Michael P. O’Donnell, PhD, MBA, MPH

Michael P. O’Donnell, PhD, MBA, MPH
AMSO & His POSSE: A Framework to Develop Effective Organization and Individual Behavior Change Programs Michael P. O’Donnell, PhD, MBA, MPH

What Works Best? Strategy to Develop the Framework
Systematic Background Benchmarking study Good, very good, best programs Systematic literature reviews Health impact of programs Financial impact of programs Refining framework C Everett Koop Award Health impact Financial impact Composite reviews 1800+ manuscripts Design/manage programs 100+ organizations

Sampling of Theories Not to mention the statistics!
Individual level Learning Theories Information processing Health Belief Model Protection Motivation Theory; Extended Parallel Process Model Theories of Reasoned Action, Planned Behavior, and Integrated Behavior Model Goal-Setting Goal goal-directed behavior Automatic behavior, impulse behavior, habits Transtheoretical Model of Behavior Change Precaution Adoption Process Model and risk communication Attribution Theory and Relapse Prevention Communication-Persuasion Matrix Elaboration Likelihood Model Self Regulation Interpersonal environment Social Cognitive Theory Stigma and Discrimination Diffusion of Innovation Social networks and social support Multi-level Systems Power Empowerment Organization level Stage Theory of Organization Change Stakeholder Theory Community level Coalition Theory Social Capital Theory Social norms Conscientization Community Organization Society and government level Agenda-building Multiple Streams Advocacy Coalition Source: Bartholomew LK, Parcel GS, Kok G, Gottleib NH, Fernandez ME, Planning Health Promotion Programs, 3rd 2011, Jossey-Bass

AMSO Behavior Change Program Portfolio
Awareness 5% Motivation 30% Skills 25% Opportunity 40% Michael P. O’Donnell, PhD, MBA, MPH © 2010

Dimensions of Opportunity: Engaging the POSSE
P: Peers O: Organizations S: State S: Society E: Environment Michael P. O’Donnell, PhD, MBA, MPH © 2010

Applying the AMSO Framework
Critique existing program Plan a new program Help an individual change habits Examine progress in your own life Focus on the framework Details will become intuitive Michael P. O’Donnell, PhD, MBA, MPH © 2010

Awareness Basis of Most Health Education
Health Risk Factors Benefits of Healthy Lifestyle What is the Impact of Awareness on Behavior? eg. tobacco use Michael P. O’Donnell, PhD, MBA, MPH © 2010

Trends in Consumption of Five or More Recommended Vegetable and Fruit Servings for Adults 18 and Older, US, Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM ( , 1996, 1998) and Public Use Data Tape (2000, 2003, 2005, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2004, 2006, 2008.

Trends in Prevalence (%) of No Leisure-Time Physical Activity, by Educational Attainment, Adults 18 and Older, US, Adults with less than a high school education All adults Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Educational attainment is for adults 25 and older. Source: Behavioral Risk Factor Surveillance System CD-ROM ( , 1996, 1998) and Public Use Data Tape (2000, 2002, 2004, 2005, 2006, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2003, 2005, 2006, 2007, 2008.

Awareness Basis of Most Health Education
Health Risk Factors Benefits of Healthy Lifestyle What is the Impact of Awareness on Behavior? Important Role in Mobilizing Group Support Michael P. O’Donnell, PhD, MBA, MPH © 2010

Enhancing Motivation Embrace people as whole beings
Engage people in design and delivery process Develop effective communication Utilize extrinsic and intrinsic incentives Provide effective leadership Tailoring programs (Skill Building discussion) Engage with health assessment Michael P. O’Donnell, PhD, MBA, MPH © 2010

Embrace People as Whole Beings
Focusing on health risk usually does not work Embrace people as whole beings Help people discover their passions Help people link passions with health Help people make a plan to achieve their goals Motivational interviewing approach Michael P. O’Donnell, PhD, MBA, MPH © 2010

