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Ix Insights: The Transtheoretical Model of Health Behavior Change and Implications for Intervention

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Title: Ix Insights: The Transtheoretical Model of Health Behavior Change and Implications for Intervention


1
Ix Insights The Transtheoretical Model of
Health Behavior Change and Implications for
Intervention Development
Center for Information Therapy Ix Insights August
15, 2006 3-4 pm ET
2
Todays Agenda
  • Introductions
  • IxCenter and IxAction Alliance highlights
  • We moved to Bethesda…..new address and s on
    www.ixcenter.org
  • Two new members
  • Eliza Corporation Ix Solutions Partner
  • Patient Education Institute Ix Supporter
  • Q A
  • Closing

3
IxCenter Updates
  • Ix Conference Sept 25-27
  • Ix Implementers Presentation application
  • Aetna, Foundation for Informed Medical Decision
    Making, Cheshire Medical, Cleveland Clinic,
    MedEncentive, Health Partners, HPN Worldwide
  • Ix Solutions Partners Demo Sessions
  • Eliza Corporation, Emmi Solutions, Enhanced
    Medical Decisions, Health Dialog, Health Outcome
    Sciences, Healthways, Healthwise, MedSeek,
    NorthPoint Domain, Resolution Health, Silverlink
  • Sponsors Group Health Cooperative-Seattle,
    Healthation, Healthways, Healthwise, Health
    Dialog, FIMDM, Kaiser Permanente, RWJ Foundation

4
Catalysts for Innovation
  • Ix Conference Sept 25-27
  • Exhibit Hall for Sponsors Monday Sept 25th
  • Member Meeting and Lunch Monday Sept 25th
  • Opening Night Reception-Gondola Ride
  • Innovation Awards Luncheon Tuesday Sept 26th
  • Two Demo Sessions Scheduled Monday or Wednesday
  • www.ixcenter.org for more details and
    registration

5
IxAction Alliance Insight Webinars
  • October 17, 3 pm ET Ix Insights
  • Hows Your Health
  • John Wasson, MD
  • Dartmouth Medical School

6
The Transtheoretical Model of Health Behavior
Change and Implications for Intervention
Development
  • Kerry E. Evers, Ph.D.
  • Director of Health Behavior Change Programs
  • Pro-Change Behavior Systems
  • Rhode Island, USA

7
Goals of Presentation
  • Pro-Change Behavior Systems, Inc.
  • Overview of the Transtheoretical Model
  • Description of Interventions
  • Demonstration (if time)

8
  • Solutions for Individuals and Organizations from
    the Science of Change

9
  • Pro-Change Behavior Systems is a research and
    development company that advances and applies the
    Transtheoretical Model of behavior change
    developed by Dr. Prochaska, one of the companys
    founders. After extensive clinical trials,
    Pro-Change applies proven results to the
    development of versatile products that enhance
    individual wellness. The resulting proprietary
    products may be customized to meet client needs
    and are delivered as print-based media and/or
    web-based services as well as protocols for
    training and coaching. Pro-Change Behavior
    Systems serves the needs of HMOs, pharmaceutical
    companies, as well as state and federal agencies.
    The firm actively teams with international and
    domestic distributors for marketing, sales, and
    customer support.

10
Why Pro-Change?
  • Programs are based on
  • 25 years of clinical and community research and
    experience.
  • 60 million worth of funded grants.
  • Insight from over 100,000 participants
  • Interactive technologies offer the most
    cost-effective modalities for bringing the
    maximum amount of science to bear on major
    behavior problems in entire populations.

11
Health Behavior Change
  • Pro-Change health programs emphasize proactive
    and interactive interventions for populations at
    all stages of change. Using this approach, we
    have developed a variety of behavior change
    solutions to the most common killers and disables
    of our time.

12
Pro-Change Process
  • Based on Transtheoretical Model of Change
  • Tailored communications that begins with
    assessments
  • Uses expert guides tailored to each individuals
    needs
  • Over 200,000 tailored messages can be generated
  • Variety of formats manuals, handbooks,
    interactive media systems, individualized
    progress reports
  • Progress is constantly assessed and interventions
    delivered.

