Prof. Frank Snyder presents at the Doctoral Midwifery Research Society Alcohol & Medication in Pregnancy Conference about 'Modifiable risk in Pregnancy & Health behaviour change: Utilising the Theory of Triadic Influence (TTI)'

1. MODIFIABLE RISK IN PREGNANCY &
HEALTH BEHAVIOUR CHANGE:
UTILISING THE THEORY OF TRIADIC
INFLUENCE (TTI)
9/9/15
Frank J. Snyder, Ph.D., M.P.H.
Assistant Professor of Public Health
Department of Health and Kinesiology
College of Health and Human Sciences
Purdue University
fsnyder@purdue.edu1

2. OUTLINE
o Introduction
o History
• Theory of Triadic Influence (TTI)
• Health behavior approaches
o TTI in detail
o Implications
o Strengths/Limitations
o Applications
2

3. ACKNOWLEDGEMENTS
3
Brian R. Flay, D.Phil.
John Petraitis, Ph.D.

4. WHAT CAUSES HEALTH BEHAVIOUR?
4

5. RELATED BEHAVIOURS
Successful,
Happy,
&
Caring
Ci4zens
Risk
Behaviours
Mental
Health
Healthy
Behaviours
Prosocial
Behaviours
Illicit
Medica4ons
Violent
Alcohol
in
Pregnancy
Externalizing
Behaviours
Stress
Depression
Health
care
Physical
Ac4vity
Nutri4on
Achievement
Connectedness
Law
Abiding
5

6. HEALTH BEHAVIOUR THEORY
o Theory can help us understand behaviour and how to
change it
o Etiology Research
• Help understand the causes/determinants of a behaviour
o Intervention/program research
• Guide the development of interventions
• Guide evaluation
6

7. HISTORY/REFERENCES
7
o Flay, B. R., & Petraitis, J. (1994). The theory of triadic influence: A
new theory of health behavior with implications for preventive
interventions. Advances in Medical Sociology, 4, 19-44.
o Petraitis, J., Flay, B. R., & Miller, T. Q. (1995). Reviewing theories of
adolescent substance use: Organizing pieces in the puzzle.
Psychological Bulletin, 117(1), 67-86.
o Flay, B. R., Snyder, F. J., & Petraitis, J. (2009). The theory of triadic
influence. In R. J. DiClemente, R. A. Crosby, & M. C. Kegler (Eds.),
Emerging Theories in Health Promotion Practice and Research
(Second ed., pp. 451-510). San Francisco, CA: Jossey-Bass.
o Snyder, F. J. (2014). Socio-emotional and character development: A
theoretical orientation. Journal of Character Education, 10(2),
107-127.

8. A BRIEF HISTORY OF HEALTH BEHAVIOR APPROACHES
8
o Information (is knowledge power?)
o Values
o Problem-solving skills (knowledge + values = informed
choice)
o Ecological approach

9. ECOLOGICAL APPROACH
o What is an ecological approach?
o An ecological approach targets multiple influences of
health (e.g., availability of alcohol, access medical clinics,
price)
o Involves long-standing changes to the physical, legal,
economic, and social environments
o Quite strong and enduring.
9

10. PERSONAL, SOCIAL, AND ENVIRONMENTAL DETERMINANTS: THE
THEORY OF TRIADIC INFLUENCE
10

11. BEHAVIOUR
Intentions/Decision
Attitudes Toward
Behaviour
Social Normative
Beliefs
Self-Efficacy
Social skills
Self management
Self-efficacy
Expectancy theories
Attitude theories
Social Norms theories
Conformity theories
Theory of Reasoned ActionTheory of Planned Behaviour
11
PROXIMAL CORRELATES OF BEHAVIOUR

12. EnvironmentIntraPersonal
Social Situation
ENVIRONMENTGENETICS
BEHAVIOUR
Intentions/Decision
Class Conflict
Low SES, Anomie
Social Disorganization
Strain Theory
(Merton)
Radical Theories
Social Control (Elliott)
Family Systems (Brooks)
Peer Clustering (Oetting)
Biological theories
Psychoanalytic theories
Resilience (Garmazey)
Personality theories
Self-Control
(Gottfredson & Hirschi)
12
DISTAL CAUSES OF BEHAVIOUR
PERSON-SITUATION-ENVIRONMENT (LEWIN, 1951)

