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

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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
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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

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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

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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

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IxAction Alliance Insight Webinars

• October 17, 3 pm ET Ix Insights
• Hows Your Health
• John Wasson, MD
• Dartmouth Medical School

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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

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Goals of Presentation

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

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• Solutions for Individuals and Organizations from
  the Science of Change

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• 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.

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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.

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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.

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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.

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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

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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.

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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)

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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

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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

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The Transtheoretical Model
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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

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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.

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The Stages of Change
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Precontemplation

• Not Ready To Act
• Have no intention to start taking action in next
  6 months

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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.

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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.

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Contemplation

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

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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

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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

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Preparation

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

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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

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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

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Action

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

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Characteristics of Action

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

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Maintenance

• Has Changed Behavior
• Consistently for 6 months or more

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Characteristics of Maintenance

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

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Decisional Balance

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

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Pros and Cons of Smoking
T Scores
Stage
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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

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Processes of Change
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Experiential Processes

• Consciousness Raising - increasing awareness
• Dramatic Relief - emotional arousal (fear)
• Self Reevaluation - self reappraisal
• Environmental Reevaluation - social reappraisal
• Social Liberation - environmental opportunities

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Behavioral Processes

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

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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

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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

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Intervention Issues
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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

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Action-oriented examples

• Individual / Clinic
• reactive recruitment 5 participation
• high efficacy 30 success
• Public Health / Community
• proactive recruitment 75 participation
• low efficacy 6 success

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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.

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Impact Equation

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

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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

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Intervention Issues

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

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Intervention Issues

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

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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
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Intervention Issues

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

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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

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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

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Intervention Issues

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

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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

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Intervention Issues

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

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Treatment Groups

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

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Percentage
Assessment Periods
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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.
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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.
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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.
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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.
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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

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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

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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)

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How to Incorporate TTM into Interventions
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Personal Interactions

• Quick Assessment of Stage
• Incorporate Stage appropriate strategies into
  counseling

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Current Interventions

• Assess current interventions
• Addressing all 5 Stages?
• CA example

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Population Assessment

• Are current interventions appropriate for your
  population?

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Measures of Success

• Stage movement, not just Action
• Benefits for morale

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Stage Based Interventions

• Manuals example

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Individualized Interventions

• Expert Systems

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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