Assignment 1 - Please submit your replies here.

HOMEWORK ASSIGNMENT 1

Part 1

For either of the case studies readings (Foy, Zoellner, or Shafer), please describe the following:

1. How did the authors use theory?  Where would you place it on a continuum of uses of theory we discussed?

In Foy et al, the authors use the Theory of Planned Behavior to try and understand what factors influenced compliance with national standards for care of women requesting an induced abortion in Scotland.  The authors measured compliance using two indicators (offer of an assessment appointment within 5 days of referral, and supply of contraceptives at discharge). Based on the Theory of Planned Behavior, the authors sought to determine what elements of the theory most influenced compliance with guidelines by measuring clinicians’ intentions to follow the guidelines, their attitudes toward the guidelines, their experience of subjective norms of guideline compliance, and their perceived level of control over following the guidelines. 

Based on the continuum of uses of theory discussed in class, I would say this falls into the first category of theory, since it seeks to understand what the relevant points of influence are for physicians following guidelines - this is exploratory and descriptive work, as there is no intervention being tested or evaluated in this article.

2. How did it relate to the uses of theory as described by Bartholemew and Mulen?

In Bartholemew and Mulen’s uses of theory, I think this article is a description of the first use of theory described, that of identification of the determinants of the behavior that is to be targeted for change.  In this article the authors are trying to create a model of why physicians do or do not follow the guidelines and what factors influence their compliance or lack thereof – they are not yet creating a causal model to change the behavior or developing interventions to that end, much less evaluating any such interventions.

3. In you view of the work, how much did they explanation of the data ‘fit’ the theoretical components?

In my view the authors collected their data in a way to be very true to the theoretical components of the Theory of Planned Behavior, so their analysis and conclusions from the data are also very close to the theory. I also think their measures were very true to the intended concepts they were trying to capture, based on the survey items they showed.  Interestingly, they were also able to measure what percentage of the variation in the different elements of the behavior continuum were explained by the theory, although I’m not sure I completely understand this sub-analysis.

Part 2

1. Select a behavior that is relevant to your area of interest.

An area of interest of mine is strategies to increase case detection for tuberculosis in high-burden, low-resource settings, particularly involving active case-finding strategies and interventions. One such intervention that we have worked with a lot is household contact investigation, in which household members of newly diagnosed TB patients are screened for TB and referred for further evaluation if symptomatic. Following screening, however, it is difficult to ensure that referred household contacts will actually go to the clinic to get evaluated.

1a.Which levels (individual, social, institutional, environmental) are most likely to have a significant role?

Regarding ensuring referred household members get evaluated for TB – I believe that all levels of factors heavily influence this behavior: environmental/contextual factors include the economic and geographic challenges associated with accessing a health center in a low-resource setting; institutional factors include stigma from providers and poor health services provided at the health centers; social factors include stigma from the community; intrapersonal factors include competing health and welfare concerns and other health beliefs regarding tuberculosis.

1b.Who would you engage to develop a formative project to understand more about this behavior?

This is actually what I did last summer – I conducted focus groups with newly diagnosed tuberculosis patients and with their household members (people at risk of getting tuberculosis) to try and elicit what they perceived were their biggest barriers to accessing care. I also conducted a survey with the focus group participants to try and get another measure of the same topics and questions. I used the Knowledge, Attitudes, Practices approach (theory? I don’t think it qualifies as a theory so much as an approach to gathering information) to try and understand what the patients and household members knew, believed, and did regarding seeking care for an illness like tuberculosis.

Beyond understanding the perspective of the individual patients, it would also be important to understand the clinician’s perspective on treating patients symptomatic for tuberculosis (I’ve participated in some of this work with Margaret). I think it would also be important to understand the National Tuberculosis Programme’s perspective on the organization of tuberculosis care in this setting, including care based at the primary health center as well as other outreach and active case-finding approaches. This could shed light on any resources that might be available to leverage to help reduce identified barriers.

For students who are applying theory to an active project:

2. For one of the behaviors relevant to your outcome, complete a table relating variables relevant to your behavior to theories presented in class and in the readings. Can you expand on these individual factors, to include other factors at the social, institutional and environmental levels?

Applying the Theory of Planned Behavior to the topic of referred household contacts going to the clinic to get evaluated:

Other important factors affecting whether a referred household contact gets evaluated for tuberculosis: 

-        Can the patient afford to go to the clinic?

-        Can the patient physically get to the clinic?

-        Will the clinic be able to perform the evaluation?

-        Will the clinic have treatment on hand if the patient tests positive for tuberculosis?

-        What are the patient’s other (more pressing?) health or welfare concerns?

-        What are the social influences surrounding going to get evaluated for tuberculosis (stigma, competing health beliefs like traditional medicine, etc)?