shapes behavior• Policies, governments, organizations shape behavior• Groups, organizations, governments are subject to

same influences of reinforcers, etc.

Behavioral & Ecological Similarities

Shared aversion to victim blamingRecognize how behaviors, lifestyles, and choices

reflect sane responses to circumstances

Hillary Clinton – It takes a village

Nancy Reagan – Just say “no”!


• SBM’s Links with Behaviorism• Social Ecological Perspectives

• How to Study Influences of Environments

• Genetics as Model for Effects of Context• Multilevel Analysis• Implications for Research• How We Think About Contexts

The Unfulfilled Legacy ofKurt Lewin

B = f (I x E)

Lewin’s Dream:Spatial Analysis

St. Louis, Missouri

Tobacco Billboards

in St. Louis

Luke et al. Tobacco Control. 2000 9:16-23.

Baker EA, Schootman M, Barnidge E, Kelly C. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Preventing Chronic Disease [serial online]. July 2006;3(3).

Supermarket inhealthiest third

Supermarket inleast healthy third

Neighborhood Food Sources andRelative Likelihood of Obesity

Supermarkets in census tract,0.83 relative to census tracts with no supermarkets

Convenience stores in census tract1.16 relative to neighborhoods with no convenience stores.

ONLY Convenience Stores in census tract1.45 relative to tracts with only supermarkets

Morland et al. Am J Prev Med 2006 30: 333-339.Adjusting for gender, race, age, income, education, and physical activity


• SBM’s Links with Behaviorism• Social Ecological Perspectives• How to Study Influences of Environments

• Genetics as Model for Effects of Context

• Multilevel Analysis• Implications for Research• How We Think About Contexts

Epigenetics

Gosden & Feinberg, editorial, NEJM 2007 356: 731-733, regarding Hitchins et al., NEJM 2007 356: 697-705

Trangenerational Epigenetic Inheritance

• Hypermethylation of allele of MLH1 conveys predisposition to cancer

• Evidence of transmission of epimutation from mother to son

Hitchins et al. NEJM 2007 356: 697-705

Maternal Nurturanceand Adult Stress Response

HormonalStress Response

Low MaternalNurturance

Meany & Szyf Trends in Neuroscience. 28: 456-463.

Epigenetic Changes MediateEffects of Maternal Nurturance

DNAMethylation

HormonalStress Response

Low MaternalNurturance

Meany & Szyf Trends in Neuroscience. 28: 456-463.

CVDRisk

↑ BP fromstress

negativeemotions

Adapted from Williams et al., Psychosom Med 2001 63:300-305.

Genes, Environment, Serotonin and CVD Risk

CVDRisk

↑ BP fromstress

negativeemotions

low CNSserotonin



CVDRisk

↑ BP fromstress

negativeemotions

low CNSserotonin

long allelepromoter region,

serotonin transporter gene



z scores for index of CNS serotonin function by long and short allele genotypes and early rearing environment (Bennett, Lesch et al., Mol Psychiat 2002 7: 118-122.)

Serotonin Function by Rearing and Genotype

-40-30-20-10

0102030405060 Peer Reared

l/l l/s

Parent Reared

l/l l/s

CVDRisk

↑ BP fromstress

negativeemotions

low CNSserotonin



Maternal deprivation



CVDRisk

↑ BP fromstress

negativeemotions

low CNSserotonin



Ethnicity< 30% China, Japan50-60% Europe> 70% Africa




CVDRisk

↑ BP fromstress

negativeemotions

low CNSserotonin




Low Socioeconomic Status


Ethnicity< 30% China, Japan50-60% Europe> 70% Africa


Genotype & Phenotype & Environment

• The phenotype of the cell is the setting for gene expression

• Phenotype precedes genotype• Development as fundamentally

adaptational process

• There is no blueprint

Michael Meany, ICBM, Bangkok, 2006

Influences of Genetics arefundamentally

dependent on context

Group Individual

Situation Behavior

Phenotype Genotype

Environment Person

Context Agent

Genetic Profiling as Modelfor Understanding Contexts

of Behavior

Genetic Profiling and Br CA Metastasis

van de Vijver et al. NEJM 2002 347:1999-2009

van de Vijver et al. NEJM 2002 347:1999-2009

Conclusions

Influences on behavior are:• Multiple (Genetic, Environmental, Social,

Psychological,…)• Multidirectional• Multiply contingent (heavily moderated)• Layered with interactions among layers

Genomics ----- Populomics??


