Behavior Change Health Promotion Programs January 31, 2008

In an effort to prevent disease and improve peoples’ health and well being, we continually ask them to… do things they have not done before stop doing things they have done for years, and do more of some things and less of other things.

“In order to change behavior…it is first necessary to understand why people behave as they do. The more one knows about the variables underlying a person’s decision to perform or not to perform a given behavior, the more likely it is that one can develop successful behavioral intervention programs.” M. Fishbein et al., 1992

Health Behavior Principles Determinants may vary by  Type of behavior  Life course stage  Whether intent is to initiate versus maintain behaviors  Whether goal is to eliminate versus encourage behaviors

Principles of Behavioral Change*  Behavioral change is best accomplished by taking advantage of the multiple opportunities for change in the environ- ment.  Interventionists should consider why people change (mediators) and evaluate the ability of their intervention (interven- tion quality) to effect change in the mediators of interest *from Maintaining Healthy Lifestyles: A Lifetime of Choices, The International Longevity Center, USA, Ltd.

Principles of Behavioral Change (cont.)  The goals of healthy behavior change should reflect a partnership between the participant and the provider and be stated in concrete terms.  The goals of behavior change should be conceptualized as moving targets that are influenced by personal/ interpersonal, life situations, the environment, & policy.

The “dynamic” relationship between the individual and his environment…  Can introduce barriers to healthy lifestyle choices and making changes in behaviors or  Can play a significant role in fostering individual behavior change by making active/ healthy lifestyle choices more available.

Determinants of Individual Dietary Behavior Elsevier Limited © 2005

Principles of Behavior Change (cont.)  The adoption and maintenance of healthy behavior requires basic skills that can be taught.  The maintenance of healthy behaviors requires planned follow-up.  A cost-benefit ratio is important to behavior change (and not always $$). Consider other potentials.

Levels of Behavioral Change Interventions Interventions can be aimed at multiple levels: personal or interpersonal level the organizational or institutional level the health care level the environmental level the policy or legislative level

Designing and Evaluating Social and Behavioral Interventions Intervention Intensity, Effects, and Reach Individually based interventions are more intensive, have stronger effects, but have less coverage. Population-based interventions are less intensive per person, may have weaker individual effects, but reach more people.

Designing and Evaluating Social and Behavioral Interventions Time frame for expected effects  Most interventions are based on acute model but conditions are typically more chronic  Short term effects typically stronger than long- term effects  Lagged effects may occur where psychosocial interventions teach skills or provide services that can be used at critical times

Designing and Evaluating Social and Behavioral Interventions Identifying optimal intervention in terms of type, dosage and frequency  Different intervention approaches target specific mediators and outcomes--menu  Some intervention efforts are too weak to initiate and sustain desired changes  What is the threshold point after which there is diminishing returns

Personal or Interpersonal Level Successful interventions include use of self-regulatory skill training  Realistic goal setting  Identification of barriers and activation of problem solving skills  Self monitoring of target health behavior  Relapse prevention

Recipe for an Effective, Tailored Intervention Ingredients – Awareness – Knowledge – Motivation – Readiness to change – A strong personal commitment or intention to perform the desired behavior* – The skills needed to establish and maintain the desired change* – Strong self-efficacy specific to the desired behavior – Opportunities to practice skills and new behaviors in a safe environment – Strong social support – A supportive environment free of any constraints to change* *According to a consensus report by the National Institute of Mental Health (Fishbein et al. 1992), these three factors are viewed as necessary and sufficient for producing behavior change. Human Kinetics ©1999

Personal or Interpersonal Level  Skill training accompanied by support and guidance from trained staff member.  Staff training and support delivered effectively through either face to face or mediated (e.g., telephone, mail, internet) communication channels.  Lay-led group support programs for coping with chronic illness also having success

Piecing Together an Intervention Puzzle Promote increased awareness and knowledge Foster supportive social networks Enhance motivation Establish and maintain a supportive physical environment Enhance readiness to change Teach or enhance the skills needed to establish and maintain the desired behavior Establish and enforce supportive policies

Intervention puzzle:  Four pieces to this puzzle are related to enhancing individual self-efficacy and strengthening one’s intention to change.  Remaining three puzzle pieces represent the environmental side of the equation.  Imagine there are many ways to arrange the interchangeable pieces to this puzzle.  Tailoring an intervention=customizing the plan of action to meet the target population and needs.

A Framework for Achieving Health Promotion Program Effectiveness Effectiveness = Efficacy +Planning + Implementation Theory Policy planning Appropriate targeting (‘evidence’)and financing framework Organizational Sufficient coverage structures and Skilled actions resources Workforce and Community community ownership capacity Monitoring and evaluation *Adapted from Lin V and Fawkes S. ‘Effectiveness of health promotion in changing environment and lifestyles in developing countries of the Western Pacific Region: A review and a proposed framework: Technical paper prepared for WHO Workshop on Capacity Building for Health Promotion. Manila, Philippines, 5-8 November Elsevier Limited © 2005

Components of the Stages of Change Model as Applied to Increasing Physical Activity Stage of Change Pre-Contemplation Not considering increasing physical activity levels Contemplation Thinks about increasing physical activity levels Preparation Consults doctor and visits local gymnasium Action Joins local gym Maintenance Has visited gym three times a week for 6 months Processes of Change Elicit positive and negative aspects of target behavior(s) and provide simple information (consciousness-raising, dramatic relief) Motivate and elicit commitment; Enhance self- efficacy; Identify physical activity classes (social liberation) Identify goals and plan start date and type of physical activity; Use social support (helping relationships); Use stimulus control Review goals and suggest coping strategies for fatigue, discomfort, lack of motivation etc.; Praise high self-efficacy; Use reinforcement management, counter-conditioning, and stimulus control Review coping strategies and reassess goals and physical activity type Elsevier Limited ©2005