HSCI 533 Lecture 2

1. Planning for Health Behavior Change Programs HSCI 533 Lecture 2

2. New Years Resolutions This year, I will change X…

3. Health Behavior As you all know – successfully adhering to new years resolutions (changing behaviors) is extremely difficult! So then, how does one go about fostering effective behavior change?

4. BASIC STEPS Target health behavior (+/-) Identify desired outcome (goals/objectives) Determine what influences it (risk-protective factors) Conceptually explain why it occurs (theories) Design an intervention to reach desired outcome Evaluate its success Not simple! Need to undergo a planning process…

5. A General Model for Program Planning • Models assist program planners with developing effective behavior change interventions

6. Health Promotion Model to Achieve Healthy Behaviors Needs Assessment Specific risk factors, diseases, &conditions Outcomes Determinants of Health • Behavior Change Goals/ Objectives Baseline Evaluation Theory Application Interventions • Information • Programs • Policies Monitoring

7. Conceptual Planning Model Participatory Research 1. Assess Needs, Assets of Population 2. Assess Causes, Set Priorities & Objectives 4. Evaluate Program Reassess causes Health Behavior Theory Selection Redesign 3. Design and Implement Program *Green & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999.

8. A General Model for Program Planning

9. Needs Assessment An initial process to understand… What types of things help to start (influence) the health behavior? Why we continue with a health behavior, even if we know it is bad/good for us? How unhealthy behaviors can be stopped or replaced with healthy ones? How healthy behaviors can be maintained over time?

10. Given that multiple factors will be related to the health behavior, it is important to consider: • The priorities (importance)? • What’s most changeable? Further Assessment

11. Useful Planning Models • PRECEDE-PROCEED • Provides a comprehensive structure for planners to develop successful health behavior change interventions • And…it’s one of the best known theoretically grounded models in health promotion field • PRECEDE: predisposing, reinforcing, and enabling constructs in educational/ecological diagnosis & evaluation • PROCEED: policy, regulatory, and organizational constructs in educational & environmental development Green & Kreuter, 3rd ed

12. How it Works? • The model begins with an analysis of final consequences • Negative health outcomes • Retrospective explanations are offered relative to causative factors, categorized as: • Predisposing: antecedent; impact motivation • Reinforcing: antecedent; barriers & vehicles • Enabling: subsequent; feedback & rewards • From an understanding of causative factors (use of theory), • Educational and policy objectives are developed to inform intervention (program activities) • Program implementation and evaluation follow

13. Phase 5 Administrative & policy assessment Phase 4 Educational & ecological assessment Phase 2 Epidemiological assessment Phase 1 Social assessment Phase 3 Behavioral & environmental assessment Predisposing Public Health Health education Behavior Reinforcing Quality of life Health Policy regulation organization Environment Enabling <-----------------------------PRECEDE Phase 6 Implementation Phase 7 Process evaluation Phase 8 Impact evaluation Phase 9 Outcome evaluation PROCEED-------------------------------->

14. PRECEDE Framework • Developed in the early 1970s • Four Phases designed to aid in the assessment (diagnosis) of health concerns for the planning of the intervention

15. Phase 1: Social Assessment Define health behaviors (problems & priorities) Consider how such health behaviors affect long-term desired outcomes Quality of Life Happiness Life Satisfaction PRECEDE Phases

16. Phase 2: Epidemiological Assessment Data gathering step on identified health behavior in terms: Health impact: disability in functioning, morbidity (illness/disease) Behavioral impact: consumption, duration/frequency, adherence, self-care, coping, service utilization Environmental impact: social (capital/connectedness, crime, homelessness), physical (neighborhood), economic (poverty) Allows for the establishment of a baseline of health behavior (prior to intervention) PRECEDE Phases

17. Phase 3: Educational & Ecological Diagnosis Identifies factors that have potential to influence health behavior change: Predisposing: Reasons for the behavior – Knowledge, Attitudes, Beliefs/Perceptions, Skills/Ability Enabling: barriers & vehicles to the behavior – Peers, Family, Friends, Media (normative standards) Reinforcing: feedback & rewards that make the behavior possible - Availability of resources, Accessibility (services), Rules/Laws PRECEDE Phases

18. Predisposing Factors Knowledge Beliefs Values Attitudes Confidence Health literacy Enabling Factors Availability of resources Accessibility of resources Laws Community Commitment Skills BEHAVIOR Reinforcing Factors Family Peers Teachers Employers Health Providers Community Leaders Decision Makers

19. Phase 4: Administrative, Policy & Intervention Alignment Aligns appropriate intervention strategies (guided by behavior change theories) to address targeted goals and objectives (desired outcomes) PRECEDE Phases

20. ABC Model • Health behavior is imbedded in a context; situations that come before and after the behavior A B C Antecedents Behavior  Consequences Cue or Stimulate Consequences Behavior affect whether or not behavior is repeated • Events that reinforce behavior or fail to do so • Physical events, inner thoughts/emotions

22. A General Model for Program Planning

23. Alice asked, “Would you tell me please, which way I ought to walk from here?” “That depends a good deal on where you want to get to,” said the Cat. “I don’t much care where,” said Alice. “Then it doesn’t matter which way you walk,” said the Cat. “—so long as I get somewhere,” Alice added as an explanation. “Oh, you’re sure to do that,” said the Cat, “if you only walk long enough!” —Lewis Carroll, Alice in Wonderland and Through the Looking Glass

24. Goals vs. Objectives

25. Goals Broad statements of direction – provide a sense of where we want to go, but they usually do not provide clear, precise statements of our destination.

