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Presentation on theme: "MEASURING HEALTH BEHAVIOR CHANGE: PROBLEMS AND PROMISE"— Presentation transcript:


CANCER PREVENTION INITIATION HEALTH PROMOTION SAFETY & INJURY MODIFICATION PREVENTION HEALTH PROTECTION SUBSTANCE ABUSE CESSATION Reducing health risks can be done is some large-scale changes in the environment, e.g. fluoridation of the water, reduction of industrial pollution and CO emissions, building safer roads, banning harmful products. However, for the most part, health promotion and prevention interventions require human intentional behavior changes where the individual must collaborate and participate in the change. Thus it is critical to understand what are the behaviors that we are asking people to avoid or make.

The Transtheoretical Model of Intentional Behavior Change STAGES OF CHANGE PRECONTEMPLATION  CONTEMPLATION  PREPARATION  ACTION  MAINTENANCE PROCESSES OF CHANGE COGNITIVE/EXPERIENTIAL BEHAVIORAL Consciousness Raising Self-Liberation Self-Revaluation Counter-conditioning Environmental Reevaluation Stimulus Control Emotional Arousal/Dramatic Relief Reinforcement Management Social Liberation Helping Relationships CONTEXT OF CHANGE 1. Current Life Situation 2. Beliefs and Attitudes 3. Interpersonal Relationships 4. Social Systems 5. Enduring Personal Characteristics MARKERS OF CHANGE Decisional Balance Self-Efficacy/Temptation

4 How Do People Change? People change voluntarily only when they
Become concerned about the need for change Become convinced that the change is in their best interests or will benefit them more than cost them Organize a plan of action that they are committed to implementing Take the actions that are necessary to make the change and sustain the change

5 Model Components (Stages)
1. Precontemplation - Not Ready to Change 2. Contemplation - Thinking About Change 3. Preparation - Getting Ready to Make Change 4. Action - Making the Change 5. Maintenance - Sustaining Behavior Change Until Integrated into Lifestyle Relapse and Recycling - Slipping Back to Previous Behavior and Re-entering the Cycle of Change Termination - Leaving the cycle of change

6 Stage of Change Tasks Precontemplation Contemplation Preparation
Action Maintenance Awareness, Concern,Confidence Risk-Reward Analysis & Decision making Commitment & Creating an Effective/Acceptable Plan Adequate Implementation of Plan and Revising as Needed Integration into Lifestyle

7 Theoretical and practical considerations related to movement through the Stages of Change
Motivation Decision-Making Self-efficacy Precontemplation Contemplation Preparation Action Maintenance Personal Environmental Decisional Cognitive Behavioral Concerns Pressure Balance Experiential Processes (Pros & Cons) Processes Recycling Relapse

8 Prescribed Health Behaviors
Pregnancy and HIV Prevention Condom use Abstinence Birth control methods Pills Patch Depo injections Spermicidal agents Emergency contraceptives Cancer Risk Reduction Screening (multiple) Smoking cessation UV Protection Environmental exposures Dietary changes Fat < 30% Fiber 20 grams Fruits & Vegetables (5)

9 Prescribed Health Behaviors
Cardiovascular Risk Reduction Physical Activity Cholesterol screening and treatment Weight Reduction Dietary changes Aspirin regimen Alcohol Moderation Diabetes Prevention and Treatment Obesity Prevention and Reduction Glucose monitoring Dietary changes Regular screening for associated problems Alcohol Consumption

10 Prescribed Health Behaviors
Similar lists of behaviors can be compiled Asthma prevention and control Obesity prevention Chronic Lung Disease Preventing and Treatment of Addictions and Substance Abuse Traffic safety Occupational Safety


Specify the broad target behavior that provides the greatest yield in health outcome for this problem. Examine the key component behaviors that are required to reach this goal target behavior Examples: pregnant drug abusing women; 30% calories from fat; abstinence or moderation This is not as easy as it sounds. One of my graduate students completed a study of pregnant drug abusers in a methadone treatment program. Most of these women smoked. Clearly the top priority of the treatment program was to get these women off heroin and onto methadone. However, the majority of these women smoked and smoking increased after being put on methadone and being in the program, especially as it moved from an inpatient stabilization phase to an outpatient one. The targeted reduction in the fat content of American diets can be achieved in many different ways and most interventions attempt to achieve this goal with shifts in a variety of behaviors. In a project I have been doing with Steve Havas, Pat Langenberg, and Jean Anliker we created an intervention that targeted multiple behaviors.

13 Defining Action: The First Step
Specifying the behavior or constellation of behaviors that would characterize the action stage of change Doing a task analysis that would indicate frequency, intensity, difficulty, and skills needed to perform the behavior Define partial goals and/or associated behaviors that indicate positive activity but fall short of the actual target behavior change (harm reduction) To understand the process of health behavior change and to be able to assess outcome specification is critical. It is also critical to know what are some partial actions that would be close but not constitute the complete behavior change. For example, abstinence versus cutting down in cigarette smoking; physical activity that is less than 30 minutes 5 times per week, using condoms but no other birth control method, breast self exam instead of mammography, use of sunscreen below 15 SPF. It is also critical to specify the frequency, intensity and types of skills needed t perform the behavior, e.g. self-administration of insulin, glucose tolerance testing, chest percussions for CF.