Engage People in Processes
Wellness committees Market research Mentorships Champions Effective programs Confidentiality & Transparency Michael P. O’Donnell, PhD, MBA, MPH © 2010

Develop Effective Communication
Consistent with corporate culture Professional Ubiquitous Michael P. O’Donnell, PhD, MBA, MPH © 2010

Utilize Extrinsic and Intrinsic Incentives
Extrinsic (Financial) Rewards Can push participation from 20% to 90%+ Capture attention, increase participation Limited long term impact on behavior Danger of attributing behavior to the incentive vs. intrinsic benefits Evolve to Intrinsic Rewards Life priorities Self image Passions Relationships Quality of life Incentives and whole program can be self funded through health plan benefit design. Sec 2705 PPAACA. Michael P. O’Donnell, PhD, MBA, MPH © 2010

Provide Effective Leadership
Recognize importance of programs Provide appropriate budget Serve as active program champions Be visible program participants Michael P. O’Donnell, PhD, MBA, MPH © 2010

Engage with Health Assessment
Health risk questionnaire Biometric screenings Motivates because it helps people understand the link between lifestyle and health in a personal way. Michael P. O’Donnell, PhD, MBA, MPH © 2010

Think about your program
Michael P. O’Donnell, PhD, MBA, MPH © 2010

Skill Building Beyond Why and What to How, When,
Where, With Whom and What If’s Goal Setting Tailoring Utilizing the Best Science Mastering New Behaviors Integrating Behaviors into Life Michael P. O’Donnell, PhD, MBA, MPH © 2010

Goal Setting Doubles success rates
Aspirational, learning & performance goals Expert guidance & personal buy in Michael P. O’Donnell, PhD, MBA, MPH © 2010

Tailoring Level of self efficacy and behavioral efficacy
Preferred learning style Genetic predisposition Motivational readiness to change Health status Level of intensity Confidentiality & transparency Michael P. O’Donnell, PhD, MBA, MPH © 2010

Self Efficacy Belief one can successfully perform behavior Predicts
Joining program Completing program Time to relapse Michael P. O’Donnell, PhD, MBA, MPH © 2010

Behavioral Efficacy Belief a behavior leads to desired outcome

Impact of Self Efficacy & Behavioral Efficacy
Person Behavior Outcome Self Efficacy Behavioral Efficacy Michael P. O’Donnell, PhD, MBA, MPH © 2010

Focusing Efforts Self Efficacy Low High Low Behavioral Efficacy High

Enhancing Self Efficacy
Personal mastery: practice Vicarious learning:Observing similar others Verbal persuasion: Respected Expert Peer Managing physical symptoms Michael P. O’Donnell, PhD, MBA, MPH © 2010

Genetic Predisposition, Physical and Mental Condition
Athletic ability and experience “Runner’s High” Weight Addiction Physical disability Mental illness Michael P. O’Donnell, PhD, MBA, MPH © 2010

Preferred Learning Style by Lifestyle Topic
Print Telephone Web Individual face to face Group Confidentiality & transparency Michael P. O’Donnell, PhD, MBA, MPH © 2010

Motivational Readiness to Change
Precontemplation Never 40% Contemplation Later 40% Preparation Soon 20% Action Now Maintenance Trying to be forever Termination Probably forever Michael P. O’Donnell, PhD, MBA, MPH © 2010

Tailoring by Stages of Motivational Readiness
Precontemplation Unconditional acceptance Indirect comments Contemplation Enhance Behavioral Efficacy Enhance Self Efficacy Expose Social Networks Aspirational Goal Setting Preparation Learning Goal Setting Introduce to Social Networks Action Performance Goal Setting Skill Building Engage in Social Networks Maintenance Maintain Social Networks Offer Leadership Opportunities Reinforce Self Efficacy Reinforce Behavioral Efficacy Michael P. O’Donnell, PhD, MBA, MPH © 2010

