Some models relevant for planning health promotion programs Ian McDowell March, 2012

1. The ‘Big Five’ Personality dimensions Extraversion: characteristics such as excitability, sociability, talkativeness, assertiveness, and emotional expressiveness. Extraverted is opposite to introverted ("Would you rather spend an evening with a friend or with a book?") Agreeableness: attributes such as trust, altruism, kindness, affection: behaviours that promote social interaction. Agreeable can be contrasted with disagreeable (“Are you interested more in other people's feelings or in your own?”) Conscientiousness: this refers to a person's thoughtfulness, their level of impulse control and goal-directed behaviors. Conscientious people are organized and pay attention to detail. Roughly the opposite of playful. Neuroticism: a tendency to experience emotional instability, anxiety, moodiness, sadness or irritability. Neurotic vs. stable (“How calm & composed do you remain in stressful circumstances?”) Openness, referring to being open to new experiences. Such people are interested in intellectual matters, whether of the imagination or of logic. Related characteristics include insight, having a broad range of interests, being imaginative, intellectual, perhaps witty.

Pathways from Personality to Health Status

Perceived Susceptibility to Disease · Demographics (age, sex, ethnicity, etc.) · Sociopsychological variables (personality, social class, peer and reference group pressures, etc.) · Structural variables (knowledge about the disease, prior experience of it, etc.) Perceived Threat of the Disease · Raised awareness (e.g., mass media campaign, newspaper article ) · Personal advice (e.g., reminder from health professional) · Personal symptoms · Illness of family member or friend Perceived benefits of taking action, minus Perceived barriers to action Likelihood of Taking Recommended Health Action Modifying Factors Perceived Severity of Disease Cues to Action 2. Health Belief Model

Intentions Behavior Threat appraisal Vulnerability + Severity of disease Coping appraisal Self efficacy + Response efficacy 3. Protection Motivation Theory

Health Behavior Behavioral Intentions Subjective norms Attitude toward changing behaviors Motivation Beliefs concerning others’ views Perceived effectiveness of recommended action Perceived importance of health issue 4. Theory of Reasoned Action

Behavioral beliefs (importance of the health issue & whether the behavior will be effective) Normative beliefs: how do others view the behaviors? Control beliefs: self-efficacy Attitude toward recommended behavior Subjective norms: felt social pressures to act Perceived behavioral control Intention to act (or not) Behavior 5. Theory of Planned Behavior

6. Stages of Change (J. Prochaska, 1985)Stages of Change Pre-contemplation no intention of changing Contemplation intends to act in a realistic time frame (+/- 6 months for smoking) Readiness for action preparing for change in immediate future Action is making, or has made changes Maintenance working to prevent relapse 8

Precontemplation Stable Lifestyle Contemplation Preparation Action Maintenance Relapse 7. Transtheoretical Model (Jim Prochaska, 1985)

Precontemplation Stable Lifestyle Contemplation Preparation Action Maintenance Relapse Precontemplation: The person does not intend to change the behavior, or is unaware of need to change, or is unwilling to do so. The physician can encourage the patient to think about the behavior and how they would feel about changing. Suggest they talk to their spouse, etc. Contemplation: The person has considered the possibility of changing, but is not ready to actively plan a change. The physician can provide information and encourage them to prepare to actually change. Preparation: The person is making plans to change in the next month (e.g., has set a quit date). The physician can refer the patient to support programs, prescribe nicotine patch, encourage them to set a quit date, etc. Action: The patient has changed. Encouragement & support are the major physician roles: arrange follow-up visits. Maintenance: The patient has practiced the new behaviour for a month or more and trying to maintain the change over the longer term. Relapse: Helping with relapse is an important role for the doctor; several attempts may be required before a behaviour is finally established. Encourage the patient to look on a relapse as gaining experience.

11 “Where is the Road Block?” Two models of behavior change Prochaska (1985) Stages of Change Stages of Change Weinstein (1998) Precaution Adoption Process Model 1. Unaware of the issue 2. Unengaged by the issue 3. Deciding about acting 4. Deciding not to act 5. Deciding to act 6. Acting 7. Maintenance 1. Pre-contemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance, relapse 6. Habitual behavior How does she feel? Analyze patient’s personal risk Supply information: pros and cons. Practical guidance: set quit date, etc Support & aids Monitoring MD’s role

Identify the administrative & financial policies needed Identify education, skills & ecology required Identify desirable outcomes: Behavioural, Environmental, Epidemiological, Social Predisposing factors Enabling factors Reinforcing factors Lifestyle Environment Planning phase What can be achieved? What needs to be changed to achieve it? What can be learned? What can be adjusted? Evaluation phase Adapted from: Green L. (Accessed May, 2009) Policies Resources Organisation Service or programme components Health status Quality of life Implementation: What is the programme intended to be? What is delivered in reality? What are the gaps between what was planned and what is occurring? Process: Why are there gaps between what was planned and what is occurring? What are the relations between the components of the programme? Impact: What are the programme’s intended and unintended consequences? What are its positive and negative effects? Outcome: Did the programme achieve its targets? Start Finish Setting up the programme 8. Precede-Proceed model

PRECEDE-PROCEED Framework Phase 1 Social Assessment Phase 3 Behavioral & Environmental Assessment Phase 2 Epidemiologic Assessment Phase 4 Educational & Ecological Assessment Phase 5 Administrative Policy Assessment Phase 6 Implementation Phase 7 Process Evaluation Phase 8 Impact Evaluation Phase 9 Outcome Evaluation HEALTH PROMOTION Health Education Policy, Regulation, Organization Predisposing factors Reinforcing factors Enabling factors Behavior & lifestyle Environment Health Quality of life

Social Marketing Cycle 1. Plan overall strategy 2. Select materials & channels 3. Develop intervention and pretest 4. Implement the program 5. Assess effectiveness (process & outcomes) 6. Use results to refine program 9. Social Marketing

The purposes of population health: A model of the various population health perspectives Interested? Other models on SIM web site: Population health modelsPopulation health models Pop health policies Pop health interventions Academic population health Describing Health Issues Analyzing Causes & Predicting Risks Developing Interventions Developing Delivery Systems Developing Healthy Policies