Measuring Health Behavior Change: Problems and Promise

Measuring Health Behavior Change: Problems and Promise

MEASURING HEALTH BEHAVIOR CHANGE: PROBLEMS AND PROMISE CARLO C. DICLEMENTE PROFESSOR & CHAIR UMBC PSYCHOLOGY HEALTH PROMOTION & DISEASE PREVENTION CANCER PREVENTION REQUIRE BEHAVIOR CHANGE INITIATION HEALTH PROMOTION SAFETY & INJURY PREVENTION MODIFICATION HEALTH PROTECTION SUBSTANCE ABUSE CESSATION The Transtheoretical Model of Intentional Behavior Change STAGES OF CHANGE

PRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE PROCESSES OF CHANGE COGNITIVE/EXPERIENTIAL BEHAVIORAL Consciousness Raising Self-Revaluation Environmental Reevaluation Emotional Arousal/Dramatic Relief Social Liberation Self-Liberation Counter-conditioning Stimulus Control Reinforcement Management Helping Relationships CONTEXT OF CHANGE 1. 2. 3. 4. 5. Current Life Situation Beliefs and Attitudes Interpersonal Relationships Social Systems Enduring Personal Characteristics MARKERS OF CHANGE

Decisional Balance Self-Efficacy/Temptation 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) 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 Theoretical and practical considerations related to movement through the Stages of Change Motivation Precontemplation Personal Environmental Concerns Pressure Decision-Making Self-efficacy Contemplation Preparation Action Maintenance Decisional Balance (Pros & Cons) Cognitive Experiential Processes

Behavioral Processes Recycling Relapse Prescribed Health Behaviors Pregnancy Prevention and HIV 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 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 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 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 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 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

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 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 Precontemplation for All Low Fat Behaviors (Items 2-8) No Eating a Low Fat Diet Yes N

% N % Chi-Square p-value 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 Reported Stage 318 Maintenance for All Low Fat Behaviors (Items 2-8) No Eating a Low Fat Diet Yes N % N % Chi-Square p-value 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 Reported Stage 51 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 1.2 Proportion of MATCH Outpatients Avoiding a Heavy Drinking (5 Drinks) Day as a Function of Time 1 0.8 0.6 0.4 0.2 0 0 100 # OF DAYS 200 CBT Days MET 300 TSF 400

Drinking and Problem Status by Treatment Condition (Outpatient) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% cbt met tsf cbt met tsf Abstinent Heavy Drinking w/minimum consequence cbt met

tsf cbt met tsf Light Drinking Heavy Drinking w/severe consequence 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 selfregulatory control, continues despite negative feedback, and becomes an integral part of the individuals life and coping 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 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 Precontemplation Personal Environmental Concerns Pressure Decision-Making Self-efficacy Contemplation Preparation Action Maintenance

Decisional Balance (Pros & Cons) Cognitive Experiential Processes Behavioral Processes Recycling Relapse Stages of Change Model Precontemplation Increase awareness of need to change Contemplation Motivate and increase confidence in ability to change Relapse Assist in Coping Maintenance Encourage active problem-solving Termination Preparation

Negotiate a plan Action Reaffirm commitment and follow-up 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 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 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 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 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 85.5 -- -- -- -- 682 Contemplation --

79.7 -- 33.1 21.8 547 Preparation -- 76.6 27.2 33.3 357 Restaged SOC based on FFQ Precontemplation 14.5 20.3 23.4 39.8

-- 397 Maintenance -- -- -- -- 44.8 74 Ns for Columns 798 536 304 254 165 2057

Action 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 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

Stage Based Epidemiology PC C PC M PA A M C A PA Smoking Cessation Stages of Change: Ever Smokers in the State of Maryland 4000 3767 3500 Numbers of Ever Smokers 3000 2500 2000 1664 1500 1000 988

691 621 500 267 0 N Precontemplation Contemplation Preparation Action Maintenance (6 mos - 5 years) Long Term Maintenance (5+ years) Table 3. Stage of Change by County of Residence (Weighted) Stage of Change % 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% Table 4. Stage of Change (Current Smokers) by County of Residence (Weighted) Current Smokers 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% 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 Stage of Change by RUNG (Q56) 10.00 9.00 8.00 7.00 6.38 6.00 5.15 5.00 4.00 3.00 2.88 2.00 1.00 0.00

RUNG Precontemplation Contemplation Preparation 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 Stage of Change by Average Number of Cigarettes Smoked per Day in the Past 30 Days (Q10) 20.0 18.0 17.4 15.3 16.0 13.3

14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 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) 9.00 8.22 8.00 6.59 7.00 6.00 5.00 5.38 4.85

4.45 4.00 3.00 2.00 1.00 0.00 # of Times Stopped Smoking 1+ Days Precontemplation Contemplation Preparation Action Maintenance Stage of Change by Generally How Purchase Cigarettes (Q18) 90.0% 80.2% 80.0% 69.3% 70.0% 60.0% 50.0% 54.3% 45.7% 40.0% 30.7%

30.0% 19.8% 20.0% 10.0% 0.0% Precontemplation Contemplation Carton Preparation Pack Stage of Change by Percentage Self/Others who Smoked in Their Home (Q76) 80.0% 70.3% 70.0% 66.0% 60.4% 60.0% 50.0% 40.0% 29.3% 30.0% 19.6%

20.0% 10.0% 0.0% 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) $3.35 $3.33 $3.30 $3.24 $3.25 $3.20 $3.17 $3.15 $3.10

$3.05 Cost of Last Pack Purchased Precontemplation Contemplation Preparation Stage of Change by Number of 4 Closest Friends who Use Tobacco Products (Q88) 4.00 3.50 3.00 2.50 2.63 2.27 2.21 1.92 2.00 1.38 1.50 1.00 0.50 0.00 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) 35.0% 32.1% 30.0% 26.4% 26.2% 25.0% 20.0% 20.0% 15.0% 11.7% 10.0% 5.0% 0.0% % Asked Someone Not to Smoke Precontemplation

Contemplation Preparation Action Maintenance TTM Profile: Outpatient PDA Baseline 0.8 Standard Scores 0.6 0.4 Abstinent Moderate Heavier 0.2 0 -0.2 -0.4 -0.6 -0.8 Pre Con Act Main

TTM Variables Conf Temp TTM Profile: Outpatient PDA Post Treatment 0.8 Standard Scores 0.6 0.4 Abstinent Moderate Heavier 0.2 0 -0.2 -0.4 -0.6 -0.8 Pre Con Act Main Conf Temp Exp TTM Variables

Beh Cautions in Assessing PreAction 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 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 Simple Continuous Measures (rulers) Multi-component attitudinal measures

Algorithms (a series of dichotomous response questions) Related assessments (pros and cons; selfefficacy; intention, beliefs) Self-reported stage status 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 What is needed are multiple assessment over short and long periods of time. Longterm follow-ups will not help us understand the process of change. Short-term followups emphasize momentary changes and action but underestimate the long haul. Successful health behavior changes must be viewed incrementally not dichotomously 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 Basic research to understand, define and assess health behaviors must precede largescale 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 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 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

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