# Lesson 4: Social, Cultural, and Environmental Theories I *Companion-podcast transcript • Sarah & Kiffer* *Office Hours episode to listen to after working through the lesson* --- **Sarah:** Here's an uncomfortable pattern. The people who most need the benefits of a new idea, such as people with less education and less wealth, are generally the last to adopt it. **Kiffer:** Rogers described that himself, in his book. He called it the innovativeness-needs paradox. **Sarah:** And the usual diffusion advice is to target early adopters first and let their example spur the rest. So a launch can look successful while the gap grows. **Kiffer:** It can. I'd still keep an early-adopter strategy, and that's where Sarah and I part ways. **Sarah:** Welcome back to Office Hours. I'm Sarah. **Kiffer:** And I'm Kiffer. We're on Lesson four, Social, Cultural, and Environmental Theories I, and we'll start with the constructs, because Social Cognitive Theory has ten of them and several of them sound alike. **Sarah:** Question one. How do you tell the constructs apart? I'll admit that when I first met this theory, self-efficacy and behavioural capability blurred together for me. **Kiffer:** Let's test that with a made-up student. Nadia is in second year at SFU, and she'd like to start cycling to the Burnaby campus, which sits at the top of Burnaby Mountain. Here are five details. She's never fixed a flat tire, and she doesn't know which route up the hill has a bike lane. She thinks she'd arrive sweaty for her morning seminar, and she'd find that embarrassing. Her roommate rides up most days and clearly enjoys it. She tried the ride once in September, had to get off and walk the last stretch, and now doubts she can make the climb. And her apartment building has no covered place to lock a bike. **Sarah:** I'll try sorting those out loud. **Kiffer:** Before Sarah does, everyone listening can try it too. Which construct does each of those five details belong to? Take a few seconds. *(Pause)* **Sarah:** Okay. The flat tire and the route: she doesn't feel able to do it, so that's low self-efficacy. Arriving sweaty is an expectation, because it's a prediction, and finding it embarrassing is an expectancy, because that's how she values the outcome. The roommate is vicarious learning. The failed climb in September and the doubt that followed are self-efficacy again. And the missing bike storage is the situation. **Kiffer:** Four of those five are right. Let me ask about the first one. If you were designing a program for Nadia, what would you do about the flat tire and the route? **Sarah:** I'd run a short bike maintenance workshop and give her a map of the route with the bike lanes marked. Oh. That's teaching a skill and giving her knowledge, so it's behavioural capability. I labelled it self-efficacy because she sounded unsure of herself. The detail itself is about what she knows and can do. **Kiffer:** That's the check I'd recommend whenever two constructs blur. Ask what the program would have to do about the detail. If the answer is to teach her something, it's behavioural capability. If she already knows how and the answer is to help her believe she can do it, it's self-efficacy. **Sarah:** And the September ride tells us where her low self-efficacy comes from. It was a mastery experience that went badly. **Kiffer:** That also points to the fix. Bandura wrote that the most effective way to build a strong sense of efficacy is through mastery experiences. A pep talk from her roommate would be verbal persuasion, and it might help a little. A better plan would have her ride the route in sections, starting with the flatter part and adding the climb a piece at a time, so that each success is her own. **Sarah:** And the sweat problem has two handles. A program could change the prediction, for example by showing her somewhere to change on campus, or it could work on the valuation, which is often harder. **Kiffer:** Right. Getting the label right matters because each construct points to a different program handle. If you call a skills gap a confidence problem, you end up offering encouragement to someone who needed a workshop. **Sarah:** Where does perceived behavioural control from Lesson three fit? Students mix that one up with self-efficacy too, and I can see why, since both describe a person's sense of being able to carry out a behaviour. **Kiffer:** They're close relatives. The difference is where the construct sits. In the Theory of Planned Behavior, it's one of three predictors of intention, in a model of one person's decision. In Social Cognitive Theory, self-efficacy sits inside a cycle with vicarious learning, reinforcement and the situation, and the cycle keeps rebuilding it. Nadia's September ride is that cycle at work. **Sarah:** Question two. Programs lean heavily on self-efficacy, and people with higher self-efficacy usually do more of the behaviour. So if a program raises self-efficacy, should we expect the behaviour to