Below, we articulate the two bodies of knowledge that we integrate as our framework for empowering parents as agents of change.
Principles of Parent Support
Drawing from grassroots knowledge about family support, PEP adheres to a set of principles that were developed collaboratively by family advocates and researchers working with Kansas Keys Inc. These principles serve to ground the work of family advocates as they work with parents to develop goals consistent with family beliefs and values, even as they are challenged to operate under the various constraints of their job context ().
Principles of parent support
Applying the Unified Theory of Behavior (UTB)
In developing a theoretical framework for helping parents become active agents of change as they work towards family goals for their children's mental health care needs, we simultaneously drew upon a substantive literature on factors that influence behavior and behavior change. Several hundred studies of health-related behaviors, including substance use, risk-taking, and sexual behavior, have relied on a small group of theories derived from social and health psychology (Fishbein 1980
; Jaccard et al. 1999
). While the various theorists do not agree on the core elements that influence behavior and behavior change (Fishbein et al. 2001
; NIMH Workshop Report 1991
), they did agree upon a general framework that has since been expanded to the Unified Theory of Behavior (UTB) (Jaccard et al. 1999
According to UTB, a person's behavior can be conceptualized along two dimensions: those pertaining to the immediate determinants
of behavior () and those pertaining to the determinants of the willingness to engage in a given behavior (). The first dimension relates to an individual's behavior, which is immediately influenced by five factors as depicted in ; these factors in combination have been found to determine behavior. In general, any given behavior is more likely to occur when the variables are aligned in favor of its enactment (Jaccard et al. 2002
Immediate determinants of behavior
Immediate determinants of behavior intention
The second dimension of UTB focuses on factors that influence an individual's willingness, intention, or decision to perform a behavior. Behavior intentions capture the motivational factors that influence behavior that is under volitional control (e.g., parents deciding to follow through with initiating a mental health evaluation for child). According to UTB, six factors comprise this category (see ). In combination, these six variables are thought to influence an individual's intention to engage in a behavior.
Taken together, the 11 variables represented in both of these figures have both a solid theoretical and empirical basis in the behavioral sciences, with hundreds of studies over five decades supporting their validity. The variables collectively comprise an integrative set of explanatory constructs that have been called the Unified Theory of Behavior (UTB), following Jaccard et al. (1999)
. According to UTB, in order to understand individual's decision to engage in a behavior, one should consider the factors (attitudes, expectancies, normative beliefs, self concept, affect, self efficacy) that influence behavioral intentions. However, even if a person makes a decision to engage in a behavior, the decision will not necessarily translate into action. More immediate determinants of behavior such as knowledge, skills and abilities, the presence of environmental constraints or facilitators, the priority attached to the behavior, and existing habits can also interfere with behavior performance. Thus, based on UTB, strategies that address both determinants of behavior intentions as well as actual behaviors may be necessary to effect behavior change.
The relative importance of the variables in Figs. and in influencing behavior differs from population to population, from behavior to behavior, and across various situations. For example, for some individuals, normative influences may be a primary determinant of the decision to perform a behavior (e.g., “People from my culture do not seek help from mental health professionals”). For other individuals, attitudes of mistrust towards health care providers (e.g., “I'm afraid they will think I am a bad parent and take my child away”) may be a primary determinant of behavioral intentions. In other situations where an individual may have decided to initiate or participate in mental health services, intervening obstacles or events (e.g., work conflict, long wait lists at clinics) may interfere with actual behavior.
