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MEASURING HEALTH BEHAVIOR CHANGE: PROBLEMS AND PROMISE. CARLO C. DICLEMENTE PROFESSOR & CHAIR UMBC PSYCHOLOGY. HEALTH PROMOTION & REQUIRE BEHAVIOR DISEASE PREVENTION CHANGE.

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MEASURING HEALTH BEHAVIOR CHANGE: PROBLEMS AND PROMISE


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measuring health behavior change problems and promise

MEASURING HEALTH BEHAVIOR CHANGE: PROBLEMS AND PROMISE

CARLO C. DICLEMENTE

PROFESSOR & CHAIR

UMBC PSYCHOLOGY

slide2

HEALTH PROMOTION & REQUIRE BEHAVIOR

DISEASE PREVENTION CHANGE

CANCER PREVENTION INITIATION

HEALTH PROMOTION

SAFETY & INJURY MODIFICATION

PREVENTION

HEALTH PROTECTION

SUBSTANCE ABUSE CESSATION

slide3

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

how do people change
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
model components stages
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

stage of change tasks
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
slide7

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

prescribed health behaviors
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
prescribed health behaviors1
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
prescribed health behaviors2
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
health behaviors
HEALTH BEHAVIORS
  • MULTIPLE
  • MULTIDIMENSIONAL
  • VARY IN FREQUENCY
  • VARY IN INTENSITY
  • REQUIRE DIFFERING LEVELS OF MOTIVATION
  • CAN BE INTEGRATED INTO DIFFERENT LIFESTYLES TO VARYING DEGREES
the first step to measuring health behaviors
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
defining action the first step
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)
food for life project
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
dietary behaviors related to diet of 30 calories from fat
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
step 2 defining maintenance
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
proportion of match outpatients avoiding a heavy drinking 5 drinks day as a function of time
Proportion of MATCH Outpatients Avoiding a Heavy Drinking (5 Drinks) Day as a Function of Time

# OF DAYS

the well maintained addiction
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
the reality of relapse
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
relapse recycling
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.
slide25

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

slide26

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

measuring change behavioral outcomes
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
examples of more objective action and maintenance outcome measures
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)
step 3 examining pre action
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
distinguishing pre action from action
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.
food for life project1
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
self report and restaging
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
the importance of measuring pre action status
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
measuring pre action
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
measuring associated markers of change
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
slide51

TTM Profile: Outpatient PDA Post Treatment

0.8

0.6

0.4

Abstinent

0.2

Moderate

Standard Scores

Heavier

0

-0.2

-0.4

-0.6

-0.8

Pre

Con

Act

Main

Conf

Temp

Exp

Beh

TTM Variables

cautions in assessing pre action
Cautions in Assessing Pre-Action
  • Pre-action stage status is volatile and changeable (even during the course of an interview)
  • Individuals move both forward and backward in considering and planning for change
  • Even for those planning change priorities change and competing problems interfere
cautions continued
Cautions continued
  • Assessment of readiness needed for overall goal behavior does not necessarily indicate readiness for all component behaviors.
  • Are importance and efficacy the only ingredients needed for readiness?
  • Prior attempts (recycling) and success or failure with similar changes are important to consider and evaluate
pros and cons of various types of measures
Pros and Cons of Various Types of Measures
  • Simple Continuous Measures (rulers)
  • Multi-component attitudinal measures
  • Algorithms (a series of dichotomous response questions)
  • Related assessments (pros and cons; self-efficacy; intention, beliefs)
  • Self-reported stage status
conclusions about measuring health behavior change
Conclusions about measuring Health Behavior Change
  • There are significant differences in attitudes and activities of individuals in different pre-action stages no matter how these are assessed (not every study but every type of measure)
  • It is complicated evaluating pre-action assessments once individuals have made behavior changes
  • Patterns of change vary greatly over time: more stability than change; rapid change; recycling
conclusions ii
Conclusions II
  • What is needed are multiple assessment over short and long periods of time. Long-term follow-ups will not help us understand the process of change. Short-term follow-ups emphasize momentary changes and action but underestimate the long haul.
  • Successful health behavior changes must be viewed incrementally not dichotomously
challenges i
Challenges I
  • We must sharpen our thinking and conceptualizing of health behaviors. Broad, general conceptualizations do as much damage to health promotion research as simply looking at regions of the brain and not neurotransmitters would do for brain research. Specificity and sophistication must be the hallmarks of the future.
challenges ii
Challenges II
  • Basic research to understand, define and assess health behaviors must precede large-scale efforts to change these behaviors
  • New technology should be incorporated into the assessment of actual behavior change (pedometers, MEMS Caps, body fat composition, computerized assessments) but cannot supplant self-reported behavior.
challenges iii
Challenges III
  • We must continue to develop more sophisticated assessments of critical attitudes, intentions and plans related to the specific health behavior change
  • We must look for benchmarks or additional markers related to movement toward change
  • We must develop a better understanding of how cultural and ethnic influences impact our outcomes and our assessments
the promise of accurate assessment
The Promise of Accurate Assessment

More sophisticated understanding of health behaviors and health behavior change

More sensitive analyses of mechanisms, contextual influences, and change

Increased accuracy of goals and target behaviors

Better targeted interventions

Better evaluation of interventions