13
The Transtheoretical Model
  • Common principles of behavior change
  • Integrates variables from other health behavior
    theories
  • INTENTIONAL Behavior Change
  • Stages of Change
  • Processes of Change
  • Decisional Balance (Pros/Cons)
  • Situational Self Efficacy
  • Different variables predict stage movement for
    each stage

14
TTM Information Therapy
  • The right information
  • The TTM provides a theoretical framework and
    evidence for what processes and intervention
    strategies are appropriate for each individual.
  • The right person
  • The Pro-Change process uses the TTM in a variety
    of different communication channels and can be
    prescribed.
  • The right time
  • Evidence and statistical decision making is used
    to tailor the appropriate intervention materials
    for each individual at every timepoint.

15
Pro-Change Prescription
  • Pro-Change programs can be prescribed by
  • Health plans (i.e. Blue Cross Blue Shield)
  • Employer  
  • Doctor or health care provider
  • Social worker (i.e. adoption program)
  • Court (domestic violence program)
  • Information counselor or human resource manager
    (i.e. CMS)
  • Self-referral (i.e. ACS)

16
Opportunities for Information Therapy
  • Examples of Behavioral Areas Pro-Change works
    with
  • Prevention depression, healthy eating, exercise,
    stress, adolescent programs, obesity prevention
  • Self-care healthy eating, exercise, stress,
    smoking, weight management
  • Self-triage depression, stress
  • Visit preparation medication adherence
  • Self-management of chronic illnesses medication
    adherence, diabetes weight management
  • Decision support CMS, depression, medication
    adherence

17
7 Prescription Strength Criteria
  • Decision-focused guiding people to make healthy
    choices and changes
  • Evidence-based statistical decision making,
    outcomes analysis, peer review
  • Reviewed by experts consultant review, internal
    clinical review
  • Referenced
  • Up to date QI process
  • Free from commercial bias programs developed
    with NIH, CDC CMS funding
  • User friendly focus groups, cognitive
    interviews, usability testing

18
The Transtheoretical Model
19
The Challenge
  • Traditional health promotion programs have been
    producing minor impacts on major health issues
  • There is a need to design cost effective,
    successful interventions that impact entire
    populations at risk

20
Historical Perspective
  • Getting a substance user to stop using is
    equivalent to taking action
  • State-of the-art action oriented programs
    available
  • Only small percentage of individuals are involved
    in programs.

21
The Stages of Change
22
Precontemplation
  • Not Ready To Act
  • Have no intention to start taking action in next
    6 months

23
Characteristics of a Precontemplator
  • Avoid reading, talking, and thinking about the
    risk or the behavior.
  • Feel pressured by others to take action, but have
    developed defenses to cope with such pressures.
  • Unaware or under-aware of their problems despite
    others awareness of problems with addictions.
  • Denial or minimization of problem.
  • Most resistant to public policy changes.

24
Characteristics of a Precontemplator
  • The least confident about ability to take action.
  • Typically seek help because of pressure from
    others.
  • Typically less than 1 of those at risk
    participate in traditional programs.
  • About 40 of people at risk are in
    Precontemplation.

25
Contemplation
  • Thinking About Taking Action
  • Intend to start in next 6 months

26
Characteristics of Contemplators
  • Substitute thinking for acting
  • Increasing awareness of benefits of staying drug
    free and the risks of using
  • Costs of quitting are very clear
  • Ambivalent about changing
  • Often waiting for the magic moment

27
Characteristics of Contemplators
  • When in doubt, dont act
  • Not confident enough about their abilities to
    quit, feel unprepared
  • Typically less than 1 of those at risk
    participate in traditional programs
  • About 40 of people at risk are Contemplators

28
Preparation
  • Getting Ready to Take Action
  • Practicing the behavior
  • Intend to start in next 30 days

29
Characteristics of Preparation
  • More confident less tempted than those in
    earlier stages
  • Assess the Benefits (Pros) as higher than the
    Costs (Cons)
  • Most likely to participate in programs and most
    likely to benefit from those programs
  • Participants that health promotion programs love

30
Characteristics of Preparation
  • Less than 20 of people at risk are in
    Preparation
  • May begin taking small steps towards action (24
    hour quit attempt)
  • May leap into action prematurely

31
Action
  • Recently Started to Change Behavior
  • Consistently for less than 6 months

32
Characteristics of Action
  • Behavior change is recent
  • Temptation and recycling a concern
  • Need to use specific processes to deal with
    temptations

