hxrefactored - pro change behavior systems inc - kerry evers

Behavior Change Tailoring: The Transtheoretical Model Kerry E. Evers, Ph.D. Pro-Change Behavior Systems, Inc.

Behavior  Change  

“Up to 40 percent of annual deaths from each of five leading US causes are preventable” CDC, Morbidity and Mortality Weekly Report, May 2014

•  Health behavior change is a science •  Health behavior change interventions should be grounded in a leading

theoretical model

Theore.cal  Base  

“Programs  to  influence  health  behavior,  including  health  promo8on  and  educa8on  programs  and  interven8ons,  are  most  likely  to  benefit  par8cipants  and  communi8es  when  the  program  or  interven8on  is  guided  by  a  theory  of  health  behavior.”                                                                                                                                                Glanz,  et  al.,  2008        -­‐  

There  is  nothing  as  prac8cal  as  a  good  theory.                                                                    Lewin,  1935    

Glanz,  K,    et    al  (Eds.)  (2008).  Health  Behavior  and  Health  Educa4on:  Theory,  Research,  and  Prac4ce,  4th  Edi4on.  San  Francisco,  CA:  Jossey-­‐Bass    

Lewin,  K.  (1935)  A  dynamic  theory  of  personality.  New  York:  McGraw-­‐Hill.  

“The  transtheore.cal  model  has  been  around  since  the  late  1970s  but  is  no  less  powerful  now  and  even  has  special  u.lity  when  two-­‐thirds  of  Americans  are  overweight  or  obese  and  600,000  of  us  are  killed  by  cardiovascular  disease  per  year."  

Dr.  Oz,  Time  Magazine,  October  2012  

Google  Search  conducted  3/17/2014

184,000  results  for  “Transtheore.cal  

Model”  

442,000  results  for  “Stages  of  Change”  

TTM  in  the  Public  Eye  

•  Search of PubMed Journal Articles •  Pubmed 1983-Present: 14,617 •  2013 Alone: 1,129

•  Search of Google Scholar •  Stage of Change Model: 1,270 •  Transtheoretical Model: 21,400

TTM  in  the  Academic  Literature  

History  of  the  TTM  

•  Smoking  cessa.on  •  Stress  management  •  Depression  preven.on  •  Weight  management  •  Exercise  acquisi.on  •  Healthy  diet  •  Responsible  drinking  •  Medica.on  adherence  •  Sun  exposure  •  Mammography  screening  •  Obesity  preven.on  •  Debt  Reduc.on  

Transtheore.cal  Model  Applica.ons  §  Collabora.on  in  health  care  §  Organ  dona.on  §  Returning  to  work  §  Bullying  preven.on  §  Juvenile  delinquency  §  Da.ng  violence    §  Domes.c  violence  §  Advancing  women  scien.sts  §  Adop.on  readiness  §  Professional  prac.ces  §  Mastering  change  in  the  workplace  §  Pain  Self  Management  §  Informed  decision  making  

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•  Integrates  ideas  from  several  different  theories  and  therapies  •  Involves  progression  through  five  stages  of  change:    

§ Precontempla.on  –  Not  yet  ready  § Contempla.on  –  Geing  ready  § Prepara.on  -­‐  Ready  § Ac.on  -­‐  Doing  the  healthy  behavior  § Maintenance  -­‐  Keeping  up  the  healthy  behavior    

•  Certain  principles  and  processes  of  change  work  best  at  each  stage  to  reduce  resistance  and  facilitate  progress  

Overview  of  the  TTM  

•  is based on principles developed from over 35 years of scientific research, intervention development, and scores of empirical studies;

•  applies the results of research funded by over $80 million worth of grants and conducted with over 150,000 research participants; and

•  is currently in use by professionals around the world.

Transtheore.cal  Model:    

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"Most  theories  are  about  behavior,    not  about  behavior  change."  –  James  O.  Prochaska  

•  Index of readiness •  Tells WHEN people change •  Predicts who will change successfully •  A dynamic, not static, client characteristic •  Inclusive, empathic, optimistic •  Guides member-treatment matching

Stage  of  Change  

Not    Ready    Have  no  inten4on  to  start  taking  ac4on  in  next  6  months  

Precontempla.on  

Geing  Ready    Intend  to  start  in  next  6  months  

Contempla.on  

Ready  

Prac4cing  the  behavior  Intend  to  start  in  next  30  days      

Prepara.on  

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

Ac.on  

Has  Overtly  Changed  Behavior    Consistently  for  6  months  or  more  

Maintenance  

Pros  =  Advantages  Of  Changing  

Cons  =  Disadvantages  Of  Changing  

Decisional  Balance:  

A  growing  awareness  that  the  advantages  (Pros)  of  changing  outweigh  the  disadvantages  (Cons)  

How  do  people  move  from  one  stage  to  another?

