MEASURING HEALTH BEHAVIOR CHANGE: PROBLEMS AND PROMISE
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Transcript of MEASURING HEALTH BEHAVIOR CHANGE: PROBLEMS AND PROMISE
MEASURING HEALTH MEASURING HEALTH BEHAVIOR CHANGE: BEHAVIOR CHANGE:
PROBLEMS AND PROMISEPROBLEMS AND PROMISE
CARLO C. DICLEMENTE
PROFESSOR & CHAIR
UMBC PSYCHOLOGY
CANCER PREVENTION INITIATION
HEALTH PROMOTION
SAFETY & INJURY MODIFICATION
PREVENTION
HEALTH PROTECTION
SUBSTANCE ABUSE CESSATION
HEALTH PROMOTION & REQUIRE BEHAVIOR
DISEASE PREVENTION CHANGE
The Transtheoretical Model of Intentional Behavior Change
STAGES OF CHANGE
PRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE
PROCESSES OF CHANGECOGNITIVE/EXPERIENTIAL BEHAVIORAL Consciousness Raising Self-LiberationSelf-Revaluation Counter-conditioningEnvironmental Reevaluation Stimulus ControlEmotional Arousal/Dramatic Relief Reinforcement ManagementSocial Liberation Helping Relationships
CONTEXT OF CHANGE
1. Current Life Situation2. Beliefs and Attitudes3. Interpersonal Relationships4. Social Systems5. Enduring Personal Characteristics
MARKERS OF CHANGEDecisional Balance Self-Efficacy/Temptation
How Do People Change? How Do People Change?
People change voluntarily only when they– Become concerned about 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 Change2. Contemplation - Thinking About Change3. Preparation - Getting Ready to Make Change4. Action - Making the Change5. Maintenance - Sustaining Behavior Change Until
Integrated into Lifestyle Relapse and Recycling - Slipping Back to Previous
Behavior and Re-entering the Cycle of ChangeTermination - Leaving the cycle of change
Stage of Change TasksStage 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
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 BehaviorsPrescribed 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 BehaviorsPrescribed Health Behaviors
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 BehaviorsPrescribed 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 BEHAVIORSHEALTH 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 THE FIRST STEP TO MEASURING HEALTH MEASURING HEALTH
BEHAVIORSBEHAVIORSSpecify 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 StepDefining 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 ProjectFood 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 Dietary behaviors related to diet of < 30% calories from fatdiet of < 30% calories from fatDrinking 1% or skim milkAvoiding fried foodsChecking labels for fat contentBuying low fat or fat free productsAvoiding High fat snacks and sweetsAvoiding high fat meatsEating more fruits & vegetables
Precontemplation for All Low Fat Behaviors (Items 2-8)
No Yes
Eating a Low Fat Diet N % N % Chi-Square p-value
Reported Stage
Precontemplation 506 29.1% 292 91.8% 448.02 .000
Contemplation 515 29.6% 21 6.6%
Preparation 301 17.3% 3 0.9%
Action 252 14.5% 2 0.6%
Maintenance 165 9.5% 0 0.0%
Totals 1739 318
Maintenance for All Low Fat Behaviors (Items 2-8)
No Yes
Eating a Low Fat Diet N % N % Chi-Square p-value
Reported Stage
Precontemplation 798 39.8% 0 0.0% 321.32 .000
Contemplation 533 26.6% 3 5.9%
Preparation 302 15.1% 2 3.9%
Action 246 12.3% 8 15.7%
Maintenance 127 6.3% 38 74.5%
Totals 2006 51
Step 2: Defining MaintenanceStep 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 Proportion of MATCH Outpatients Avoiding a Heavy Drinking (5 Drinks) Avoiding a Heavy Drinking (5 Drinks)
Day as a Function of TimeDay as a Function of Time
0
0.2
0.4
0.6
0.8
1
1.2
0 100 200 300 400
DaysCBT MET TSF# OF DAYS
Drinking and Problem Status by Drinking and Problem Status by Treatment Condition (Outpatient)Treatment Condition (Outpatient)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
cbt met tsf cbt met tsf cbt met tsf cbt met tsf
Abstinent Light Drinking
Heavy Drinking w/minimum consequence Heavy Drinking w/severe consequence
The Well-Maintained AddictionThe 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 RelapseThe 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 & RecyclingRelapse & 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.
