Presentation on theme: "MEASURING HEALTH BEHAVIOR CHANGE: PROBLEMS AND PROMISE"— Presentation transcript:
1MEASURING HEALTH BEHAVIOR CHANGE: PROBLEMS AND PROMISE CARLO C. DICLEMENTEPROFESSOR & CHAIRUMBC PSYCHOLOGY
2HEALTH PROMOTION & REQUIRE BEHAVIOR DISEASE PREVENTION CHANGE CANCER PREVENTION INITIATIONHEALTH PROMOTIONSAFETY & INJURY MODIFICATIONPREVENTIONHEALTH PROTECTIONSUBSTANCE ABUSE CESSATIONReducing 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.
3PRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE The Transtheoretical Model of Intentional Behavior ChangeSTAGES OF CHANGEPRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCEPROCESSES OF CHANGECOGNITIVE/EXPERIENTIAL BEHAVIORALConsciousness Raising Self-LiberationSelf-Revaluation Counter-conditioningEnvironmental Reevaluation Stimulus ControlEmotional Arousal/Dramatic Relief Reinforcement ManagementSocial Liberation Helping RelationshipsCONTEXT OF CHANGE1. Current Life Situation2. Beliefs and Attitudes3. Interpersonal Relationships4. Social Systems5. Enduring Personal CharacteristicsMARKERS OF CHANGEDecisional Balance Self-Efficacy/Temptation
4How Do People Change? People change voluntarily only when they Become concerned about the need for changeBecome convinced that the change is in their best interests or will benefit them more than cost themOrganize a plan of action that they are committed to implementingTake the actions that are necessary to make the change and sustain the change
5Model Components (Stages) 1. Precontemplation - Not Ready to Change2. Contemplation - Thinking About Change3. Preparation - Getting Ready to Make Change4. Action - Making the Change5. Maintenance - Sustaining Behavior Change Until Integrated into LifestyleRelapse and Recycling - Slipping Back to Previous Behavior and Re-entering the Cycle of ChangeTermination - Leaving the cycle of change
6Stage of Change Tasks Precontemplation Contemplation Preparation ActionMaintenanceAwareness, Concern,ConfidenceRisk-Reward Analysis & Decision makingCommitment & Creating an Effective/Acceptable PlanAdequate Implementation of Plan and Revising as NeededIntegration into Lifestyle
7Theoretical and practical considerations related to movement through the Stages of Change Motivation Decision-Making Self-efficacyPrecontemplation Contemplation Preparation Action MaintenancePersonal Environmental Decisional Cognitive BehavioralConcerns Pressure Balance Experiential Processes(Pros & Cons) ProcessesRecycling Relapse
8Prescribed Health Behaviors Pregnancy and HIV PreventionCondom useAbstinenceBirth control methodsPillsPatchDepo injectionsSpermicidal agentsEmergency contraceptivesCancer Risk ReductionScreening (multiple)Smoking cessationUV ProtectionEnvironmental exposuresDietary changesFat < 30%Fiber 20 gramsFruits & Vegetables (5)
9Prescribed Health Behaviors Cardiovascular Risk ReductionPhysical ActivityCholesterol screening and treatmentWeight ReductionDietary changesAspirin regimenAlcohol ModerationDiabetes Prevention and TreatmentObesity Prevention and ReductionGlucose monitoringDietary changesRegular screening for associated problemsAlcohol Consumption
10Prescribed Health Behaviors Similar lists of behaviors can be compiledAsthma prevention and controlObesity preventionChronic Lung DiseasePreventing and Treatment of Addictions and Substance AbuseTraffic safetyOccupational Safety
11HEALTH BEHAVIORS MULTIPLE MULTIDIMENSIONAL VARY IN FREQUENCY VARY IN INTENSITYREQUIRE DIFFERING LEVELS OF MOTIVATIONCAN BE INTEGRATED INTO DIFFERENT LIFESTYLES TO VARYING DEGREES
12THE FIRST STEP TO MEASURING HEALTH BEHAVIORS 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 behaviorExamples: pregnant drug abusing women; 30% calories from fat; abstinence or moderationThis 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.
13Defining Action: The First Step Specifying the behavior or constellation of behaviors that would characterize the action stage of changeDoing a task analysis that would indicate frequency, intensity, difficulty, and skills needed to perform the behaviorDefine 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.
14Food for Life ProjectOver 2000 women in WIC (Women, Infants, & Children) programs10 sites with each acting as own control and contributing women to intervention and controlMail and in person intervention that was intensiveSignificant results: < Fat; > F & V
15Dietary behaviors related to diet of < 30% calories from fat Drinking 1% or skim milkAvoiding fried foodsChecking labels for fat contentBuying low fat or fat free productsAvoiding High fat snacks and sweetsAvoiding high fat meatsEating more fruits & vegetablesObviously 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.