• SBM’s Links with Behaviorism• Social Ecological Perspectives• How to Study Influences of Environments• Genetics as Model for Effects of Context

• Multilevel Analysis• Implications for Research• How We Think About Contexts

Multilevel Analysis of Adolescent Alcohol Use

HighSES

ParentAlcohol

Use

ParentalMonitoring

Peer Alcohol Use

AdolescentAlcohol Use

LowSES

A

B

C

+

-

+

Chuang, Ennett, Bauman & Foshee J Health and Soc Beh 2005 46: 187–204

AdolescentsParentsNeighborhood

Neighborhood ClimateSocial NetworksSocial Support

Neighbor-hood

Climate

SocialSupport

SocialIntegration

?→

?→

Neighbor-hood

Climate

SocialSupport

SocialIntegration

CynicalMistrust

?→

?→

?→

Risk for CVD“No one cares much what

happens to you.”“Most people make friends

because friends are likely to be useful to them.”

Neighbor-hood

Climate

SocialSupport

SocialIntegration

CynicalMistrust

?→

?→

?→

“If you fell on the sidewalk or street in your neighborhood, would people help you?”“Do you see people in angry arguments in your neighborhood?”

Neighbor-hood

Climate

SocialSupport

SocialIntegration

CynicalMistrust

?→

?→

?→

Social Integration (Orth-Gomer)Network: Overall, how many people –

with similar interests to you – do you have contact with?

Intimacy: Do you feel there is one particular person who feels very close to you?

Neighbor-hood

Climate

SocialSupport

SocialIntegration

CynicalMistrust

?→

?→

?→

Nondirective – Cooperative without “taking over”“Make it easy for you to talk about anything you think is

important”“Offer a range of suggestions”

Directive – Take control, tell you what to feel, what to choose“Don't let you dwell on upsetting thoughts”“Tell you what to do”

Structural Equation Model

NeighborhoodClimate

Directive

Non-directive

SocialIntegration

CynicalMistrust

-.257

.170

.499

-.232

.301

-.270

-.156

301 community members in St. Louis, MO76.7% Female, 52.2% African American76% Beyond High School (41% College Graduate)


• SBM’s Links with Behaviorism• Social Ecological Perspectives• How to Study Influences of Environments• Genetics as Model for Effects of Context• Multilevel Analysis

• Implications for Research• How We Think About Contexts

Design Considerations

Experimental Designs• Randomized controlled trials• Within-subjects, repeated measures designs• Multiple baseline designs

Intended to evaluate an object controlling for effects of context

How do we evaluate the effects of context?

Mother’sSocialIsolation

.271

Baseline Acute Care

Acute Care in 3rd Year

AsthmaManage-ment

Attitudes

Mother’sEducation

-.174

.223

.241 -.105

.281

Engagementin Program

ClassesContacts withNeighborhoodWorkers

-.242.206

.912.968

Structural Equation Analysis ofNeighborhood Asthma Coalition

Mark Walker in Fisher et al Pediatrics 2004 114: 116-123.

Generalizing the Model

Pre-Measure of Outcome

OutcomesKey

BehaviorsPredisposing,

EnablingFactors

Social, demographicconfounders

ExposureEngagement

ExposureIndicator

ExposureModerators

ExposureIndicator

Generalizing the Model

Pre-Measure of Outcome

OutcomesKey

Behaviors

Predisposing,EnablingFactors

Social, demographic variables

Intervention:Exposure,

Engagement

ExposureIndicator

ExposureIndicator

InterventionImplementation

InterventionSettingPolicy

NeighborhoodCommunity

Genetic,Constitutional

Factors

Evaluating Community Interventions

COMMIT• Community based promotion of smoking

cessation• 11 pairs of communities, randomized to

community based intervention or comparison• Community was the unit of randomization and

of analysis• Results – Quit Rates in Intervention &

Comparison Communities– Heavy Smokers: 0.180 vs 0.187, NS– Light Smokers: 0.306 vs 0.275, p = 0.004

The COMMIT Research Group. Am J Public Health. 1995 85:183-192)

Rethinking COMMITRandomized Control Design• Specifying content of community based

intervention• Evaluate the impacts of the specified

intervention, broad as it was, independent of its context

• Missed opportunity??– Broader policy, environmental approaches– Grass roots community organization

approaches

Rethinking COMMIT

Alternative Design• Descriptive, multi-level analysis• Encourage intervention variation• Study effects of variation• Study interactions of context with

intervention elements• NB: COMMIT cohort > 20,000

Fisher’s Dream COMMIT Cohort > 20,000

Baseline Smoking & History

SmokingStatus

Quitting Behaviors;

Processes ofChange

Smoking History o

Personality

Individual-Level Social, Economic and Demographic Variables


Engagement

ExposureIndicator

ExposureIndicator

Breadth andExtent ofImplementation

InterventionSettingPolicy

NeighborhoodCommunity

Smoking-Related

GenotypesQuit

Attempts

For Unreconstructed Experimentalists

Baseline Smoking & History

SmokingStatusQuitting

Behaviors;Processes of

Change

Smoking History o

Personality

Individual-Level Social, Economic and Demographic Variables


Engagement

ExposureIndicator

ExposureIndicator

Breadth andExtent ofImplementation

InterventionSetting

PolicyNeighborhoodCommunity

Smoking-Related

Genotypes

QuitAttempts

ExperimentalIntervention

Earliest Multilevel Analysis PapersListed in PubMedMultilevel analysis

Kim, I.K. A multilevel analysis of fertility behavior in Korea. Stud Comp Int Dev. 1985 Summer;20(2):65-90.