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
PrecontemplationIncrease awareness of need to change
ContemplationMotivate and increase confidence
in ability to change
ActionReaffirm commitment
and follow-up
Termination
Stages of Change Model
RelapseAssist in Coping
MaintenanceEncourage activeproblem-solving
PreparationNegotiate a plan
Measuring Change: Measuring Change: Behavioral OutcomesBehavioral 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 Examples of More Objective Action and Maintenance Action and Maintenance
Outcome MeasuresOutcome MeasuresSteps 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-actionStep 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 Distinguishing Pre-Action from ActionAction
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 ProjectFood 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-Reported Stage of Change for Eating a Low Fat Diet
PC C PA A M Ns for Rows
Restaged SOC based on FFQ
Precontemplation 85.5 -- -- -- -- 682
Contemplation -- 79.7 -- 33.1 21.8 547
Preparation -- 76.6 27.2 33.3 357
Action 14.5 20.3 23.4 39.8 -- 397
Maintenance -- -- -- -- 44.8 74
Ns for Columns 798 536 304 254 165 2057
Self-Report and RestagingSelf-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 The Importance of Measuring Pre-Action StatusPre-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
Smoking Cessation Stages of Change: Ever Smokers in the State of Maryland
1664
691 621
267
988
3767
0
500
1000
1500
2000
2500
3000
3500
4000
N
PrecontemplationContemplationPreparation ActionMaintenance (6 mos - 5 years)Long Term Maintenance (5+ years)
Numbers of Ever Smokers
Table 3. Stage of Change by County of Residence (Weighted)
% of Ever
County Smokers a Precontemplation Contemplation Preparation Action Maintenance
Allegany 44.1% 52.9% 10.9% 10.2% 8.6% 17.4%
Anne Arundel 49.1% 44.2% 17.2% 11.6% 8.5% 18.6%
Baltimore 49.1% 40.1% 17.1% 11.6% 9.8% 21.4%
Calvert 51.9% 42.9% 15.7% 16.2% 4.2% 21.0%
Caroline 51.9% 40.3% 18.5% 12.0% 5.4% 23.8%
Carroll 45.7% 48.1% 12.1% 15.3% 5.0% 19.5%
Cecil 50.5% 44.2% 22.4% 14.0% 4.5% 14.9%
Charles 45.4% 45.8% 11.4% 15.1% 3.6% 24.1%
Dorchester 54.9% 42.2% 23.3% 12.0% 2.7% 19.7%
Frederick 46.5% 43.3% 18.0% 17.2% 4.5% 17.0%
Garrett 48.1% 46.4% 12.0% 20.7% 2.9% 18.0%
Harford 49.0% 37.7% 15.3% 17.4% 8.3% 21.3%
Howard 39.3% 41.9% 12.2% 16.1% 4.6% 25.3%
Kent 53.5% 38.3% 11.3% 13.9% 5.3% 31.1%
Montgomery 38.9% 35.1% 8.3% 17.4% 5.9% 33.3%
Prince George's 39.6% 34.3% 12.5% 20.2% 8.3% 24.7%
Queen Anne's 50.9% 36.6% 21.1% 18.9% 2.2% 21.2%
St. Mary 49.9% 39.5% 17.4% 18.8% 7.9% 16.4%
Somerset 51.7% 32.5% 19.1% 16.2% 7.0% 25.1%
Talbot 43.5% 38.1% 18.6% 14.5% 5.1% 23.7%
Washington 49.6% 50.4% 22.4% 12.5% 1.4% 13.3%
Wicomico 50.5% 43.8% 16.9% 12.4% 4.1% 22.7%
Worcester 49.3% 49.6% 14.3% 16.3% 4.0% 15.8%
Baltimore City 53.6% 37.6% 25.9% 19.1% 2.8% 14.7%
Percentages bolded and italicized are the 2 lowest percentages for each columnPercentages bolded and underlined are the 2 highest percentages for each columna Ever Smokers are staged individuals who are either current smokers or those who have quit smoking 5 years ago or lessNote: Of the staged residents in Allegany County, 52.9% were in Precontemplation, 10.9% were in Contemplation, 10.2% were in Preparation, 8.6% were in Action & 17.4% were in Maintenance
Stage of Change
Table 4. Stage of Change (Current Smokers) by County of Residence (Weighted)
County % Current Smokers Precontemplation Contemplation Preparation
Allegany 18.9% 71.5% 14.7% 13.7%
Anne Arundel 19.2% 60.6% 23.6% 15.8%
Baltimore 16.8% 58.3% 24.9% 16.8%
Calvert 21.3% 57.3% 21.0% 21.7%
Caroline 23.1% 56.9% 26.2% 16.9%
Carroll 18.0% 63.7% 16.0% 20.2%
Cecil 23.3% 54.8% 27.8% 17.4%
Charles 18.7% 63.4% 15.8% 20.9%
Dorchester 25.8% 54.5% 30.0% 15.5%
Frederick 17.9% 55.2% 22.9% 21.9%
Garrett 21.1% 58.6% 15.2% 26.2%
Harford 17.8% 53.5% 21.7% 24.8%
Howard 11.8% 59.7% 17.3% 23.0%
Kent 18.9% 60.3% 17.8% 21.9%
Montgomery 9.2% 57.7% 13.6% 28.7%
Prince George's 14.1% 51.2% 18.7% 30.1%
Queen Anne's 23.8% 47.7% 27.6% 24.7%
St. Mary 20.8% 52.1% 23.1% 24.8%