Developing the PEP Model of Parents as Agents of Change
In applying UTB to PEP, we adapted the UTB framework to fit existing knowledge from the literature about barriers to mental health care as well as feedback based on the practical experience of various family stakeholders. The resulting PEP framework (see ) emphasizes four primary determinants of behavior intentions. Using this framework, advocates apply the Principles of Family Support to help parents set priorities and identify family goals and actions. As parents act to achieve identified goals, family advocates systematically utilize the Parents as Agents of Change framework to help them understand factors that may be operating to influence their intentions and behavior with respect to goal attainment. Based on the UTB premise that behaviors can often be predicted from an individual's intentions, a starting point in working with parents involves assessing parents' behavior intentions, and as necessary, working to increase motivational factors that might influence such intentions. In PEP, the primary determinants influencing parent intentions to initiate or participate in mental health care involve four key variables. (1) Beliefs and expected value: the degree to which a parent is likely to initiate or participate in treatment depends on how he or she perceives the benefits (e.g., child will be less disruptive at school and at home) and whether these benefits outweigh the perceived cost or barriers that must be overcome (e.g., arranging time off from work to get service vs. less likely to be called out of work for child's misbehavior at school). (2) Social norms or pressure: whether a parent is motivated to participate in care may depend on what he or she thinks other parents in their situation do and whether important people in their lives (e.g., spouse, other family members) are supportive of it. (3) Attitudes toward mental health problems and the mental health care system: parents' understanding and perception of mental illness (e.g., stigma, child just needs better discipline) as well as past experiences with the mental health care system can also influence their motivation to seek help. Lack of knowledge or misconceptions about child mental health problems (e.g., this problem will go away with time) and negative experiences with health care providers (e.g., they treated me like I caused this problem in my child) can be key motivating factors in some parents' willingness to participate in care. (4) Self-efficacy: a parent's perception of how difficult it might be to initiate care, access resources, or participate in treatment also influences their behavior. This perception is assumed to reflect past experience, second-hand information, experiences of acquaintances and friends, and anticipated obstacles or the presence or absence of requisite resources and opportunities. Thus, a parent who believes that they have the skill, knowledge, information or resources available to support their likelihood of success will be more likely to follow through.
PEP model: parents as agents of change
While the UTB model also includes the constructs of self-concept and affect as variables that influence behavior intentions, in PEP, the focus is on four primary constructs (beliefs and expectances, social norms, attitudes, and self-efficacy), with self-concept and affect operating through the four primary constructs. For example, how a parent feels (affect) about initiating or participating in mental health services may be influenced by what they expect to get out of it and/or beliefs or attitudes toward mental health problems. A parent who believes that a child's behavior is simply a result of poor classroom management or who is mistrustful of mental health providers is likely to feel negatively about initiating mental health services. Similarly, how participating in mental health services may fit in with their self-image could also be influenced through their beliefs and attitudes toward mental health problems (“my child has this problem because I am a bad parent”) or through social pressure (“my family thinks I just need to discipline him better”).
depicts the practical application of this framework that we use to provide examples of how family advocates can systematically assess motivational factors in order to identify specific intervention strategies. For example, if a parent is reluctant to engage in mental health services, underlying factors (e.g., belief that child will outgrow problem, concerns about stigma, fear of blame by providers, belief that they lack the competence to overcome obstacles in getting services) that may influence intentions or behavior are assessed and specific strategies targeted to strengthen their intentions or action (e.g., provide education about the nature of the disorder, specific information and skills to improve perceived competence).
Practical application of the PEP model of change
On the other hand, if parents have decided to seek or participate in their child's mental health care (i.e., behavior intentions are in place), understanding and problem solving around factors that may influence the actual behavior (e.g., providing specific knowledge or information about who to call, what to ask for, and how to prepare, teaching assertiveness skills, figuring out who can help with transportation or child care issues, etc.) can help increase the likelihood of follow through. Understanding where parents are at in this process and what specific factors stand in their way is important as it can help family advocates focus their intervention efforts. Because behavior change is a process and not an all-or-nothing phenomenon that occurs immediately or not at all, a parent's difficulty in activating change should be seen as an important opportunity in the intervention process. Systematically reviewing factors that might have gotten in the way of action can often uncover previously overlooked or unforeseen obstacles (e.g., family pressure against mental health services, mistrust due to past negative experience with helping institutions, lack of skill, change in insurance, lack of available services, etc.). Thus, parent difficulties with activating change can be seen as opportunities to problem solve around barriers, or to make appropriate adjustments to an existing action plan.
In the PEP framework, assessment of where parents are at in the help seeking process is key. Using this framework, family advocates are trained to systematically consider key factors that might influence a parent's intentions to engage or to participate in their child's care. Based on this assessment, family advocates can apply a variety of strategies to address motivational issues or problem solve around barriers that may interfere with their intentions or actual behaviors. Such intervention strategies may include providing specific information to change or shift a parent's expectancies, attitudes and beliefs, coaching to improve specific skills, providing support to boost parent's sense of efficacy, or problem solving around concrete obstacles. Clearly, the PEP framework is not meant to capture all possible variables (e.g., personality variables, family demographics, provider characteristics) that might influence a parent's willingness to initiate or to participate in their child's mental health care. Motivating factors and barriers to change can and do vary from parent to parent and from situation to situation. This framework provides a starting point to better understand motivations and barriers, thus identifying points of leverage to effect change.