16Precontemplation for All Low Fat Behaviors (Items 2-8) NoYesEating a Low Fat DietN%Chi-Squarep-valueReported StagePrecontemplation50629.1%29291.8%448.02.000Contemplation51529.6%216.6%Preparation30117.3%30.9%Action25214.5%20.6%Maintenance1659.5%0.0%Totals1739318
17Maintenance for All Low Fat Behaviors (Items 2-8) NoYesEating a Low Fat DietN%Chi-Squarep-valueReported StagePrecontemplation79839.8%0.0%321.32.000Contemplation53326.6%35.9%Preparation30215.1%23.9%Action24612.3%815.7%Maintenance1276.3%3874.5%Totals200651
18Step 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
19Proportion of MATCH Outpatients Avoiding a Heavy Drinking (5 Drinks) Day as a Function of Time # OF DAYS
20Drinking and Problem Status by Treatment Condition (Outpatient)
21The Well-Maintained Addiction Defining action and maintenance is critical for initiation of health risks, like addiction, as well as health protection behaviorsRegular, 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 copingNFL Substance abuse program; adolescent smokers who are nicotine dependent
22The Reality of RelapseMany individuals who attempt to make a health behavior change fail to do soNon 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
24Relapse & RecyclingRelapse 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.
25Theoretical and practical considerations related to movement through the Stages of Change Motivation Decision-Making Self-efficacyPrecontemplation Contemplation Preparation Action MaintenancePersonal Environmental Decisional Cognitive BehavioralConcerns Pressure Balance Experiential Processes(Pros & Cons) ProcessesRecycling Relapse
26Stages of Change Model Precontemplation Increase awareness of need to changeContemplationMotivate and increase confidencein ability to changeRelapseAssist in CopingPreparationNegotiate a planMaintenanceEncourage activeproblem-solvingActionReaffirm commitmentand follow-upTermination
28Measuring Change: Behavioral Outcomes Crucial challenge: Operationally defining Action, Maintenance, and Relapse for this particular health behaviorCreating sensitive and clear evaluations for each of these three constructsFinding ways to validate all of these critical health behavior change outcomes using both self-report and more objective measuresIf all that you need is an assessment of outcomes that are behavioral in nature, you can stop here.
29Examples 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 screensMedical 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.
30Step 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 & planningIdentifying associated variables
31Distinguishing 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.
32Food 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
33Self-Reported Stage of Change for Eating a Low Fat Diet PCCPAAMNs for RowsRestaged SOC based on FFQPrecontemplation85.5--682Contemplation79.733.121.8547Preparation76.627.233.3357Action14.520.323.439.8397Maintenance44.874Ns for Columns7985363042541652057
34Self-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 varianceIdentifying discrepant individuals can increase our understanding of self-evaluations and problems in measurement
35The Importance of Measuring Pre-Action Status However, much of the process of change happens prior to action being initiatedSubdividing pre-action status into stages helps to understand challenges of individuals and populations of interest prior to actionEnables fine tuning of intervention efforts including targeting feedback and adapting interventionsProvides a more sensitive and fine-grained assessment of movement and intervention impact over time
40Measuring Pre-ActionCan approximate how far or close individuals are to being committed and planning action using many different methodsMeasures of attitudes and self-statements (URICA, Readiness to Change; pros & cons)Stage classification algorithmsSimpler ruler or ladder types of assessmentsInterview evaluationsSelf or peer nominations
42Measuring Associated Markers of Change We need to understand associated behaviors and activities that coincide with stage statusThese markers can provide additional targets of intervention or assessmentFor 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
51TTM Profile: Outpatient PDA Post Treatment 0.80.60.4Abstinent0.2ModerateStandard ScoresHeavier-0.2-0.4-0.6-0.8PreConActMainConfTempExpBehTTM Variables
52Cautions 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 changeEven for those planning change priorities change and competing problems interfere
53Cautions continuedAssessment 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
54Pros and Cons of Various Types of Measures Simple Continuous Measures (rulers)Multi-component attitudinal measuresAlgorithms (a series of dichotomous response questions)Related assessments (pros and cons; self-efficacy; intention, beliefs)Self-reported stage status
55Conclusions 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 changesPatterns of change vary greatly over time: more stability than change; rapid change; recycling
56Conclusions IIWhat 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
57Challenges IWe 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.
58Challenges IIBasic research to understand, define and assess health behaviors must precede large-scale efforts to change these behaviorsNew 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.
59Challenges IIIWe must continue to develop more sophisticated assessments of critical attitudes, intentions and plans related to the specific health behavior changeWe must look for benchmarks or additional markers related to movement toward changeWe must develop a better understanding of how cultural and ethnic influences impact our outcomes and our assessments
60The Promise of Accurate Assessment More sophisticated understanding of health behaviors and health behavior changeMore sensitive analyses of mechanisms, contextual influences, and changeIncreased accuracy of goals and target behaviorsBetter targeted interventionsBetter evaluation of interventions