13. LEVEL OF TYPES OF INFLUENCE
INFLUENCE INTRAPERSONAL SOCIAL SITUATION/
INTERPERSONAL
ENVIRONMENTAL/
ATTITUDINAL
ULTIMATE Biological theories
Psychoanalytic theories
Resilience (Garmazey)
Personality theories
Self-Control (Gottfredson &
Hirschi)
Social Control (Elliott)
Family Systems (Brooks)
Peer Clustering (Oetting)
Class Conflict
Low SES
Anomie
Social Disorganization
Strain Theory (Merton)
Radical Theories
DISTAL Personal competence
Self-Esteem theories
Self-Derogation (Kaplan)
Personal control theories
Social attachment/bonding
Social Development (Hawkins)
Differential Association
Social Learning (Akers, Bandura)
(General knowledge)
Cultural Identity
Values theories
Motivation theories
PROXIMAL Social skills
Self regulation/control
Self-efficacy (Bandura)
Social Norms theories
Conformity theories
Expectancy theories
Attitude theories
Fishbein & Ajzen (TRA); Ajzen (TPB)
Feedback Systems Theories
A MATRIX OF THEORIES (PETRAITIS, FLAY & MILLER,
PSYCHOLOGICAL BULLETIN, 1995)
13

14. BEHAVIOUR
Intentions/Decision
Environment
Attitudes Toward
Behaviour
Social Normative
Beliefs
IntraPersonal
Self-Efficacy
Social Situation
GENETICS ENVIRONMENT
14
THEORY OF TRIADIC INFLUENCE (TTI)

15. DECISIONS/INTENTIONS
SOCIAL
SITUATION
BIOLOGY/
PERSONALITY
ATTITUDES
TOWARD THE
BEHAVIOUR
CULTURAL
ENVIRONMENT
SOCIAL
NORMATIVE
BELIEFS
Trial Behaviour
EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological
SELF-EFFICACY
BEHAVIOURAL
CONTROL
Nurture/CulturalBiological/Nature
Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream
15
BEHAVIOUR

16. DECISIONS/INTENTIONS
SOCIAL
SITUATION
BIOLOGY/
PERSONALITY
ATTITUDES
TOWARD THE
BEHAVIOUR
CULTURAL
ENVIRONMENT
SOCIAL
NORMATIVE
BELIEFS
Trial Behaviour
EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological
SELF-EFFICACY
BEHAVIOURAL
CONTROL
Nurture/CulturalBiological/Nature
Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream
Values/
Evaluations
Knowledge/
Expectancies
Perceived
Norms
Information/
Opportunities
Interpersonal
Bonding
Social
Competence
Interactions w/
Social Instit’s
Others’
Beh & Atts
Motivation
to Comply
Skills:
Social+General
Sense of
Self/Control
Self
Determination
1 2 3
7 8 9 10 11 12
13 14 15 16 17 18
4 5 6
19 20 21
22
23
Distal
Influences
Proximal
Predictors
Levels of
Causation
Ultimate
Causes
Social/
Personal
Nexus
Expectancies
& Evaluations
Affect and
Cognitions
Decisions
Experiences
16
BEHAVIOUR

17. DECISIONS/INTENTIONS
SOCIAL
SITUATION
BIOLOGY/
PERSONALITY
ATTITUDES
TOWARD THE
BEHAVIOUR
CULTURAL
ENVIRONMENT
SOCIAL
NORMATIVE
BELIEFS
Trial Behaviour
EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological
SELF-EFFICACY
BEHAVIOURAL
CONTROL
Nurture/CulturalBiological/Nature
Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream
Values/
Evaluations
Knowledge/
Expectancies
Perceived
Norms
Information/
Opportunities
Interpersonal
Bonding
Social
Competence
Interactions w/
Social Instit’s
Others’
Beh & Atts
Motivation
to Comply
Skills:
Social+General
Sense of
Self/Control
Self
Determination
1 2 3
7 8 9 10 11 12
13 14 15 16 17 18
l
4 5 6
19 20 21
22
23
Distal
Influences
Proximal
Predictors
Levels of
Causation
Ultimate
Causes
Social/
Personal
Nexus
Expectancies
& Evaluations
Affect and
Cognitions
Decisions
Experiences
a
b c d e
f
g h i
j
k m n
o
p q r
s
t u v w
x
17
BEHAVIOUR