Tailoring Motivational readiness to change
Level of self efficacy and behavioral efficacy Preferred learning style Genetic predisposition Health status Level of intensity Confidentiality & transparency Michael P. O’Donnell, PhD, MBA, MPH © 2010

Utilize the Best Science

Effects of Integrated Medication and Behavioral Interventions
5 10 15 20 25 30 No Behavioral Therapy Brief Advice No Medication Medication Rates doubled with brief advice & triple combining pharmacological and behavioral inventions Typical Long Term Quit Rates Hughes JR. CA Cancer J Clin. 2000; 50:

Best Science for Tobacco Treatment
Meta-analyses of 27 different topics Combined approaches: Brief MD advice+ behavior therapy + medication Minutes of therapy: 300 Number sessions: 8 Type and number of staff: 2-3 including one physician Medication type: outcomes by medication Behavioral therapy type: outcomes by type Treating Tobacco Use and Dependence: 2008 Update, Fiore, et al, HHS

Best Methods for Weight Control?

Workplace Health Promotion Overall Processes
What Works in Worksite Health Promotion: Systematic Review Findings and Recommendations from the Task Force on Community Preventive Services Robin E. Soler, Nicholaas Pronk, Ron Goetzel American Journal of Preventive Medicine Volume 38(2) Supplement 2, February, 2010 The Community Guide

Methodology Search databases:
Medline, Employees Benefits,NTIS, Sports Information Resource Guide, Cambridge Scientific Abstracts, Business Week, ABI Inform, Health Promotion and Education, Cumulative Index to Nursing and Allied Health Literature, Office of Smoking and Health, AIDSLine, PsychInfo, and Sociological Abstracts Inclusion Criteria Primary research in peer review journal or technical report Published January 1980-June 2005 Meet research quality criteria Evaluate impact of workplace health promotion program Measure change in one or more outcomes of interest Studies found Abstracts and titles: 4,584 Studies examined in detail: 334 Studies meeting all criteria: 86 Ratings Study design: threats to internal validity: greatest, moderate, least Quality of execution: good, fair, limited Effect size: quantitative, qualitative

Scope of Review Incentives and Competition to Reduce Tobacco Use
Health Assessment with Feedback vs Health Assessment with Feedback Plus Intervention Incentives and Competition to Reduce Tobacco Use Smoke-free Policies to Reduce Tobacco Use Point of Decision Prompts to Increase Stair Use

Health Assessment with Feedback
Conclusion: Insufficient evidence to recommend Reasons: Small effect size Small number of studies (32) Poor study design

Health Assessment with Feedback Plus Intervention*
Conclusion: Strong evidence of effectiveness Tobacco use (30) % pp prevalence % consumption Dietary fat consumption (11) % pp prevalence Blood Pressure control (31) % pp prevalence Cholesterol management (36) % pp prevalence mg/dl Absence from work (10) days/year less Conclusion: Sufficient evidence of effectiveness Seat belt use (10) % pp prevalence Heavy drinking (9) % pp prevalence Physical activity (18) % pp prevalence Health risk score (21) Medical utilization (7) Conclusion: Insufficient evidence of effectiveness Fitness (9) positive outcomes small effect sizes, multiple measures Body composition (27) - BMI (8) BMI unit consistent findings - Weight (17) pds small effect size - Fat (6) % small effect size Conclusion: Not effective Fruit and vegetable consumption (8) minimal changes observed *Numbers of studies are shown in parentheses ( )

Incentives and Competition to Reduce Tobacco Use
Conclusion: Insufficient evidence of effectiveness Incentives and Competition Only Number of studies: 1, 0 qualified Conclusion: Strong evidence of effectiveness Incentives and Competition Plus Other Interventions Number of studies: 26; 14 qualified Impact: All studies - 4.4% pp median (2.7%-9.4%) prevalence 67% improvement - 13.7% median quit rate (8% -20.5%) Incentives + skills+ social support (5) - 10% pp median (2.7%-9.4%) prevalence 168% improvement - 21% median quit rate Participation rates (11) 28% median participation of smokers (12%-84%)

