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

Stage Based EpidemiologyStage Based Epidemiology

PC

CPA A

M

MPC

CPA

A

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