18. DECISIONS/INTENTIONS
SOCIAL
SITUATION
BIOLOGY/
PERSONALITY
ATTITUDES
TOWARD THE
BEHAVIOUR
CULTURAL
ENVIRONMENT
SOCIAL
NORMATIVE
BELIEFS
Trial Behaviour
EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological
SELF-EFFICACY
BEHAVIOURAL
CONTROL
Nurture/CulturalBiological/Nature
Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream
Values/
Evaluations
Knowledge/
Expectancies
Perceived
Norms
Information/
Opportunities
Interpersonal
Bonding
Social
Competence
Interactions w/
Social Instit’s
Others’
Beh & Atts
Motivation
to Comply
Skills:
Social+General
Sense of
Self/Control
Self
Determination
1 2 3
7 8 9 10 11 12
13 14 15 16 17 18
l
4 5 6
19 20 21
22
23
Distal
Influences
Proximal
Predictors
Levels of
Causation
Ultimate
Causes
Social/
Personal
Nexus
Expectancies
& Evaluations
Affect and
Cognitions
Decisions
Experiences
a
b c d e
f
g h i
j
k m n
o
p q r
s
t u v w
x
C
F
IB
E
HA D G
18
BEHAVIOUR

19. DECISIONS/INTENTIONS
SOCIAL
SITUATION
BIOLOGY/
PERSONALITY
ATTITUDES
TOWARD THE
BEHAVIOUR
CULTURAL
ENVIRONMENT
SOCIAL
NORMATIVE
BELIEFS
Trial Behaviour
EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological
SELF-EFFICACY
BEHAVIOURAL
CONTROL
Nurture/CulturalBiological/Nature
Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream
Values/
Evaluations
Knowledge/
Expectancies
Perceived
Norms
Information/
Opportunities
Interpersonal
Bonding
Social
Competence
Interactions w/
Social Instit’s
Others’
Beh & Atts
Motivation
to Comply
Skills:
Social+General
Sense of
Self/Control
Self
Determination
1 2 3
7 8 9 10 11 12
13 14 15 16 17 18
l
4 5 6
19 20 21
22
23
Distal
Influences
Proximal
Predictors
Levels of
Causation
Ultimate
Causes
Social/
Personal
Nexus
Expectancies
& Evaluations
Affect and
Cognitions
Decisions
Experiences
a
b c d e
f
g h i
j
k m n
o
p q r
s
t u v w
x
Related Behaviour
J
K
C
F
IB
E
HA D G
19
BEHAVIOUR

20. & Personality
Biology
BEHAVIOUR
Values
Evaluations
Bonding
Sense of
Self
Environment
Social
Skills
Self
Determin-
ation
SELF
EFFICACY
Social
Competence
Decisions/
Intentions
Religion
Culture
Perceived
Norms
Motivation
to Comply
Others'
Beh&&Atts
SOCIAL
NORMATIVE
BELIEFSContext
Social
DNA
ATTITUDES
Informational
Environment
Cultural
Knowledge
Expectancies
Evaluations
Values
Environment
20

21. The TTI Developmental-Ecological System
P PS S
S
E
P
Eval
Behaviour
SNB Self
Efficacy
Att Att
Intentions
Will + Skill ExpMc NB
KnowValue Social
Bonds
Role
Models
Self-
Control
Com-
petence
SNB
Values
Environment
Knowledge
Environment
ENVIRONMENT
Situation
Person
E E
DEVELOPMENT & TIME
Ultimate
Underlying
Causes
Levels of
Causation
Distal
Predisposing
Influences
Proximal
Immediate
Predictors
21

22. NCI MULTILEVEL EPIDEMIOLOGY
22
NCI MONOGRAPH

23. BRONFENBRENNER’S: SOCIOECOLOGICAL MODEL
23

24. THE THEORY OF TRIADIC INFLUENCE
ECOLOGICAL SYSTEM
24
P PS S
S
E
P
Eval
SNB Self
Efficacy
Att Att
Intentions
Will + Skill ExpMC NB
KnowValue Social
Bonds
Role
Models
Self
Control
Com-
petence
SNB
Values
Environment
Knowledge
Environment
Cultural Environment
Social Situation
PersonalAffective/ControlSub-streams
Cognitive/Competence
Sub-streams
E E
BehaviorTIME
Levels of
Causation
Ultimate
Underlying
Causes
Distal
Predisposing
Influences
Proximal
Immediate
Predictors