Structural Equation ModelingCox CL, Roghmann KJ. Empirical test of the interaction

model of client health behavior. Res Nurs Health. 1984 Dec;7(4):275-85.

Spatial analysis– 672 articles in Pub Med– First in 1950– 508 of the 672 since 1997

(search, 3/18/07)

Dissemination

• RE-AIM (Glasgow and colleagues, www.re-aim.org)

– Reach– Efficacy/Effectiveness– Adoption– Implementation– Maintenance

• Practical Clinical Trials• Preference Designs


• SBM’s Links with Behaviorism• Social Ecological Perspectives• How to Study Influences of Environments• Genetics as Model for Effects of Context• Multilevel Analysis• Implications for Research

• How We Think About Contexts

Wisdom of Lazarus

Arnold Lazarus1966, Sausalito, California

“Science is defined not by its methods but by the way we talk about our data”

Fundamental, Irreducible Role of Scholarly Judgment

No matter how well designed the studies from which evidence gathered

No matter how many times studies replicated

No matter how strong the meta-analytic reviews

Still need judgment:• For an individual problem• In an individual setting and circumstance• Previous findings may be wisely applied

Jane Loevinger:“The world is not orthogonal”

Fisher’s CorollaryInteractions and moderation are the ways of the world, not main effects

Conventional experimental designs not well suited to study multilevel interactions

How should we best frame our questions to study contexts and their interactions?

Gail Kennedy, FolgerProfessor of Philosophy, Amherst College, 1968:

“Getting the right answer is the easy part.

It’s asking the right question that’s important.”

SBM Leaders – Collegial Support

Colleagues – Friends – TeachersDavid Abrams Barbara Anderson Victoria Anwuri Cynthia Arfken Zev Ashenberg Wendy Auslander Stephen Ayres Ray Battalio Terry Bazzarre Laura Bayer Robert Birney Don Bishop Gordon Bloomberg Carol Brownson Ross Brownson Bob Carney Edith Chen Rod Coe Jerry Cohen Cathleen Connell Richard Crespo Bill Daughaday Jim Davis Kim Davis Wayne Davis Jerry Davison Alan Delamater Bob DeVellis Brenda DeVellis Tom DiLorenzo Jo Anne Earp George Eberle

Susan Ennett Hege Eriksen Kelly Everard Patricia Fazzone Irene Fischer Vangie Foshee Ken Freedland Carol Friedling Jeanne Gabriele Russ Glasgow Richard Gram Sol Garfield Len Green Ellen Gritz Debra Haire-Joshu Kent Harber Laura Hayman Bernadette Heckman Joan Heins Susan Hopper David Jaffe Donna Jeffe Randi Joffe John Kagel Peter Kaufmann Gail Kennedy David Kipnis Betty Kirkley Judy Kopp Maria Kopp Nick Kotchabhakdi Nittaya Kotchabhakdi

Len Krasner Jean Kristeller Linda Krug-Porzelius Steve Kurtz Annette La Greca Jeff Levenkron Tami Levitt-Gilmour Ed Lichtenstein Marcia Lange Jeff Levenkron Laura Linnan Bert Loro Michael Lowe Roland Maiuro David Marrero Joni Mayer Rosemary McConkey Bill McReynolds Karen Meredith Rich Milich Greg Miller Phil Miller Karen Monaco Glen Morgan Hiltrud Mueller Jan Munro Judy Ockene Brian Oldenburg Tracy Orleans Mary O’Toole Fran Porter Gabe Reed Highstein

Howard Rachlin Veronica Richardson Barbara Rimer Katharine Rost Julio Santiago Ken Schechtman Joanne Schneider Mario Schootman Catina Scott Judy Skala Celette Skinner Walton Sumner Linda Susman Adrienne Stauder Bob Strunk Roslyn Sykes Deb Tate Tiffany Tibbs Helen Todora Kim Trinkaus Antti Uutela Stuart Valins Elaine Walker Elizabeth Walker Mark Walker Elizabeth Warren-

Boulton Patti Watkins Redford Williams Virginia Williams Kevin Whitney Robin Winkler

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