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

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

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

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

3 HUH? Michael P. O’Donnell, PhD, MBA, MPH © 2010

4 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, 3 rd 2011, Jossey-Bass

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

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

7 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

8 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

9 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, Trends in Consumption of Five or More Recommended Vegetable and Fruit Servings for Adults 18 and Older, US,

10 Trends in Prevalence (%) of No Leisure-Time Physical Activity, by Educational Attainment, Adults 18 and Older, US, 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, Adults with less than a high school education All adults

11 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

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

13 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

14 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

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

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

17 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

18 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

19 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

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

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

22 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

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

24 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

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

26 Behavioral Efficacy Belief a behavior leads to desired outcome Michael P. O’Donnell, PhD, MBA, MPH © 2010

27 Impact of Self Efficacy & Behavioral Efficacy PersonBehaviorOutcome Self Efficacy Behavioral Efficacy Michael P. O’Donnell, PhD, MBA, MPH © 2010

28 Focusing Efforts High Low Self Efficacy Behavioral Efficacy Michael P. O’Donnell, PhD, MBA, MPH © 2010

29 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

30 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

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

32 Motivational Readiness to Change –Precontemplation Never40% –Contemplation Later40% –Preparation Soon20% –Action Now –Maintenance Trying to be forever –Termination Probably forever Michael P. O’Donnell, PhD, MBA, MPH © 2010

33 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 –Enhance Self Efficacy –Enhance Behavioral Efficacy –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

34 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

35 Utilize the Best Science

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

37 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

38 Best Methods for Weight Control? ? ? ? ? ? ? ? ?

39 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

40 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 1. Primary research in peer review journal or technical report 2. Published January 1980-June Meet research quality criteria 4. Evaluate impact of workplace health promotion program 5. Measure change in one or more outcomes of interest Studies found 1. Abstracts and titles: 4, Studies examined in detail: Studies meeting all criteria: 86 Ratings 1. Study design: threats to internal validity: greatest, moderate, least 2. Quality of execution: good, fair, limited 3. Effect size: quantitative, qualitative

41 Scope of Review 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

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

43 Health Assessment with Feedback Plus Intervention* Conclusion Conclusion: Strong evidence of effectiveness Tobacco use (30) % pp prevalence- 2.3 % consumption Dietary fat consumption (11) % pp prevalence Blood Pressure control (31) % pp prevalence Cholesterol management (36)- 6.6 % pp prevalence- 4.8 mg/dl Absence from work (10)- 1.2 days/year less Conclusion Conclusion: Sufficient evidence of effectiveness Seat belt use (10) % pp prevalence Heavy drinking (9)- 2.0 % pp prevalence Physical activity (18)-15.3 % pp prevalence Health risk score (21) Medical utilization (7) Conclusion Conclusion: Insufficient evidence of effectiveness Fitness (9)positive outcomes small effect sizes, multiple measures Body composition (27) - BMI (8)-.5 BMI unitconsistent findings - Weight (17)-.56 pdssmall effect size - Fat (6)-2.2 %small effect size Conclusion Conclusion: Not effective Fruit and vegetable consumption (8)minimal changes observed *Numbers of studies are shown in parentheses ( )

44 Incentives and Competition to Reduce Tobacco Use Conclusion Conclusion: Insufficient evidence of effectiveness Incentives and Competition Only Number of studies:1, 0 qualified Conclusion 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%) prevalence67% improvement % median quit rate (8% -20.5%) Incentives + skills+ social support (5) - 10% pp median (2.7%-9.4%) prevalence168% improvement - 21% median quit rate Participation rates (11) 28% median participation of smokers (12%-84%)

45 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

46 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

47 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

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

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

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

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

52 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

53 Become Obese 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 Christakis NA, Fowler JH. N Engl J Med 2007;357: Likelihood & degrees of separation 1: 45% 2: 20% 3: 10% Geographic separation Effect maintained 0,.26,1.5,3.4,9.3,471 miles

54 Quit Smoking 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 Christakis NA, Fowler JH. N Engl J Med 2008;358:

55 O:Organizations Employer –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 Employers need to leverage or overcome the influence of other organizations Michael P. O’Donnell, PhD, MBA, MPH © 2011

56 S: the “State” National 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 Michael P. O’Donnell, PhD, MBA, MPH © 2011 Are you a passive citizen or a policy advocate?

57 Michael P. O’Donnell, PhD, MBA, MPH © 2010 Smoking Rates, Cleveland, Ohio & US,

58 S:Society Broad cultural norms –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 Michael P. O’Donnell, PhD, MBA, MPH © 2011 Baezconnde-Garbanati, AJHP, 2011

59 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

60 Typical American gains 2 pounds per year after college

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64 Sprawl Is Associated with More Health Problems Ewing, AJHP, 2003

65 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

66 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 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): *using Add Health data Odds of having 5 or more bouts of MVPA Odds of being overweight Referent

67 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.

68 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 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.

69 Wener RE, Evans GW. A morning stroll: Levels of physical activity in car and mass transit commuting. Environment and Behavior 2007; 39(1): 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.

70 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): 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%).

71 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.

72 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

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

75 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

76 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

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

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

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

81 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

82 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

83 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

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


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