33
Maintenance
  • Has Changed Behavior
  • Consistently for 6 months or more

34
Characteristics of Maintenance
  • Problems with atypical temptations that have not
    occurred before
  • May be overconfident and court relapse
  • Not static stage - Still using processes

35
Decisional Balance
  • Pros of Change
  • perceived positive consequences
  • the benefits of changing
  • Cons of Change
  • perceived negative consequences
  • costs of changing

36
Pros and Cons of Smoking
T Scores
Stage
37
Processes of Change
  • HOW people change
  • Cognitive, affective, evaluative, interpersonal,
    and behavioral strategies and techniques used to
    change behavior
  • Mediate transitions between stages
  • Foundation of intervention design

38
Processes of Change
39
Experiential Processes
  • Consciousness Raising - increasing awareness
  • Dramatic Relief - emotional arousal (fear)
  • Self Reevaluation - self reappraisal
  • Environmental Reevaluation - social reappraisal
  • Social Liberation - environmental opportunities

40
Behavioral Processes
  • Helping Relationships - supporting
  • Reinforcement Management - rewarding
  • Counterconditioning - substituting
  • Self Liberation - committing
  • Stimulus Control - re-engineering

41
Stages by Processes
Precontemplation Contemplation
Preparation Action Maintenance
Consciousness Raising
Dramatic Relief Environmental
Reevaluation Social Liberation
Self-reevaluation Self
Liberation Helping Relationships
Stimulus Control Reinforcement
Management Counterconditioning

42
Self-Efficacy
  • Degree of confidence that one can engage in a
    health behavior or level of temptation to engage
    in an unhealthy behavior in a variety of
    difficult situations
  • Confidence and temptation are inversely
    negatively correlated
  • Individuals in PC have lowest confidence and
    highest degree of temptation

43
Intervention Issues
44
Action-oriented interventions
  • 1 - 5 participation rates
  • Less than 20 of people are ready to participate
  • High drop-out rates
  • Small impacts on populations with risky health
    behaviors
  • Demoralized researchers and health care providers

45
Action-oriented examples
  • Individual / Clinic
  • reactive recruitment 5 participation
  • high efficacy 30 success
  • Public Health / Community
  • proactive recruitment 75 participation
  • low efficacy 6 success

46
Stage-Matched Interventions
  • Recognize - behavior change happens in stages of
    change.
  • Are tailored to the needs of all participants,
    not just those ready for action
  • Set goal - one stage movement.
  • Target different variables-each stage.
  • Appropriate for all stages of change.
  • Can show 75-80 participation rates.
  • Can produce 2-3 times more impact than
    action-oriented programs.

47
Impact Equation
  • Impact
  • Participation X
  • Efficacy X
  • Number of Risk Behaviors

48
Impact of Stage-Matched Programs
  • Efficacy X Participation Impact
  • Individual/Clinic
  • 30 X 5 1.5
  • Public Health/Community
  • 6 X 75 4.5
  • Stage-Matched Proactive
  • 20 X 75 15

49
Intervention Issues
  • 1. Recruitment
  • 2. Retention
  • 3. Progress
  • 4. Process
  • 5. Outcomes

50
Intervention Issues
  • 1. Recruitment
  • 2. Retention
  • 3. Progress
  • 4. Process
  • 5. Outcomes

51
Prediction of Drop-Out
  • 385 clients voluntarily admitted to residential
    treatment and randomly assigned to 3 or 6 month
    treatment
  • Logistic regression used to identify best
    predictors of drop-out within 60 days
  • Stage of change was among the strongest
    predictors
  • PC 2 -3 X more likely to drop out as compared to
    C or PR

Tsoh, 1995
52
Intervention Issues
  • 1. Recruitment
  • 2. Retention
  • 3. Progress
  • 4. Process
  • 5. Outcomes

53
Reconceptualizing Progress
  • Within stage paradigm, any forward stage movement
    is conceptualized as progress
  • Stage-matching begins with setting realistic
    goals
  • Realistic goal Progress one stage
  • Progressing from PC to C doubles chances that an
    individual will take action in the next six
    months

54
Progressing One Stage at a Time
  • Allowing individuals to make stage progression
    is not enabling them to continue engaging in high
    risk behavior, but rather enabling them to begin
    making positives changes