follow? **Kiffer:** Let's look at that with a made-up survey. A health authority asks eight hundred adults how confident they are that they could walk for thirty minutes on most days, and how many days they actually walked in the past seven. People in the top third for confidence walked on about five days. People in the bottom third walked on about two. Here's the question. Which part of Social Cognitive Theory itself predicts that the influence could run the other way, from walking to confidence? Take a few seconds. *(Pause)* **Sarah:** Reciprocal determinism, and mastery experience in particular. People who already walk most days have been collecting small successes, so their confidence is partly a result of the walking. It's the bicycle story again. Once the child can ride, the self-efficacy follows. **Kiffer:** Right. The theory itself says that confidence and behaviour shape each other, so a one-time survey will show them moving together whichever way the influence runs. There's also a third explanation. Someone who lives beside a flat, safe path and has a flexible schedule will probably walk more and feel more confident about walking. That's the situation construct acting on both at once. **Sarah:** So the survey can't tell us how much extra walking we'd get by raising confidence. **Kiffer:** That question needs a design where a program changes confidence for some people and leaves others as a comparison, with behaviour followed over time. The Chronic Disease Self-Management Program from the lesson, which is built on self-efficacy, was tested with that kind of design. In a randomized trial published in 1999, nine hundred fifty-two adults living with heart disease, lung disease, stroke or arthritis were assigned either to the program or to a wait list. Over six months, the program group exercised more and had fewer hospital stays and fewer days in hospital. Bandura was one of the authors. **Sarah:** But that program changed a lot of things at once. Lay leaders who live with a chronic condition, weekly action plans, group problem-solving. Which construct gets the credit? **Kiffer:** That's the catch with a package like this. The trial shows that the package worked. It can't show which construct did the work, and that's the grab-bag critique turning up in practice. The church study in the lesson found that self-regulation was the strongest factor, which is a useful reminder that self-efficacy doesn't always lead. **Sarah:** So if I were designing a program, I'd write down in advance which constructs I'm targeting and why. I'd measure those constructs along with the behaviour, more than once, and check whether the construct moved before the behaviour did. **Kiffer:** That's the approach I'd recommend. If self-efficacy rose and the behaviour stayed flat, that tells you something about the theory you chose. When a program targets self-efficacy, I'd still build it around mastery experiences, since Bandura considered them the strongest source, but I'd want the measurement to test that choice. **Sarah:** Question three. When a behaviour clusters in a social network, is it travelling along the ties? I'm thinking of the teenagers in the vaping scenario from the lesson who say they vape because everyone at lunch does. **Kiffer:** Social Network Theory invites you to say yes, since it explains behaviour through relationships. When friends share a behaviour, though, there are at least three explanations. The first is influence, which is what the theory is most interested in. The second is selection. People choose friends who are like them, which researchers call homophily, and it's one reason networks show the homogeneity quality from the lesson. **Sarah:** And the third would be a shared situation. Friends at the same school share a lunch spot, a corner store and a set of rules, so they can end up doing the same things without influencing each other at all. Is there evidence that this matters in real studies? **Kiffer:** A memorable example is a 2008 paper in the BMJ by Cohen-Cole and Fletcher. They took the methods used in earlier network studies and applied them to a large American study of adolescents and their friends. They chose outcomes that can't plausibly spread between friends, namely acne, headaches and height. The methods found apparent friend effects for all three. When they adjusted for shared environment, mainly by comparing students within the same school, the effects shrank and were no longer statistically significant. **Sarah:** So the same kind of analysis that suggested friends influence each other's health also suggested that friends make each other taller. That's very hard to explain as influence. **Kiffer:** Peer influence may well be part of what happens at that lunch table. The point is that a correlation between friends, on its own, can't separate influence from selection and a shared situation. **Sarah:** Then why use the theory at all, if we can't tell whether the ties are doing the