Tailoring Motivational Readiness to Change
Level of Self Efficacy and Behavioral Efficacy Preferred Learning Style (Skill Building) Health Status Level of Intensity Confidentiality & Transparency Michael P. O’Donnell, PhD, MBA, MPH © 2010

Mastering New Behaviors
Translating skills into practice Forming new habits How long does it take for new skills to become established habits? Michael P. O’Donnell, PhD, MBA, MPH © 2010

Integrating Behaviors into Life
How to overcome barriers How to overcome social influences How to create opportunities Michael P. O’Donnell, PhD, MBA, MPH © 2010

POSSE: The Dimensions of Opportunity
A large group with a common interest..Merriam Webster Your crew, your hommies, people who (sometimes) have your back…Urban Dictionary P: Peers O: Organizations S: State S: Society E: Environment Michael P. O’Donnell, PhD, MBA, MPH © 2011

P: Peers Most important influence group - Close friends
- Close co-workers Michael P. O’Donnell, PhD, MBA, MPH © 2011

Social Networks and Lifestyle
Design: Framingham Heart Study; longitudinal observational study Sample: 12,067 people, 3 generations 53% women 47% men 21-70 years, mean 38 0-17 years of education, mean 13.6 Measures: Biometrics including BMI All 1st order relatives At least one close friend Neighbors 1973,1981,1985,1989,1992,1997,1999,2003 Obesity, smoking, depression, alcohol Christakis, NEJM, 357;4;2007 Michael P. O’Donnell, PhD, MBA, MPH © 2010

Probability That an Ego Will Become Obese According to the Type of Relationship with an Alter Who May Become Obese in Several Subgroups of the Social Network of the Framingham Heart Study Geographic separation Effect maintained 0,.26,1.5,3.4,9.3,471 miles Likelihood & degrees of separation 1: 45% 2: 20% 3: 10% Figure 4. Probability That an Ego Will Become Obese According to the Type of Relationship with an Alter Who May Become Obese in Several Subgroups of the Social Network of the Framingham Heart Study. The closeness of friendship is relevant to the spread of obesity. Persons in closer, mutual friendships have more of an effect on each other than persons in other types of friendships. The dependent variable in each model is the obesity of the ego. Independent variables include a time-lagged measurement of the ego's obesity; the obesity of the alter; a time-lagged measurement of the alter's obesity; the ego's age, sex, and level of education; and indicator variables (fixed effects) for each examination. Full models and equations are available in the Supplementary Appendix. Mean effect sizes and 95% confidence intervals were calculated by simulating the first difference in the contemporaneous obesity of the alter (changing from 0 to 1) with the use of 1000 randomly drawn sets of estimates from the coefficient covariance matrix and with all other variables held at their mean values. Christakis NA, Fowler JH. N Engl J Med 2007;357:

Probability That a Subject Will Quit Smoking According to the Type of Relationship with a Contact Who Quits Smoking, in the Social Network of the Framingham Heart Study Figure 4. Probability That a Subject Will Quit Smoking According to the Type of Relationship with a Contact Who Quits Smoking, in the Social Network of the Framingham Heart Study. The dependent variable in each model is smoking by the subject. Separate generalized-estimating-equation logit models for smoking were specified for each type of social tie. Independent variables include a time-lagged measurement of the subject's smoking status at the previous examination; the contact's smoking status; a time-lagged measurement of the contact's smoking status; the subject's age, sex, and level of education; and fixed effects for each examination. Full models and equations are available in the Supplementary Appendix. Mean effect sizes and 95% confidence intervals were calculated by simulating the first difference in the contemporaneous smoking of the contact (changing from 1 to 0) with the use of 1000 randomly drawn sets of estimates from the coefficient covariance matrix and with all other variables held at their mean values. "Coworkers in small firms" means that six or fewer Framingham Heart Study participants worked at the same physical location. Christakis NA, Fowler JH. N Engl J Med 2008;358:

