Society of Behavioral Medicine 2007

The Importance of Context in Understanding Behavior and Promoting Health Edwin B. Fisher Department of Health Behavior and Health Education School of Public Health The University of North Carolina at Chapel Hill [email protected]

Interaction and Moderation in 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

Past Experience Governs Impacts of Present Example: How We Respond To Ambiguous Stimuli 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.

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.

Low SES and Past Experience Lower socioeconomic status confers: • More experience with negative outcomes • In ambiguous situations: – Greater likelihood of negative outcomes – Greater sense of perceived threat

Influence of Past Experience/SES on Response to Threat Unambiguous Negative Video Low Parental Educ & Occup

β = .09

Perception of Threat

Ambiguous Video Low Parental Educ & Occup

β = .43

Perception of Threat

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

SES, Perception of Threat, and CVD Risk Ambiguous Video

Low Parental Educ & Occup

Perception of Threat

Heart Rate DBP

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

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

Social-Ecological Model

Over the life span

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

Marmot and the Causes of Causes Disparities from Material conditions, Income poverty Country

GNP per capita (US $s)

Life Expectancy

USA

$34,000

76.9 years

Greece

$17,000

78.1 years

Costa Rica

< $10,000

77.9 years

Cuba

< $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

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 skills Self-management skills Includes 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

Built Environment

Community Resources and Policies

Health System Self Management Support

Worksites

Informal Community Social Organizations Networks

Organization of Health Care Delivery System Design

Decision Support

Clinical Information Systems

Families

Implementation e.g, Resources & Supports for Self Management

Impacts e.g., AADE 7 Self-Care Behaviors

Community Resources

Healthy Eating

Ongoing Follow Up and Support

Being Active

Skills Instruction

Monitoring

Collaborative Goal Setting

Taking Medication

Individualized Assessment

Problem Solving

Clinical Status & Quality of Life

Healthy Coping

Continuity of Quality Clinical Care

Reducing Risks

Professors at SUNY at Stony Brook Gerald Davison and Stuart Valins Complex social influences that surround and contribute to behavior influence

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

Robin Winkler Token economies Æ Behavioral economics

Leonard Krasner & Leonard Ullmann Krasner & Ullmann Research in behavior modification. 1965. Ullmann & Krasner Case studies in behavior modification. 1965. 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,”

Behavioral & Ecological Similarities Behaviorism: • History and experience of individual guides behavior Ecological perspective: • Social, organizational layers as architecture of experience Share • 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 blaming Recognize how behaviors, lifestyles, and choices reflect sane responses to circumstances

9

Hillary Clinton – It takes a village Nancy Reagan – Just say “no”!

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

The Unfulfilled Legacy of Kurt 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.

Supermarket in healthiest third Supermarket in least healthy third

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).

Neighborhood Food Sources and Relative Likelihood of Obesity

Supermarkets in census tract, 0.83 relative to census tracts with no supermarkets Convenience stores in census tract 1.16 relative to neighborhoods with no convenience stores. ONLY Convenience Stores in census tract 1.45 relative to tracts with only supermarkets Adjusting for gender, race, age, income, education, and physical activity Morland et al. Am J Prev Med 2006 30: 333-339.

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

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 Nurturance and Adult Stress Response

Low Maternal Nurturance

Hormonal Stress Response

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

Epigenetic Changes Mediate Effects of Maternal Nurturance

Low Maternal Nurturance

DNA Methylation

Hormonal Stress Response

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

Genes, Environment, Serotonin and CVD Risk

negative emotions CVD Risk ↑ BP from stress

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

Genes, Environment, Serotonin and CVD Risk

negative emotions low CNS serotonin

CVD Risk ↑ BP from stress

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

Genes, Environment, Serotonin and CVD Risk

negative emotions long allele promoter region, serotonin transporter gene

low CNS serotonin

CVD Risk ↑ BP from stress

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

Serotonin Function by Rearing and Genotype 60 50 40 30 20 10 0 -10 -20 -30 -40

Peer Reared

l/l

l/s

Parent Reared

l/l

l/s

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: 118122.)