14 Food for Life Project Over 2000 women in WIC (Women, Infants, & Children) programs 10 sites with each acting as own control and contributing women to intervention and control Mail and in person intervention that was intensive Significant results: < Fat; > F & V

15 Dietary behaviors related to diet of < 30% calories from fat
Drinking 1% or skim milk Avoiding fried foods Checking labels for fat content Buying low fat or fat free products Avoiding High fat snacks and sweets Avoiding high fat meats Eating more fruits & vegetables Obviously these are still broad categories and include a number of sub behaviors. In an obesity prevention project with adolescents under the direction of Maureen Black at UM,B we are looking at avoiding supersized portions of fries and soft drinks specifically.

16 Precontemplation for All Low Fat Behaviors (Items 2-8)
No Yes Eating a Low Fat Diet N % Chi-Square p-value Reported Stage Precontemplation 506 29.1% 292 91.8% 448.02 .000 Contemplation 515 29.6% 21 6.6% Preparation 301 17.3% 3 0.9% Action 252 14.5% 2 0.6% Maintenance 165 9.5% 0.0% Totals 1739 318

17 Maintenance for All Low Fat Behaviors (Items 2-8)
No Yes Eating a Low Fat Diet N % Chi-Square p-value Reported Stage Precontemplation 798 39.8% 0.0% 321.32 .000 Contemplation 533 26.6% 3 5.9% Preparation 302 15.1% 2 3.9% Action 246 12.3% 8 15.7% Maintenance 127 6.3% 38 74.5% Totals 2006 51

18 Step 2: Defining Maintenance
What would this behavior look like in terms of frequency, intensity, and completeness if it were integrated into the lifestyle of the individual (mammograms every 2 years; never more that 4-5 drinks of alcohol per occasion) What would criteria be for defining a slip (temporary non adherence) or a relapse (a pattern that substantively failed to meet criterion) Does maintenance make sense for infrequent acts

19 Proportion of MATCH Outpatients Avoiding a Heavy Drinking (5 Drinks) Day as a Function of Time

20 Drinking and Problem Status by Treatment Condition (Outpatient)

21 The Well-Maintained Addiction
Defining action and maintenance is critical for initiation of health risks, like addiction, as well as health protection behaviors Regular, dependent use of a substance that creates creates a pattern that eludes self-regulatory control, continues despite negative feedback, and becomes an integral part of the individual’s life and coping NFL Substance abuse program; adolescent smokers who are nicotine dependent

22 The Reality of Relapse Many individuals who attempt to make a health behavior change fail to do so Non adherence rates for a wide range of health behaviors range from 20 to 80% Adherence is often higher at short-term follow-up than it is one year after an intervention


24 Relapse & Recycling Relapse is not a problem of substance abuse or addictions; relapse is part of the process of behavior change. The reality of Relapse requires successive approximations to instigate successful, sustained health behavior change. Most successful changers make repeated efforts to get it right that are part of a learning process to remediate inadequate completion of stage tasks.

25 Theoretical and practical considerations related to movement through the Stages of Change
Motivation Decision-Making Self-efficacy Precontemplation Contemplation Preparation Action Maintenance Personal Environmental Decisional Cognitive Behavioral Concerns Pressure Balance Experiential Processes (Pros & Cons) Processes Recycling Relapse

26 Stages of Change Model Precontemplation
Increase awareness of need to change Contemplation Motivate and increase confidence in ability to change Relapse Assist in Coping Preparation Negotiate a plan Maintenance Encourage active problem-solving Action Reaffirm commitment and follow-up Termination


28 Measuring Change: Behavioral Outcomes
Crucial challenge: Operationally defining Action, Maintenance, and Relapse for this particular health behavior Creating sensitive and clear evaluations for each of these three constructs Finding ways to validate all of these critical health behavior change outcomes using both self-report and more objective measures If all that you need is an assessment of outcomes that are behavioral in nature, you can stop here.

29 Examples of More Objective Action and Maintenance Outcome Measures
Steps per day or week measured by pedometers assessed during a one week period every three months for a year. Self-reported abstinence from illegal drugs confirmed by random drug screens over one year with a minimum of 90% clean screens Medical record confirmed mammograms every 2 years (within a 2 to 3 year period) Some behaviors are easier and some harder to operationalize and validate. Here are some examples.