O: Organizations Employer Faith Community
Health promotion program Smoke free campus, hiring smokers Absenteeism, health plan, compensation Nurturing vs. toxic mission and management Safety hazards/protections Cafeteria, walkable campus, fitness center Faith Community Norms, mission, messages Access to programs Schools, especially for families with children Clubs Others? Employers need to leverage or overcome the influence of other organizations Michael P. O’Donnell, PhD, MBA, MPH © 2011

S: the “State” National policy State policy Local policy
Agriculture, transportation, education policy National campaigns: SBWG, national HP strategy Support for health research Integration of wellness into Medicare & insurance policy Social safety net Tobacco policy State policy Smoke free workplace laws, quitline coverage Gun safety laws Speed limits, helmet policies Medicaid eligibility and scope of services Local policy Smoke free public places Tobacco excise taxes Restaurant ingredients & labeling Local campaigns Active transportation options City planning, zoning, pollution control Are you a passive citizen or a policy advocate? Michael P. O’Donnell, PhD, MBA, MPH © 2011

Smoking Rates, Cleveland, Ohio & US, 2003-2009

S: Society Broad cultural norms Ethnic norms Celebrity role models
Fitness & sports: 25,000 finished US marathon in 1976, 507,000 in 2010 Second hand smoke: annoyance in 1980, deadly in 2011 Smoke free workplaces: rare in 1980, the norm in 2011 Vegetarian diet Ethnic norms Expressing emotions Significance of food Asking for help and helping others Eg. Cultural value of familismo, respeto, simpatia and personalismo make Hispanic/Latino families want to protect their families from second hand smoke BUT reluctant to ask neighbors to refrain from smoking Celebrity role models Oprah weight loss and gain Starlets pursuit of perfect body Actors smoking in movies Miss Universe Sushmita Sen (India), 1994 Baezconnde-Garbanati, AJHP, 2011 Michael P. O’Donnell, PhD, MBA, MPH © 2011

E: Environment Assess to smoke free clean air
At work Restaurants Public spaces Access to nutritious affordable food Cafeteria at work Neighborhood stores Opportunities for physical activity Michael P. O’Donnell, PhD, MBA, MPH © 2011

Typical American gains 2 pounds per year after college

Sprawl Is Associated with More Health Problems
I would reverse the order of this and the previous slide--show this result first and the the information in the prior slide Ewing, AJHP, 2003

The Impact of Sprawl on Health and Behavior
Urban Sprawl Utilitarian walking Leisure time walking Increases BMI Increases in BP Source: Ewing et al. (2003) AJHP

A national study of US adolescents (N=20,745)
A national study of US adolescents (N=20,745)* found a greater number of physical activity facilities is directly related to increased physical activity and inversely related to risk of overweight Odds of having 5 or more bouts of MVPA 1.26 Referent Odds of being overweight .68 *using Add Health data Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the built environment underlies key health disparities in physical activity and obesity. Pediatrics 2006; 117(2):

The Effect of Mixed Use on Obesity
Participants were divided into four groups based on the level of land use mix Each quartile increase in land use mix was associated with a 12.20% reduction in the odds of being obese. The difference in weight for an average 5’ 10” white males in the lowest quartile of mixed use and the highest quartile of mixed use was 10 pounds. Frank, L., Andresen, M., and Schmid, T., Obesity Relationships With Community Design, Physical Activity, and Time Spent in Cars. American Journal of Preventive Medicine. June 2004.