Genes, Environment, Serotonin and CVD Risk Maternal deprivation

negative emotions long allele promoter region, serotonin transporter gene

low CNS serotonin

CVD Risk ↑ BP from stress

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

Genes, Environment, Serotonin and CVD Risk Maternal deprivation

negative emotions long allele promoter region, serotonin transporter gene

Ethnicity < 30% China, Japan 50-60% Europe > 70% Africa

low CNS serotonin

CVD Risk ↑ BP from stress

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

Genes, Environment, Serotonin and CVD Risk Low Socioeconomic Status

Maternal deprivation

negative emotions long allele promoter region, serotonin transporter gene

Ethnicity < 30% China, Japan 50-60% Europe > 70% Africa

low CNS serotonin

CVD Risk ↑ BP from stress

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

Genotype & Phenotype & Environment Michael Meany, ICBM, Bangkok, 2006

• The phenotype of the cell is the setting for gene expression • Phenotype precedes genotype • Development as fundamentally adaptational process • There is no blueprint

Influences of Genetics are

fundamentally dependent on context

Phenotype

Genotype Situation

Group

Behavior

Individual Environment

Context

Person

Agent

Genetic Profiling as Model for 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??

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

Multilevel Analysis of Adolescent Alcohol Use Neighborhood

Low SES

Parents

A

Parental Monitoring

B High SES

C

Adolescents

-

Adolescent Alcohol Use

+ Parent Alcohol Use

+ Peer Alcohol Use

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

Neighborhood Climate Social Networks Social Support

Neighborhood Climate

? →

? Social Integration

→

Social Support

Neighborhood Climate

? →

? Social Integration

→

? Social Support

→

Cynical Mistrust

Risk for CVD “No one cares much what happens to you.” “Most people make friends because friends are likely to be useful to them.”

Neighborhood Climate

? →

? Social Integration

“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?”

→

? Social Support

→

Cynical Mistrust

Neighborhood Climate

? →

? Social Integration

→

? Social Support

→

Cynical Mistrust

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?

Neighborhood Climate

? →

? Social Integration

→

? Social Support

→

Cynical Mistrust

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 -.257

-.232 .499

Neighborhood Climate

.301

Nondirective

-.270

Cynical Mistrust

Social Integration

Directive -.156 301 community members in St. Louis, MO 76.7% Female, 52.2% African American 76% Beyond High School (41% College Graduate)

.170

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

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?

Structural Equation Analysis of Neighborhood Asthma Coalition .912

Mother’s Social Isolation

Classes .968

.271

Engagement in Program

.206

.241

Attitudes

Contacts with Neighborhood Workers

-.242

Asthma Management

-.105

Acute Care in 3rd Year

.223

Mother’s Education

-.174

Baseline Acute Care

.281

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

Generalizing the Model Exposure Indicator Exposure Moderators

Exposure Indicator

Exposure Engagement

Predisposing, Enabling Factors

Social, demographic confounders

Key Behaviors

Outcomes

Pre-Measure of Outcome

Generalizing the Model Policy Neighborhood Community

Intervention Setting

Predisposing, Enabling Factors

Intervention Implementation

Intervention: Exposure, Engagement

Genetic, Constitutional Factors

Key Behaviors

Social, demographic variables

Exposure Indicator Exposure Indicator

Outcomes

Pre-Measure of Outcome

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 COMMIT Randomized 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 Policy Neighborhood Community

Intervention Setting

Smoking History o Personality SmokingRelated Genotypes

Breadth and Extent of Implementation

Exposure Indicator Exposure Indicator

Intervention: Exposure, Engagement

Quitting Behaviors; Processes of Change

Individual-Level Social, Economic and Demographic Variables

Quit Attempts

Smoking Status

Baseline Smoking & History

For Unreconstructed Experimentalists Intervention Setting Policy Neighborhood Community

Exposure Indicator Experimental Intervention Smoking History o Personality

SmokingRelated Genotypes

Breadth and Extent of Implementation

Exposure Indicator

Intervention: Exposure, Engagement

Quitting Behaviors; Processes of Change Individual-Level Social, Economic and Demographic Variables

Quit Attempts

Smoking Status

Baseline Smoking & History

Earliest Multilevel Analysis Papers Listed in PubMed Multilevel analysis Kim, I.K. A multilevel analysis of fertility behavior in Korea. Stud Comp Int Dev. 1985 Summer;20(2):6590.

Structural Equation Modeling Cox 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

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

Wisdom of Lazarus

Arnold Lazarus 1966, 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 Corollary Interactions 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, Folger Professor 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 – Teachers David 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 WarrenBoulton Patti Watkins Redford Williams Virginia Williams Kevin Whitney Robin Winkler