work? **Kiffer:** Because a network map is useful for delivery whatever the answer is. Even if Ed's jogging friends were already the jogging type, Ed is still the person who can reach all of those subgroups with information. The two steps from the lesson, mapping the network and then working through it, hold up even when you can't prove that a behaviour spreads. **Sarah:** Let's do a harder example that puts the network together with diffusion of innovations. **Kiffer:** This one builds on the naloxone case from the lesson, with made-up details. A harm reduction coordinator in a mid-sized city in the BC Interior wants more people who use drugs to carry naloxone. She interviews four well-connected peers about whom they use with, share supplies with, and would call in an emergency. One person, let's call her Dee, is named by all four. Another, Marco, is named by only one, and he's the only link to a small group who use alone at a camp by the river. She trains six central peers, including Dee, to carry kits and teach others. Marco isn't one of them. **Sarah:** So these are ego-centred interviews, and she chose on centrality. Dee is the obvious pick. Marco is a bridge to the group that looks most at risk, and the map nearly missed him because only one of the four peers knew him. **Kiffer:** Right. With ego-centred interviews, you see a bridge only if someone you happened to interview knows about it. So suppose she fixes that and asks Marco to carry the program to the river camp. In diffusion terms, he's now a linkage agent, and the kit is the innovation. Let's rate it on the innovation attributes for the people at the camp, starting with relative advantage. For someone who uses alone, how much does carrying a kit of their own add? Take a few seconds. *(Pause)* **Sarah:** My first thought is that it adds a lot, since naloxone can reverse an opioid overdose. Then I remember that you can't use naloxone on yourself during an overdose. Someone else has to give it. So for a person who uses alone, a kit in their own pocket does little for their own overdose. What it adds is the ability to help somebody else. **Kiffer:** That's the trap in this example. The program defined the innovation as carrying a kit, and for this group that version has little relative advantage. The attributes are judged by the people who would adopt the innovation, so this sends the program back to innovation development, the formative research stage, done with the people at the camp. What would help them is someone with a kit within reach when they use. **Sarah:** So the innovation becomes an arrangement. Maybe two people at the camp agree to stay within reach of each other, or a trained person checks in on whoever is using. Then the other attributes look different. Trialability is good, because a pair could try it for one night. Complexity is fairly low, since with basic training people can learn to recognize an overdose and give naloxone. **Kiffer:** Here's one more made-up detail. Marco says the people at the camp use alone because they don't trust anyone they don't know. Which attribute does that detail hit hardest? **Sarah:** Compatibility. An arrangement that puts a stranger nearby clashes with the reason they use alone. And that's where the network comes back in. Marco is someone they already know, so the person who checks in could be Marco, or someone he vouches for. That's the communication patterns quality, whose word carries credibility. **Kiffer:** So the two theories do different jobs in this example. The network map finds the channel and shows who is trusted along it. Diffusion of innovations tells you what has to travel along that channel and where it will meet resistance. Fixing the map by itself would have sent Marco to the camp carrying an innovation with little relative advantage for the people there. **Sarah:** Question four. Is social marketing mostly advertising? Promotion is the part people see, so I understand why students tend to think of it that way. **Kiffer:** Promotion is one of four Ps, though, and in my view the other three often decide whether a campaign works. Here's a made-up case. A community health centre in a small BC city offers a free strength and balance class for older adults to prevent falls, and hardly anyone signs up. Interviews with older adults in the city turn up four findings. **Sarah:** What did the interviews find? **Kiffer:** People in their sixties and early seventies say falls happen to frail people, so the class isn't for them. People who've already had a fall like the idea but can't get there without a ride. Several people say they'd be embarrassed to walk into a room with falls prevention on the door. And most say they'd go if their doctor or pharmacist suggested it. Here's the question. Which of the four Ps does the embarrassment finding belong to? Take a few seconds. *(Pause)* **Sarah:** I want to say promotion, because the fix sounds like a new name. The finding itself, though, is about what it costs