Network approaches to behavior change

Carl Latkin, Department of Health, Behavior & Society

Johns Hopkins Bloomberg School of Public Health

Recruitment of network members

• Maximize number of alters with network inventory
• (feedback to interviewers, placement of inventory, name generator questions first, ask why should people give you good data, you can include cool name generators but not too many, Network Canvas)
• Collect more network data than in your proposal & some dull measures but not too dull (like dull theories or hypotheticals)
• Assist participants in recruitment network for interventions
• Plan for difficulties in recruiting network members, but networks can help with retention
• For the intervention, ensure that there’s the potential for social influence (e.g., frequency of contact)
• Think about creating sociometric networks from collecting egocentric data. What unique identifiers do you need?

An aside on improving behavioral sciences

• Theories don’t capture behavior complexity
• We don’t collect sufficient data on mechanisms of behavior change
• We focus too much on individual level factors, though social & structural factors are more powerful
• We don’t systematically improve measurement of self-reported data (exception: mhealth) but obsess about reliability
• We learn more by mucking about in a social environment than studying static phenomena

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Social network peer intervention

• Intervention focus: HIV prevention (people who inject drugs, heterosexual women, and men who have sex with men),family planning methods, weight reduction interventions, smoking, exercise, and the well-being of people with schizophrenia
• Interventions modality: face-to-face; social media components, online only
• Network interventions: Egocentric, dyads, and sociometric networks

�Theory/methods Network interventions

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• Active learning, social cognitive theory (role plays, modeling, symbolic and tangible rewards)
• Realistic scenarios, practice new behaviors, modeling by facilitators, review of experiences outside of intervention group (homework)

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• Increase salience of health promotion social norms within networks
• Norms with networks are often contradictory
• Enhance acceptability and frequency of talking about behavior or disease

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• Social diffusion of behavior change flowing through networks (diffusions of innovation)
• Structure of network
• Role in network (opinion leader)
• Type of behavior

Social roles and self-concept�making change agents�

• Promoting health behaviors can be self-rewarding as they may enhance self-concept, provide meaningful social roles,
• The role may provide social status, a sense of identity, a social identity of belonging to a valued group.
• Promoting behavior change among network members may also enhance important social relationships.
• Social roles should be culturally consistent and believable.
• Roles need to be constructed so that they garner rewards and positive feedback from social network members.

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Key components of network approaches

• Identify stable sources of network influence for health behaviors
• Identify motives for network members to promote risk reduction
• Provide training in communications skills to promote risk reduction
• Recruiting (and retaining) network members
• Evaluate behavior change in the peer educators and their networks

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Key network factors to assess

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• Specificity of influence by network members

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• How do you know if there’s social influence or differential affiliation and does it matter?

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Cognitive consistency as mechanism of behavior change for peer educators

• Promote pro-social identities that provided & reinforced meaningful social role (peer health educator, friend, HIV expert)
• Self-identity as community member who could improve the health and well-being friends and community members
• Identity reinforced by social network and larger community

• Inconsistencies between participants’ outreach messages and risk behaviors would motivate behavior change to conform to risk reduction messages

Communication skills training�

• Trainings in communication skills are necessary to initiate and maintain conversations about health behaviors and frame the topic
• Train in communication skills to verbally reward others who engage in the behavior, present information or model behaviors that is credible, and discuss health behaviors in a manner that does not elicit reactance.

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Communication example:

Using the SAFE skills will help you as a peer educator in conversations so people will listen to you and avoid conflict. 