Confidence  

Degree  to  which  individuals  believe  they  can  achieve  a  healthy  goal  even  under  temp.ng  

situa.ons  

DiClemente  CC,  Prochaska  JO,  Fairhurst  SK,  Velicer  WF.  The  Process  of  Smoking  Cessa.on:  An  Analysis  of  Precontempla.on,  Contempla.on,  and  Prepara.on  Stages  of  Change.  J  Consult  Clin  Psychol.  1991;  59:295-­‐304.  

Self-­‐Efficacy  

•  HOW people change •  Experiential and behavioral strategies and techniques used to change

behavior •  Facilitate transitions between stages •  Used as basis of intervention design

Processes  of  Change  

Prochaska,  J.O.,  DiClemente,  C.C.,  &  Norcross,  J.C.  (1992).    In  search  of  how  people  change:  Applica.ons  to  addic.ve  behaviors.  American  Psychologist,  47(9),  1102-­‐1114.  

Precontempla?on   Contempla?on   Prepara?on   Ac?on   Maintenance  

Self-­‐Reevalua?on  

Self-­‐Libera?on  

Helping  Rela?onships  

Counter  Condi?oning  

Reinforcement  Management  

S?mulus  Control  

Social  Libera?on  

Drama?c  Relief  

Consciousness  Raising  

Environmental  Reevalua?on  

Processes  of  Change:  The  “How”  of  Change  

GeNng  the  Facts  

Use  Subs?tutes  

Make  a  Commitment  

Get  Support  

Use  Rewards  

Manage  your  Environment  

No?ce  your  Effects  on  Others  

Pay  AVen?on  to  Feelings  

Create  a  New  Self-­‐Image  

No?ce  Social  Trends  

Experiential

Behavioral

One  Size  Fits  All   Targeted  

Stage  Matched  Ac?on  Oriented  

Levels  of  Tailoring  

Precontempla?on   Contempla?on   Prepara?on   Ac?on   Maintenance  

Environmental  Reevalua?on   No?ce  your  Effects  on  Others  

Precontempla?on   Contempla?on   Prepara?on   Ac?on   Maintenance  

Drama?c  Relief   Pay  AVen?on  to  Feelings  

Precontempla?on   Contempla?on   Prepara?on   Ac?on   Maintenance  

Helping  Rela?onships  Get  Support  

Prepara?on   Ac?on   Maintenance  

Reinforcement  Management  Use  Rewards  

Contempla?on   Prepara?on   Ac?on   Maintenance  

S?mulus  Control  Manage  your  Environment  

A-CHESS (Addiction – Comprehensive Health Enhancement Support System)

Personal  Ac.vity  Center  (PAC)  

Stage  Matched  Feedback  

One  Size  Fits  All   Targeted   Tailored  

Stage  Matched   Stage  +  Pros  +  Cons  +    Self-­‐Efficacy  +  10  Processes  

Ac?on  Oriented  

Depth  of  Tailoring  

Hall,  K.  L.  &  Rossi,  J.  S.  (2008).  Meta-­‐analy.c  examina.on  of  the  strong  and  weak  principles  across  48  health  behaviors.  Preven4ve  Medicine,  46,  266-­‐274.  

The  Pros  &  Cons  of  Changing  Across  Stage  of  Change:  48  Behaviors  

Confidence  

Degree  to  which  individuals  believe  they  can  achieve  a  healthy  goal  even  under  temp.ng  

situa.ons  

DiClemente  CC,  Prochaska  JO,  Fairhurst  SK,  Velicer  WF.  The  Process  of  Smoking  Cessa.on:  An  Analysis  of  Precontempla.on,  Contempla.on,  and  Prepara.on  Stages  of  Change.  J  Consult  Clin  Psychol.  1991;  59:295-­‐304.  