26. Ex: Goals for Healthy People Healthy People 2010 defines two overarching goals for the nation: Goal 1: Increase quality of years of healthy life Goal 2: Eliminate health disparities

27. Break broad statements into objectives…. What do we have to do to reach our goal?

28. Objectives Precise statements of intended targets of change to see desired behavioral outcome Specified in measurable terms Considered to be assessment tools b/c they inform program evaluation

29. Where to Start… Take needs assessment information to guide the formation of objectives for a behavior change intervention Develop Baselines (for each objective) Brainstorm about what can be changed Choose Objective targets Assess changeability

31. Establish a Baseline Monitor the targeted behavior (and corresponding causal factors  objectives) for two weeks to understand where you stand with regards to specified objectives. What is knowledge level? What is skill level? What are attitudes? What is status of social support? What is current behavioral pattern?

32. Importance of Goals & Objectives in health behavior change interventions

33. Health Behavior Change “If you do not know where you want to go, it is usually impossible to get there” Need to be clear about where the somewhere is in order to: Design an intervention – clarify what needs to be done to address health behavior Evaluate its effects – measure if change has occurred

34. Example of General Goals • At the end of the program, participant will be able to prepare healthy meals. • At the end of the program, participant will reduce the use of non-prescription drugs. • At the end of the program, participants will develop good parenting skills. • At the end of the program, unwanted pregnancies will be reduced.

35. Writing Objectives • Begin with the question: “what is the target of change?...” • …then clearly and specifically state exactly what you intend to change with the intervention.

36. Framework to Follow SMART • Specific (what exactly is being changed and in whom) • Measurable (% of change to be seen – use a baseline) • Action (list, describe, indentify, explain) • Realistic (must be achievable) • Time-bound (end of session, end of year)

37. Suggested Guidelines in Writing Objectives • Make a rough outline of what you hope to accomplish with the intervention--Jot down key elements of what you hope to achieve. • Ask yourself the following:When you get done with the intervention: “How will the participant (you) feel or act, or what new knowledge or skills will you possess that were not present before the intervention?” • Begins with: The [participant]will be able to . . .Select action verb • list seven dietary recommendations from established guideline. • avoid frequenting liquor stores saturated in the neighborhood

38. Suggested Verbs for Goals and Objectives Goals Apply Appreciate Commit Demonstrate Perform Synthesize Analyze Create Plan Know Use Conceptualize Objectives Arrange Categorize Choose Clean Compute Conduct Construct Define Describe Design Diagram Discuss Drink Eat Identify Itemize Lead List Mark Match Name Operate Perform Pick Position Report Show a willingness Sort Specify Underline Volunteer

40. Examples of Goals & Objectives Health Behavior Problem: need to change unhealthy eating habits Goal: Reduce risk for obesity Objective 1: Increase cognitive capacity to avoid junk food (i.e., thought stopping) (skill) Objective 2: Increase knowledge of well-balanced “nutritious” diet (knowledge) Objective 3: Increase awareness of stress control (i.e., breathing techniques) (knowledge/skill) Objective 3: Increase attitudinal awareness of societal trends and norms of obesity (attitudinal) Objective 4: Reduce junk food intake (behavioral)

41. One more thing about Objectives… • Can each objective be evaluated? If not, restate. • The [participant] will be able to . . .verb after intervention (as measured against XX baseline)

42. Examples • Educational Objective: • By the end of intervention, individuals will know 15 benefits of exercise (baseline: 1 benefit) • Behavioral Objective: • By the end of intervention, individuals will increase physical activity to 3 times a week (baseline: 0 times). • Educational Objective: • By the end of intervention, individuals will know how to access resources about diet and internet (baseline: no access).

43. Skill Building Exercise • What is your health behavior targeted for change? • Using SMART way of writing objectives, write at least 3 intervention objectives that would help bring about change in this behavior.

44. A General Model for Program Planning

45. Intervention • Total overall strategy to achieve our objectives • Vs Method: one component of the intervention

46. Objectives as Drivers of Selection Interventions (and methods) must be linked with the objectives they are likely to achieve. In other words, the objectives should play a role in driving the selection of all intervention methods.

47. Health Behavior Theories as Drivers Health Behavior theories link objectives and methods to provide strategies for interventions  identifying strategies that will bring about successful behavior change B/C altering health behavior is extremely difficult, one must consider foundational theoretical explanations that describe the forces that: Initiate Maintain Could replace the behavior

48. Health Behavior Theories: Depends on X and Y THEORIES (indv, group, community) X ? Y? Different theories interpret “X” and “Y” differently (based on theoretical assumptions about causation).

49. Causes Inform Theory Selection • If we think in terms of predisposing, reinforcing, and enabling factors as capacities to encourage healthy choices, then it makes sense to identify theories to strengthen these capacities. • Example: if a barrier to the performance of a behavior is tied to deficiencies in skills, inappropriate attitudes or inadequate knowledge then theories containing constructs that emphasize skill improvement, attitude change, or increased knowledge should be selected.

50. Selecting Appropriate Theories • Theories are built upon a set of constructs (guiding principles of behavior) – much like bricks function as base units to create buildings. • As you begin to analyze the factors facilitating or hindering a behavior, guiding principles or “constructs” begin to emerge that relate to needs assessment info…