55
Intervention Issues
  • 1. Recruitment
  • 2. Retention
  • 3. Progress
  • 4. Process
  • 5. Outcomes

56
Stage-Matching Interventions Precontemplation
to Contemplation
  • Utilize stage appropriate process Consciousness
    Raising
  • How do you react when you hear the effects of
    smoking?
  • As PCs start to become more aware of Pros of
    quitting and the Cons of using drugs, they begin
    moving more towards the Contemplation Stage

57
Intervention Issues
  • 1. Recruitment
  • 2. Retention
  • 3. Progress
  • 4. Process
  • 5. Outcomes

58
Treatment Groups
  • 1. Action-oriented Manuals
  • 2. Stage-Matched Manuals
  • 3. Stage-Matched Computers Manuals
  • 4. Counselors Stage-Matched
  • Computers

59
Percentage
Assessment Periods
60
Percentage in Action/Maintenance at each
Assessment for Completers in the Treatment and
Control Groups
Percentage
Assessment Periods
Evers, KE, Prochaska, JO, Johnson, JL, Mauriello,
LM, Padula, JA., Prochaska, JM. (in press). A
Randomized Clinical Trial of a Population and
Transtheoretical-Based Stress Management
Intervention. Health Psychology, 00, 00-00.
61
Adherence Treatment Success Pre-Action
Sample
6 mo z2.11, p lt .05, h.31 18 mo z2.38, p lt
.01, h.36
Johnson, S.S., Driskell, MM., Johnson, J.L,
Dyment, S., Prochaska, J.O., Prochaska, J.M.,
Bourne, l. (2006). Transtheoretical model
intervention for adherence to lipid-lowering
drugs. Disease Management, 9(2), 102-114.
62
Proportion of Pre-Action Participants Reaching
Action/Maintenance for Exercise
6 mo z2.51, plt.05, h.39 12 mo z1.70, plt.05,
h.28 18 mo z2.37, plt.05, h.40
Johnson, S.S., Driskell, MM., Johnson, J.L,
Dyment, S., Prochaska, J.O., Prochaska, J.M.,
Bourne, l. (2006). Transtheoretical model
intervention for adherence to lipid-lowering
drugs. Disease Management, 9(2), 102-114.
63
Proportion of Pre-Action Participants Reaching
Action/Maintenance for Dietary Fat Reduction
18 mo z2.06, plt.05, h.32
Johnson, S.S., Driskell, MM., Johnson, J.L,
Dyment, S., Prochaska, J.O., Prochaska, J.M.,
Bourne, l. (2006). Transtheoretical model
intervention for adherence to lipid-lowering
drugs. Disease Management, 9(2), 102-114.
64
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65
Expert System
What is an Expert System?
  • A software system that mimics the reasoning of a
    human expert
  • Provides computer generated progress reports
    based on periodic assessment

66
Benefits of Stage-matched Expert Systems
  • Provides individualized feedback
  • Appropriate for participants at all stages of
    readiness to change, not only those ready to take
    action
  • Potentially cost-effective
  • Integrates multiple risk behaviors
  • Integrates multimedia components
  • Can be used confidentially

67
Benefits of E.S.s continued
  • Can be updated to add new content, new response
    modalities, and/or new health promotion topics
  • Potential for wide dissemination to additional
    settings
  • schools, other health clinics, worksites,
    prisons, community centers, etc.
  • Has potential to increase public health impact
  • Contextual issues (normative databases)

68
(No Transcript)
69
How to Incorporate TTM into Interventions
70
Personal Interactions
  • Quick Assessment of Stage
  • Incorporate Stage appropriate strategies into
    counseling

71
Current Interventions
  • Assess current interventions
  • Addressing all 5 Stages?
  • CA example

72
Population Assessment
  • Are current interventions appropriate for your
    population?

73
Measures of Success
  • Stage movement, not just Action
  • Benefits for morale

74
Stage Based Interventions
  • Manuals example

75
Individualized Interventions
  • Expert Systems

76
Discussion and Contact Information
  • Center Staff
  • Josh Seidman jseidman_at_IxCenter.org
  • Dorothy Jeffress djeffress_at_IxCenter.org
  • Kyle Silk-Eglit ksilk-eglit_at_IxCenter.org
  • Alana Hill ahill_at_IxCenter.org
  • Presenters
  • Kerry Evers, PhD kevers_at_prochange.com
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