25. System Postulates 1,2,&3
1. Provides a meta-theoretical view
• Higher order description and explanation
– Integrates multiple levels of organization
• No one existing theory can provide a satisfactory
description. It is a model
• Certainly, no one variable can provide an adequate
explanation
2. All behavioural choices are influenced by the interaction of
genetic/nature and environmental/nurture factors
3. Each behavioural choice is influenced by a complex
system of PERSONAL, SOCIAL and ENVIRONMENTAL
factors
25
THE THEORY OF TRIADIC INFLUENCE:
Implications for Description and Explanation

26. System Postulates 4 & 5:
4. All three (triadic) streams of influence each have two
substreams (making 6 altogether):
– 3 informative/cognitive/thoughts substreams
– 3 control/affective/feelings substreams
5. All (sub)streams of influence flow from causes most
distant (ultimate and distal) to causes closest to
(proximal to) the behaviour of interest -- a cascade of
multiple and interacting influences
– Proximal causes predict most behaviour
– Distal and ultimate causes help explain it
THE THEORY OF TRIADIC INFLUENCE:
IMPLICATIONS FOR DESCRIPTION AND EXPLANATION
26

27. System Postulates 6-8:
6. Most influences can be positive or negative
– The more positive influences there are, the more likely positive
behaviour
– The more negative influences there are, the more likely negative
behaviour
7. The most proximal control/affect factors have values (probabilities)
that range from zero to one
8. Interactions across streams can increase or reduce risks/protection
– e.g.,
+sense of self can reduce risk in disorganized communities
-sense of self can increase risk in protective families
+community/family forces can protect against -sense of self
27
THE THEORY OF TRIADIC INFLUENCE:
IMPLICATIONS FOR DESCRIPTION AND EXPLANATION

28. System Postulate 9:
9. Once a behaviour occurs, the resulting reactions and/or
experiences (thoughts and feelings) feed back to
change the original causes
Reciprocal feedback occurs through all streams and levels
Engaging in a behaviour changes one’s attitudes,
normative beliefs, and self efficacy
It also changes one’s knowledge, relationships with
parents and peers, and sense of self
28
THE THEORY OF TRIADIC INFLUENCE:
IMPLICATIONS FOR DESCRIPTION AND EXPLANATION

29. FEEDBACK ALSO SHOWN THIS WAY
B
I
E
Att
SNB
P
SE
S
B
I
E
Att
SNB
P
SE
S
B
I
E
Att
SNB
P
SE
S
DEVELOPMENT & TIME
29

30. System Postulate 10:
10. The reactions to certain behaviours feed back to
influence the causes of RELATED BEHAVIOURS
e.g., smoking and other drug use
Thus, causes and effects are in a continuous cycle:
– Mutually influential individual ßà contextual relations
Related behaviours have similar causes, with the more
distal causes being the most similar
- Less related behaviours (e.g., smoking and cycling) have
fewer causes in common
THE THEORY OF TRIADIC INFLUENCE:
IMPLICATIONS FOR DESCRIPTION AND EXPLANATION
30

31. A
single
behaviour
Eg,
smoking
Two
closely
related
behaviours.
Eg, smoking
and drinking
Less and
less related
behaviours.
Eg, smoking,
drug abuse,
sex, exercise.
E
S P
E
S P
E
S
P
E
S P
E
SP
CLOSELY AND LESS RELATED BEHAVIOURS: ULTIMATE
CAUSES MAY BE THE SAME, DISTAL PREDICTORS LESS SO
31

32. o OLD APPROACHES TO PREVENTION COULD NOT HAVE
WORKED WELL
• Resistance skills programs often focus on one social
skill
• Only a few recent programs include changing social
normative beliefs
• Informational approaches focus only on knowledge
• Values clarification approaches focus only on values
• Decision-making focuses only on the attitudinal stream
o USE BEHAVIOURAL CHANGE STRATEGIES FROM ALL SIX
SUBSTREAMS
32
IMPLICATIONS OF THE TTI