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SAFE has 4 steps: 

• S stands for see if it’s the right time and place 
• A stands for ask questions and listen 
• F stands for Find Options & Friendly Feedback 
• E stands for Encourage others to Plan 

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Communication skills training

• One conversation is not likely to lead to behavior change. Structure intervention for repeat interaction. Don’t focus on disseminating information.
• Peer educators (as does everyone) have mental models of behavior change that are incomplete

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Measuring outcomes

• Indexes (change agents) tend to change the most
• Long term outcomes can be advantageous if there’s a control group
• Although RCTs are great, there may be other viable study designs, such as serial cross-sectional or no control group, longitudinal

Assessing & addressing contamination

• The best network intervention could lead to no outcome differences between experimental and control group
• Measure and analyze contamination
• Analyze network overlap, assess exposure (tracers)
• Three group analyses, adjust
• Prevent: Focus intervention, distance between conditions

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Potential problems with network approaches

• Many support interventions do not include methods to facilitate reciprocity and only focus on the individuals in need of health support.
• The support may lead to conflict and greater stress in the relationship due to recipient and supporter both trying to assert control over the health behaviors.
• Network members may challenge the credibility of the individuals promoting behavior change

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Network Interventions: Examples

• Randomized clinical trials (Are there viable alternatives?)
• VCT provided to all participants
• Index participants recruit specific network members
• Index participants in the experimental condition trained ( about 6 sessions) to promote risk reduction among their networks
• Equal attention control groups
• Evaluated in network up to 30 months

Intervention example: HPTN 037

A randomized study to evaluate the efficacy of a network-oriented peer intervention for HIV prevention among injection drug users and their risk network members (drug & sex). The study sites were in the US and Thailand A Study of the HIV Prevention Trials Network (HPTN)

HPTN 037 example

• 6 sessions, small group, cognitive behavioral intervention, focuses on social identity, promoting risk reduction norms, social skills building, and motivations.

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HPTN 037 Results: Ten or more HIV risk reduction conversations

HPTN 037 Results: Philadelphia �Effect of treatment vs. control on HIV risk behavior

Social norms and behavior: HPTN 037�

• Examined the relationship between social norms and behaviors among 652 people who inject drugs, interviewed every 6 months for up to 30 months.
• Descriptive social norms were paired with the behaviors self-reported by the participants.
• Injection behaviors were measured every 6 months (0, 6, 13, 18, 24) and social norms at (0, 12, 24) months

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• Addiction. 2013 May;108(5):934-43

Change in Social Norm Scores over time

Self Reported Risk Behavior at Visits Following Reporting Of Social Norms

Self-Reported Behavior as a Predictor of Subsequent Report of Social Norms

HIV seroincidence

• Lancet HIV, The, 2016-10-01, Volume 3, Issue 10, Pages e482-e489

Considerations in intervention

• Social support isn’t all good--look carefully
• Changing behaviors can threaten relationship
• Specific social network factors are associated with specific health outcomes
• Do you want to change social networks, social norms, and behavior?

Major impediments for network approaches

• Numerous life events and neighborhood stressors that alter network composition
• Lack of resources, competing demands
• Some ties are fluid
• Individuals with high centrality or those who have influential roles may not be interested in partaking in the intervention.

Potential Adverse Consequences

• Role conflict between member of community and institutional representative
• Lack of control over the messages
• Negative reaction from network members
• What happens to participants after programs end?

Questions for network approaches to reaching specific populations�

• What are the important domains to generate social networks inventories?
• What are the necessary skills need to train network members?
• How do you providing key network members with the credibility to be effective?

What are the best techniques for behavior change?

• Does it work better to reward or punish?
• What should be the strength of ties or relationships?
• Weak ties versus strong ties
• Direct or indirect influence?
• Are social norms an attribute or dynamic process of the whole network?
• Do you focus intervention on self-efficacy, perceived risk, social norms, rewards?

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More questions for network intervention development

• What are the key subgroups in the population?
• What would motivate participation?
• What are effective methods of promoting health behaviors in the community?
• What skills training is necessary to promote behavior change?

Questions and caveats for social network approaches

• Can you delineate important social network members
• Can people recollect the names of their network members, are these reports reliable?
• Can they accurately report on the behaviors of network members?

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• Ethics
• Is it ethical to inquire about people that you do not have informed consent?
• What are the ethics of promoting behavior change among individuals who did not consent?

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• Networks are the social construction of academics, not necessarily the way individuals view their social world.

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Acknowledgements: Study participants, Lauren Dayton, Melissa Davey-Rothwell, Seun Falde, Xiangrong Kong, NIH, & great NIDA staff

Carl.Latkin@jhu.edu