Sustaining Behavior Change Stephen Horan, PhD Community Health Solutions August 3, 2005

2 The Question How can we get our healthy lifestyles clients to sustain positive behavior changes over time? How can we get our healthy lifestyles clients to sustain positive behavior changes over time?

3 The Challenge The literature on initial behavior change is substantial The literature on initial behavior change is substantial The literature on sustained behavior change is minimal The literature on sustained behavior change is minimal We are left to develop a program theory based on informed hypotheses rather than hard and fast models of “what works” We are left to develop a program theory based on informed hypotheses rather than hard and fast models of “what works”

4 Building Blocks of Program Theory How do people go through the stages of deciding to change, adopting change, and sustaining change? How do people go through the stages of deciding to change, adopting change, and sustaining change? What levels of intervention are helpful for getting people to each stage? What levels of intervention are helpful for getting people to each stage? How can we assure that the right interventions are “turned on” to sustain change? How can we assure that the right interventions are “turned on” to sustain change?

5 Building Blocks of Program Theory Stages of Change Model Stages of Change Model –The trans-theoretical model of behavior change  Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38–48. Levels of Intervention Model Levels of Intervention Model –Institute of Medicine  Ecological Approach to Health and Behavior Research and Practice –From Health and Behavior, The Interplay of Biological, Behavioral, and Societal Influences (2001)

6 Building Blocks of Program Theory Stages of Change Pre- Contem- plation Contem- plation Prepa- ration ActionMainten- ance Levels of Intervention Individual? Family/ Social Networks? Organization? Community? Societal? The question of “how do we sustain change” becomes a question of “how can we help people get to maintenance stage and stay there?”

7 Building Blocks of Program Theory Stages of Change Model Stages of Change Model –The basic premise:  Behavior change is a process and not an event  Individuals are at varying levels of motivation, or readiness, to change  People at different points in the process of change can benefit from different interventions, matched to their stage at that time.  By knowing an individual’s current stage, you can help set realistic program goals  You can also tailor messages, strategies, and programs to the appropriate stage

8 Building Blocks of Program Theory Stages of Change Model Stages of Change Model Five distinct stages: Five distinct stages: –Precontemplation –Contemplation –Preparation –Action –Maintenance  It is important to note that this is a circular, not a linear, model. People don’t go through the stages and "graduate"; they can enter and exit at any point, and often recycle.

9 Building Blocks of Program Theory Stages of Change Model Stages of Change Model –Precontemplation Stage  People are not intending to take action in the foreseeable future, usually measured as the next six months.  People may be in this stage because they are uninformed or under-informed about the consequences of their behavior.  Or they may have tried to change a number of times and become demoralized about their ability to change.  They are often characterized in other theories as resistant or unmotivated or as not ready for health promotion programs.  Traditional health promotion programs are often not designed for such individuals and are not matched to their needs.

10 Building Blocks of Program Theory Stages of Change Model Stages of Change Model –Contemplation Stage  People are intending to change in the next six months.  They are more aware of the pros of changing but are also acutely aware of the cons.  This balance between the costs and benefits of changing can produce profound ambivalence that can keep people stuck in this stage for long periods of time.  These people might not be ready for traditional action oriented programs.

11 Building Blocks of Program Theory Stages of Change Model Stages of Change Model –Preparation Stage  People are intending to take action in the immediate future, usually measured as the next month.  They have typically taken some significant action in the past year.  They have a plan of action  These are ready to be recruited into a healthy lifestyle program

12 Building Blocks of Program Theory Stages of Change Model Stages of Change Model –Action Stage  People have made specific overt modifications in their life-styles within the past six months.  Not all modifications of behavior count as action in this model. People must attain a criterion that scientists and professionals agree is sufficient to reduce risks for disease.  The Action stage is also the stage where vigilance against relapse is critical.

13 Building Blocks of Program Theory Stages of Change Model Stages of Change Model –Maintenance Stage  People are working to prevent relapse but they do not apply change processes as frequently as do people in action.  They are less tempted to relapse and increasingly more confident that they can continue their change.

14 Building Blocks of Program Theory Levels of Intervention Model Levels of Intervention Model –Five levels of intervention:  Individual  Family, Social Networks  Organization  Community  Society

15 Building Blocks of Program Theory Levels of Intervention Model Levels of Intervention Model –Individual Level  Focus on the individual person  Change process might by physiological, psychological, or both  Target outcomes may include knowledge, attitudes, beliefs, skills, behaviors, clinical status

16 Building Blocks of Program Theory Levels of Intervention Model Levels of Intervention Model –Family/Social Network Level  Focus on the people surrounding the client  Change process is mainly psychosocial  Target outcomes may changing group norms which influence the client’s behavior

17 Building Blocks of Program Theory Levels of Intervention Model Levels of Intervention Model –Organization Level  Focus on the organization surrounding the client (school, work, other)  Change process is psychosocial and structural  Target outcomes may include changing group norms which influence the client’s behavior as well as organization structures (food service, physical education, wellness programs, exercise programs, financial incentives, etc.)

18 Building Blocks of Program Theory Levels of Intervention Model Levels of Intervention Model –Community Level  Focus on the community surrounding the client (neighborhood, faith community, other)  Change process is cultural, social, and structural  Target outcomes may include changing community awareness, knowledge, attitudes in an effort to influence to individual actions  May also include structural changes (transportation, parks, food markets, etc.)

19 Building Blocks of Program Theory Levels of Intervention Model Levels of Intervention Model –Societal Level  Focus on the public policy system  Change process is political  Target outcomes may include changing laws, regulations, funding in an effort to influence individual actions

20 Building Blocks of Program Theory Stages of Change Pre- Contem- plation Contem- plation Prepa- ration ActionMainten- ance Levels of Intervention Individual? Family/ Social Networks? Organization? Community? Societal? The question of “how do we sustain change” becomes a question of “how can we help people get to maintenance stage and stay there?”

21 Some Keys to Sustaining Change From a programmatic standpoint: From a programmatic standpoint: –The risk of relapse can be reduced to the extent that all five levels of intervention provide consistent messaging and support –You can only control so much with your particular program –Try to do an excellent job within your scope of control –Try to network with others who are working beyond your scope of control

22 Some Keys to Sustaining Change From an individual client standpoint: From an individual client standpoint: –People do better when they:  Experience frequent and consistent messaging from their family, social network, and community  Have access to personal counseling or coaching  Have access to biofeedback  Have access to proper food and exercise resources  Pick right back up after relapsing (if not, they can go right back to pre-contemplation stage)

23 Some Keys to Sustaining Change Let’s brainstorm some maintenance strategies for our programs… Let’s brainstorm some maintenance strategies for our programs…