Data collected in from 3,161 Atlanta children show 5 to 18 year olds were more likely to walk for transportation if they lived in mixed-used neighborhoods with parks, schools, and commercial destinations nearby. Frank L, Kerr J, Chapman J, Sallis J. Urban form relationships with walk trip frequency and distance among youth. American Journal of Health Promotion 2007; 21(4S): 305. ALR Funded

Pedometer data collected from over 100 New Jersey train and car commuters revealed that those who commuted by train walked 30% more steps a day and were 4 times more likely to meet recommended 10,000 steps daily than car commuters. Wener RE, Evans GW. A morning stroll: Levels of physical activity in car and mass transit commuting. Environment and Behavior 2007; 39(1):

A study of 33 California cities found that adults who drove the most had obesity rates (27%) that were three times higher than those who drove the least (9.5%). Lopez-Zetina J, Lee H, Friis R. The link between obesity and the built environment. Evidence from an ecological analysis of obesity and vehicle miles of travel in California. Health & Place 2006; 12(4):

The Impact of Driving and Walking on Obesity
Every additional 30 minutes spent driving per day translates into a 3% increase in the odds of being obesity Every additional Kilometer (.6 miles) walked translates into nearly a 5% reduction in the odds of being obese Frank, L., Andresen, M., and Schmid, T., Obesity Relationships With Community Design, Physical Activity, and Time Spent in Cars. American Journal of Preventive Medicine. June 2004.

Built Environment and Physical Activity Research Conclusions
Living in Activity Friendly Communities could… Generate 2 more walk/bike trips per person per week Prevent up to 1.7 pounds of weight gain per year Positively affect walking/cycling for transportation Positively impact the total number of minutes of physical activity (40% more physical activity) Decrease amount of time spent in a car. Each hour spent in a car is associated with a 6% increase in the likelihood of obesity. Increase life expectancy by 4 years. Ewing et al 2003, Saelens et al 2003, Giles-Corti 2003, Frank et al 2003, Sturm et al 2004, Frank et al 2004, Lopez 2004

Opportunity Genetic Predisposition, Physical and Mental Condition
Athletic ability “Runner’s High” Weight Addiction Physical disability Mental illness

Natural Environment Santa Cruz: body surfing & cycling
Michigan: indoor swimming & X country skiing Seoul: hiking in the mountains Pittsburgh: crew Michael P. O’Donnell, PhD, MBA, MPH © 2010

Environment Will you choose your environment?
Will you shape your environment? Or Will your environment shape you? Michael P. O’Donnell, PhD, MBA, MPH © 2011

AMSO & HIS POSSE FOCUS ON THE FRAMEWORK Awareness 5% Motivation 30%
Skills 25% Opportunity 40% FOCUS ON THE FRAMEWORK Michael P. O’Donnell, PhD, MBA, MPH © 2010

Fortunately, tobacco use has dropped remarkably in the past 40 years.

AMSO Range of Values Awareness 0-23% Motivation 3-40.7% Skills 2-37.3%
Opportunity % Michael P. O’Donnell, PhD, MBA, MPH © 2010

What is stalling change at a personal level?
Think of a behavior or health issue you or associate “should” be addressing but are not Clarify role: Active listener or stalled changer Reflect on why you are not addressing it Lack of Awareness Lack of Motivation Lack of Skills Lack of Opportunity Michael P. O’Donnell, PhD, MBA, MPH © 2010

How well does your program help your employees improve?
Think about a health behavior or condition that has not improved very well through your wellness program Clarify role: Active listener or program analyzer Review how you scored your program on AMSO Framework Discuss areas that you would like to improve your program What changes would have the most impact? What changes are you most able to change? What is your plan for areas with greatest impact that you are able to change? Michael P. O’Donnell, PhD, MBA, MPH © 2010

How well does your program help your employees improve?
Think about a health behavior or condition that has not improved very well through your wellness program Clarify role: Active listener or program analyzer How well does your program do each of the following? Enhance Awareness Motivate Change Convey Skills Provide Opportunity Michael P. O’Donnell, PhD, MBA, MPH © 2010

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