33. The Big 3
Causes Of
Behaviour
INTRAPERSONAL
Genetic/Biological, Personality
SOCIAL SITUATION/CONTEXT
Family, School, Friends
SOCIO-CULTURAL
ENVIRONMENT
Culture/Ethnicity, SES, Media
Exposure, Social (Dis)organization
The 6 Causes
Of Behaviour
Sense of self,
self
determination,
self control
General
competence,
social skills
Social attachment
to (bonding with)
family, friends,
school
Observed (modeled)
behaviours &
attitudes of others
Value of
expected
consequences
Knowledge of
expected
consequences
Big 3 Self-Efficacy Social Normative Beliefs Attitudes toward the behaviour
Six Reasons
for Behaviour
Change
I really want to
OR I can't help
myself
I find it easier to
do than not to
To please others --
Social acceptance
Because "everyone
else is doing it"
To improve myself
(or my health) in
ways I value
To avoid negative
consequences or
gain positive ones
6 Classes Of
Strategies for
Contextual
Change
Improve group
empowerment
Improve
general/social
competencies
Change sources
and levels of
social support
Change
normative
environnent,
role models
Change the
socio-cultural/
values
environnent
Change the
informational
environment
6 Classes Of
Strategies for
Behavioral
Change
Improve self
control/image;
Provide cues &
reminders
Teach, learn,
practice
improved (social)
skills
Increase social
attachments;
Provide/find
sources of social
support
Model desired
behaviour; Correct
or alter normative
expectations
Teach cultural
values, clarify or
(re)develop
values/evaluations
Provide
information,
change
expectations
Instruction in problem-solving and
decision-making skills
Modes Or
Channels Of
Change
Individual counseling, small groups,
schools; media for modeling and cues
Modeling and increasing opportunities in
communities, schools, families and small
groups, parent training, support groups,
Societal opportunities, legislation,
policies, taxes, media, communities,
schools, health care systems
Causes, Reasons, and Strategies for Contextual and
Behavioural Change

34. SOME LIMITATIONS
34
o Comprehensiveness à complexity
o Decisions?
o Defining certain variables (e.g. personality variables)

35. ETIOLOGY APPLICATION STRENGTHS
35
o Help coherently organize behavioural influences
o Structured outline of multivariate hypotheses
• Mediation
• Moderation

36. 36
Bavarian et al. (2014). Using structural equation modeling to
understand prescription stimulant misuse: A test of the Theory of
Triadic Influence. Drug And Alcohol Dependence, 138, 193-201.

37. INTERVENTION APPLICATION STRENGTHS
37
o Importance of value-expectancy
o Encourage developers to use multiple options
o Helps anticipate size of program effects
o Helps point toward location of effects
o Encourages careful thought about appropriate target
audiences (interaction/moderation)
o Highlights the importance of ultimate causes and distal
influences
o Provides framework to evaluate and analyze

38. DECISIONS/INTENTIONS
SOCIAL
SITUATION
Values/
Evaluations
Knowledge/
Expectancies
BIOLOGY/
PERSONALITY
ATTITUDES
TOWARD THE
BEHAVIOR
Perceived
Norms
Information/
Opportunities
Interpersonal
Bonding
Social
Competence
CULTURAL
ENVIRONMENT
SOCIAL
NORMATIVE
BELIEFS
Interactions w/
Social Instits
Others’
Beh & Atts
Motivation
to Comply
Skills:
Social+General
Sense of
Self/Control
Self
Determination
SELF-EFFICACY
BEHAVIOURAL
CONTROL
THE POSITIVE ACTION PROGRAM:
AN APPLICATION OF THEORY
Program Components: Family Classroom School Community
Self
Concept
Self Mgmt:
Time
Talents
Anger
Social &
Emotional
Health
Feeling
Empathy
How to
Treat
Others
Comm.
Skills
Conflict
Resolution
How You
Like To Be
Treated
Health
Info
Thinking
Skills
Creativity
Decision-
Making
BEHAVIOUR
Snyder,
F.
J.
(2014).
Socio-­‐emo7onal
and
character
development:
A
theore7cal
orienta7on.
Journal
of
Character
Educa1on,
10(2),
107-­‐127.

39. 4-H PALS PROGRAM
39

40. o NEW ETIOLOGY RESEARCH AND INTERVENTIONS
NEED TO BE BROADER AND DEEPER, …
• But should not throw out all of the content of
traditional approaches
• Consider teaching multiple relevant skills
• Etiology research should consider multiple
influences on behavior
• Special interventions for high-risk groups
• Consider how to change broad sociocultural
influences
– Train peer advocates
– reduce sales/access (alcohol)
– exposure on TV and in movies
40
CONCLUDING THOUGHTS