30 Step 3: Examining Pre-action
Identifying critical markers of movement toward action. Various models identify various indicators: beliefs, intentions, efficacy, decision making. Stage specific tasks: concern and consideration, decision making, commitment & planning Identifying associated variables

31 Distinguishing Pre-Action from Action
It is difficult to evaluate concerns, attitudes, beliefs, intentions, and plans unless you are able to distinguish those already engage in the action and those who do not need to make changes from those at risk and needing to change. Problem definitions and action/maintenance criteria are essential to do this.

32 Food For Life Project Block Dietary assessment
Self-reported stage of change for eating a low fat diet, eating five or more fruits and vegetables per day, eating a high fiber diet, and for each of the component dietary behaviors (skim milk, avoiding high fat) How to reconcile objective and self-report measures and to evaluate what any discrepancies mean to the individual and for research

33 Self-Reported Stage of Change for Eating a Low Fat Diet
PC C PA A M Ns for Rows Restaged SOC based on FFQ Precontemplation 85.5 -- 682 Contemplation 79.7 33.1 21.8 547 Preparation 76.6 27.2 33.3 357 Action 14.5 20.3 23.4 39.8 397 Maintenance 44.8 74 Ns for Columns 798 536 304 254 165 2057

34 Self-Report and Restaging
For the most part self-report is a very good approximation of where a person is in the process of change with significant and substantial correspondence between objective measures and reported stage even when there is a vague criterion like <30%. However, eliminating or restaging based on objective measures can help get rid of problematic variance Identifying discrepant individuals can increase our understanding of self-evaluations and problems in measurement

35 The Importance of Measuring Pre-Action Status
However, much of the process of change happens prior to action being initiated Subdividing pre-action status into stages helps to understand challenges of individuals and populations of interest prior to action Enables fine tuning of intervention efforts including targeting feedback and adapting interventions Provides a more sensitive and fine-grained assessment of movement and intervention impact over time

36 Stage Based Epidemiology

37 Numbers of Ever Smokers



40 Measuring Pre-Action Can approximate how far or close individuals are to being committed and planning action using many different methods Measures of attitudes and self-statements (URICA, Readiness to Change; pros & cons) Stage classification algorithms Simpler ruler or ladder types of assessments Interview evaluations Self or peer nominations


42 Measuring Associated Markers of Change
We need to understand associated behaviors and activities that coincide with stage status These markers can provide additional targets of intervention or assessment For interventions that do not produce gross behavior change, stage tasks and markers represent the only way to evaluate if they have had any effect on the process









51 TTM Profile: Outpatient PDA Post Treatment
0.8 0.6 0.4 Abstinent 0.2 Moderate Standard Scores Heavier -0.2 -0.4 -0.6 -0.8 Pre Con Act Main Conf Temp Exp Beh TTM Variables

52 Cautions in Assessing Pre-Action
Pre-action stage status is volatile and changeable (even during the course of an interview) Individuals move both forward and backward in considering and planning for change Even for those planning change priorities change and competing problems interfere

53 Cautions continued Assessment of readiness needed for overall goal behavior does not necessarily indicate readiness for all component behaviors. Are importance and efficacy the only ingredients needed for readiness? Prior attempts (recycling) and success or failure with similar changes are important to consider and evaluate

54 Pros and Cons of Various Types of Measures
Simple Continuous Measures (rulers) Multi-component attitudinal measures Algorithms (a series of dichotomous response questions) Related assessments (pros and cons; self-efficacy; intention, beliefs) Self-reported stage status

55 Conclusions about measuring Health Behavior Change
There are significant differences in attitudes and activities of individuals in different pre-action stages no matter how these are assessed (not every study but every type of measure) It is complicated evaluating pre-action assessments once individuals have made behavior changes Patterns of change vary greatly over time: more stability than change; rapid change; recycling

56 Conclusions II What is needed are multiple assessment over short and long periods of time. Long-term follow-ups will not help us understand the process of change. Short-term follow-ups emphasize momentary changes and action but underestimate the long haul. Successful health behavior changes must be viewed incrementally not dichotomously

57 Challenges I We must sharpen our thinking and conceptualizing of health behaviors. Broad, general conceptualizations do as much damage to health promotion research as simply looking at regions of the brain and not neurotransmitters would do for brain research. Specificity and sophistication must be the hallmarks of the future.

58 Challenges II Basic research to understand, define and assess health behaviors must precede large-scale efforts to change these behaviors New technology should be incorporated into the assessment of actual behavior change (pedometers, MEMS Caps, body fat composition, computerized assessments) but cannot supplant self-reported behavior.

59 Challenges III We must continue to develop more sophisticated assessments of critical attitudes, intentions and plans related to the specific health behavior change We must look for benchmarks or additional markers related to movement toward change We must develop a better understanding of how cultural and ethnic influences impact our outcomes and our assessments

60 The Promise of Accurate Assessment
More sophisticated understanding of health behaviors and health behavior change More sensitive analyses of mechanisms, contextual influences, and change Increased accuracy of goals and target behaviors Better targeted interventions Better evaluation of interventions


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