Somerset 19.6% 47.9% 28.2% 23.9%
Talbot 14.2% 53.6% 26.1% 20.4%
Washington 22.0% 59.1% 26.2% 14.7%
Wicomico 22.0% 59.9% 23.1% 17.0%
Worcester 21.4% 61.9% 17.8% 20.3%
Baltimore City 29.9% 45.5% 31.4% 23.1%
Percentages bolded and italicized are the 2 lowest percentages for each column
Percentages bolded and underlined are the 2 highest percentages for each columna Current Smokers are staged individuals who are current smokers Note: Of the staged residents in Allegany County, 71.5% were in Precontemplation, 14.7% were in Contemplation, and 13.7% were in Preparation
Current Smokers
Measuring Pre-ActionMeasuring 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
Stage of Change by RUNG (Q56)
2.88
5.15
6.38
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
RUNG
Precontemplation Contemplation Preparation
Measuring Associated Measuring Associated Markers of ChangeMarkers 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
Stage of Change by Average Number of Cigarettes Smoked per Day in the Past 30 Days (Q10)
17.4
15.3
13.3
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
Past 30 days, avergage cigarettes smoked/day
Precontemplation Contemplation Preparation
Stage of Change by Number of Times Stopped Smoking Cigarettes 1+ Days because Trying to Quit (Q46A)
4.45
5.38
8.22
6.59
4.85
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
# of Times Stopped Smoking 1+ Days
Precontemplation Contemplation
Preparation Action
Maintenance
Stage of Change by Generally How Purchase Cigarettes (Q18)
45.7%
30.7%
19.8%
54.3%
69.3%
80.2%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
Precontemplation Contemplation Preparation
Carton Pack
Stage of Change by Percentage Self/Others who Smoked in Their Home (Q76)
70.3%66.0%
60.4%
29.3%
19.6%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Percentage of Self/Others who Smoked in Home During Past Week
Precontemplation Contemplation
Preparation Action
Maintenance
Stage of Change by Perceived Cost of Last Pack of Cigarettes (Q19)
$3.17
$3.24
$3.33
$3.05
$3.10
$3.15
$3.20
$3.25
$3.30
$3.35
Cost of Last Pack Purchased
Precontemplation Contemplation Preparation
Stage of Change by Number of 4 Closest Friends who Use Tobacco Products (Q88)
2.63
2.27 2.21
1.92
1.38
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
Number of 4 Closest Friends Who Use Tobacco Products
Precontemplation Contemplation
Preparation Action
Maintenance
Stage of Change by Percentage who Asked Someone Else around them Not to Smoke in the Past Year (Q72)
11.7%
20.0%
26.4% 26.2%
32.1%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
% Asked Someone Not to Smoke
Precontemplation Contemplation
Preparation Action
Maintenance
TTM Profile: Outpatient PDA Baseline
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
Pre Con Act Main Conf TempTTM Variables
Sta
nd
ard
Sco
res
Abstinent
Moderate
Heavier
TTM Profile: Outpatient PDA Post Treatment
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
Pre Con Act Main Conf Temp Exp BehTTM Variables
Sta
nd
ard
Sco
res
AbstinentModerateHeavier
Cautions in Assessing Pre-Cautions in Assessing Pre-ActionAction
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 continuedCautions 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 Pros and Cons of Various Types of MeasuresTypes of Measures
Simple Continuous Measures (rulers)Multi-component attitudinal measuresAlgorithms (a series of dichotomous
response questions)Related assessments (pros and cons; self-
efficacy; intention, beliefs)Self-reported stage status
Conclusions about measuring Conclusions about measuring Health Behavior ChangeHealth 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 IIConclusions 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 IChallenges 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 IIChallenges 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 IIIChallenges 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 The Promise of Accurate AssessmentAssessment
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 interventionsBetter evaluation of interventions