a person to show up, the social cost of being seen as someone who needs that class. So it's price. **Kiffer:** That's right. Price covers time, effort, embarrassment and anything a person gives up, along with money. Where do the fixes for that finding land? **Sarah:** In the other Ps. Calling it a strength class changes how the product is framed, and holding it in the fitness room at the local community centre changes the place. And the findings point to two segments. The active people in their sixties don't see themselves at risk, so the product for them is staying strong for the things they love, like gardening or travel, promoted through the fitness programs they already use. For the people who've had a fall, the main price is getting there, so place matters most, through a ride program or a class held in their own building. **Kiffer:** And the doctor and pharmacist finding is a promotion channel, chosen because the audience already trusts the messenger, much as the people at the river camp trusted Marco. Of all those fixes, that channel is the closest thing to advertising, and even it works through a trusted person. **Sarah:** Which brings us to where we disagree. The usual diffusion advice is to target early adopters first and let their example spur the rest. In this case, once the class is reframed, the likely early adopters are the active people in their sixties, who can get there on their own. The people who've already fallen, who need the class most, would come last. **Kiffer:** At first, yes, and I think that's often the right order. Early adopters make an innovation visible and credible. If nobody respected takes it up early, it may never spread to anyone. **Sarah:** Rogers saw the problem himself. In his book he described what he called the innovativeness-needs paradox: the people who most need the benefits of a new idea, such as people with less education and less wealth, are generally the last to adopt it. And in 2000, Cesar Victora and colleagues, working with child health studies in Brazil, proposed the inverse equity hypothesis. New public health interventions tend to reach better-off groups first, so inequities can widen before they narrow. A launch built around early adopters can look successful while the gap grows. **Kiffer:** I agree the gap is a real risk. Where I'd push back is on dropping early adopters. If the class never gets a good reputation, the people who need it most won't hear about it from anyone they trust. I'd keep an early-adopter strategy and choose the early adopters differently. **Sarah:** Differently how? **Kiffer:** From inside the group you most need to reach. Here, that might be a well-known resident of a seniors' building who has had a fall and is willing to talk about the class. That's the natural helper idea from the network section, put to work as an early adopter. **Sarah:** That helps, but I'd go further. I'd start the rides and the classes in seniors' housing in the first month, before any promotion, so the people with the highest barriers aren't left waiting for word to reach them. **Kiffer:** That's fair, and it costs more at the start. I think we can agree on a rule. Decide at the outset which group the program most needs to reach. Find early adopters and linkage agents inside that group. And report uptake separately for each group from the first month, so a widening gap shows up while there's still time to act. **Sarah:** I'd still put more of the budget into removing barriers than Kiffer would, but I agree with that rule. **Kiffer:** Let's pull it together with three things to take away. **Sarah:** First, when two constructs blur, ask what the program would have to do about the detail. Teaching points to behavioural capability, building belief points to self-efficacy, and a prediction is an expectation while a valuation is an expectancy. **Kiffer:** Second, when a construct goes along with a behaviour, or friends share a behaviour, there's more than one explanation. Influence in the other direction, selection and a shared situation can all produce the same pattern, so a claim about cause needs change measured over time and a comparison group. **Sarah:** And third, social marketing has four Ps, and promotion is one of them. Price includes social costs like embarrassment, and before a launch, decide which group you most need to reach and track uptake in that group from the start. **Kiffer:** If you'd like more practice, go back to the naloxone example from this episode. Rate the check-in arrangement at the river camp on three attributes we skipped: observability, communicability, and risk and uncertainty, and then say which of those ratings Marco's involvement would change. **Sarah:** Next time, it's Lesson five, Social, Cultural, and Environmental Theories II, which keeps moving outward to communications theory, community and organizational change, political economy, and cultural theory. **Kiffer:** Take care, everyone. **Sarah:** See you in Lesson five.