MEASURING HEALTH BEHAVIOR CHANGE: PROBLEMS AND PROMISE

1. MEASURING HEALTH BEHAVIOR CHANGE: PROBLEMS AND PROMISE CARLO C. DICLEMENTE PROFESSOR & CHAIR UMBC PSYCHOLOGY

2. HEALTH PROMOTION & REQUIRE BEHAVIOR DISEASE PREVENTION CHANGE CANCER PREVENTION INITIATION HEALTH PROMOTION SAFETY & INJURY MODIFICATION PREVENTION HEALTH PROTECTION SUBSTANCE ABUSE CESSATION

3. The Transtheoretical Model of Intentional Behavior Change STAGES OF CHANGE PRECONTEMPLATION  CONTEMPLATION  PREPARATION  ACTION  MAINTENANCE PROCESSES OF CHANGE COGNITIVE/EXPERIENTIALBEHAVIORAL 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 BalanceSelf-Efficacy/Temptation

4. How Do People Change? • People change voluntarily only when they • Become concernedabout 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. 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 Stage of Change Tasks

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. 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) Prescribed Health Behaviors

9. 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 Prescribed Health Behaviors

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

11. HEALTH BEHAVIORS • MULTIPLE • MULTIDIMENSIONAL • VARY IN FREQUENCY • VARY IN INTENSITY • REQUIRE DIFFERING LEVELS OF MOTIVATION • CAN BE INTEGRATED INTO DIFFERENT LIFESTYLES TO VARYING DEGREES

12. THE 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 behavior • Examples: pregnant drug abusing women; 30% calories from fat; abstinence or moderation

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)

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

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 # OF DAYS

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

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

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)

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

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 PC M PC C M C A A PA PA

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