Self-­‐Efficacy  

Computer-­‐Tailored  Interven.ons  (CTI)  

Reliable,  valid  assessments  of  most  important  behavior  change  constructs  

Evidence-­‐based,    sta.s.cally-­‐derived    decision-­‐making  rules  

Individualized,  tailored  behavior  change  guidance  

Feedback  dynamically  updated  based  on  new    

assessment  data    

Questions

Internet-based expert system Data collection/analysis/feedback/assessment

Responses

Tailored Feedback

Individuals

0

5

10

15

20

25

Precontemplation Contemplation

Norma.ve  Tailoring  

0

5

10

15

20

25

30

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Precontemplation Contemplation Preparation Action Maintenance

Rate  of  Change  

Rate  of  Change  

Rate  of  Change  

Norma.ve  &  Ipsa.ve  Clinical  Guidance  

Norma.ve  &  Ipsa.ve  Tailored  Feedback  

Processes  Feedback:  Sample  Screen  

•  Fred  Pennic  Outlined  findings  from  Mobiuity  Report    •  Create  an  individualized  solu.on  •  Analy.c  models  that  trigger  the  appropriate  interven.ons  and  outcomes  for  each  user    

•  Personalized  communica.ons  to  increase  engagement  •  Low-­‐effort  data  collec.on  

4  Best  Prac.ces  for  Crea.ng  Behavior  Changing  Mobile  Health  Apps    

hop://www.hitconsultant.net/2013/07/26/4-­‐best-­‐prac.ces-­‐for-­‐crea.ng-­‐behavior-­‐changing-­‐mobile-­‐health-­‐apps/  

•  Theore.cal  variables  that  produce  large  effect  sizes  when  included  in  tailored  communica.ons  compared  to  tailored  communica.ons  that  exclude  these  variables:  

§  Stages  of  Change  § Pros  and  Cons  of  Changing  §  Self-­‐Efficacy  § Processes  of  Change  § Aitudes  §  Social  Support  

Tailored  Communica.ons  that  Tailor  Each  of  the  Following  Variables  

Theore.cal  Variables  that  Produce  Smaller  Effect  Sizes  

Perceived  Suscep.bility    

Noar,  S.  M.,  Benac,  C.  N.,  &  Harris,  M.  S.  (2007).  Does  tailoring  maoer?  Meta-­‐analy.c  review  of  tailored  print  health  behavior  change  interven.ons.  Psychological  Bulle4n,  133,  673-­‐693.  

Theore.cal  Variables  that  DO  NOT    Make  a  Difference  

Behavior  Inten.ons  

Social  Norms    

Noar,  S.  M.,  Benac,  C.  N.,  &  Harris,  M.  S.  (2007).  Does  tailoring  maoer?  Meta-­‐analy.c  review  of  tailored  print  health  behavior  change  interven.ons.  Psychological  Bulle4n,  133,  673-­‐693.  

Number  of  Tailoring  Variables  that  make  a  difference  

0-­‐2     <   3-­‐5     >   6-­‐9  

Compara.ve  Outcomes  of  Interven.ons  

Johnson,  J.L.,  Prochaska,  J.O.,  Paiva,  A.L.,  Fernandez,  A.C.,  DeWees,  S.L.,  and  Prochaska,  J.M.  (2013)  Advancing  Bodies  of  Evidence  for  Popula.on-­‐based  Health  Promo.on  Programs:  Randomized  Controlled  Trials  and  Case  Studies.  Popula4on  Health  Management,  16(6),  373-­‐380.  

Well-­‐Being:  Change  Over  Time  

Prochaska,  J.O.,  Evers,  K.E.,  Castle,  P.H.,  Johnson,  J.L.,  Prochaska,  J.M.,  Rula,  E.Y.,  Coberley,  C.,  &  Pope,  J.E.  (2012).  Enhancing  Mul.ple  Domains    of  Well-­‐being  by  Decreasing  Mul.ple  Health  Risk  Behaviors:  A  Randomized  Clinical  Trial.  Popula4on  Health  Management,  15  (5),  276-­‐286.  

Improvements  in  Well-­‐Being  

Overall   Individual  Domains  

Prochaska,  J.O.,  Evers,  K.E.,  Castle,  P.H.,  Johnson,  J.L.,  Prochaska,  J.M.,  Rula,  E.Y.,  Coberley,  C.,  &  Pope,  J.E.  (2012).  Enhancing  Mul.ple  Domains    of  Well-­‐being  by  Decreasing  Mul.ple  Health  Risk  Behaviors:  A  Randomized  Clinical  Trial.  Popula4on  Health  Management,  15  (5),  276-­‐286.  

Contacts  

Pro-­‐Change  Behavior  Systems,  Inc.  • www.prochange.com

Online  Basic  Transtheore?cal  Model  Training    • www.prochange.com/e-learning

Demo  of  Domes?c  Violence  Program    • www.prochange.com/domesticviolencedemo

Demo  of  Healthy  Pregnancy  Program  • www.prochange.com/pregnancydemo

Coaches  Guide  for  Using  TTM  with  Clients  • www.prochange.com

Online  MyHealth  Behavior  Change  Programs  • www.prochange.com/myhealth

Mastering  Change  in  the  Workplace  • www.prochange.com/products

Janice  M.  Prochaska  •  jmprochaska@prochange.com