Changing Behavior
|
|
|
|
|
|
|
Jill Gallin BSN, MS, CPNP |
|
Health Promotion Disease Prevention |
|
N4225 |
The Extended Parallel
Process Model
|
|
|
|
Two appraisal processes |
|
Threat Appraisal |
|
Efficacy Appraisal |
|
|
|
Three Outcomes |
|
No response with low perceived threat |
|
Acceptance when perceived threat and
efficacy are high |
|
Rejection when perceived threat is
high, but efficacy is low |
|
|
|
Example (seat belts) |
|
|
Persuasive Message Theories
|
|
|
Health Belief Model |
|
Theory of Reasoned Action |
|
Social Cognitive Theory |
|
Elaboration Likelihood Model |
|
|
|
|
Health Belief Model
|
|
|
|
Very popular! |
|
|
|
Example (immunization campaigns) |
|
|
|
Five Factors |
|
Perceived barriers to performing the
recommended response |
|
Perceived benefits of performing the
recommended response |
|
Perceived susceptibility to a health
threat |
|
Cues to action (media, family, etc.) |
Theory of Reasoned Action
|
|
|
|
One’s own beliefs about performing a
behavior (attitude) |
|
|
|
Subjective norm |
|
Beliefs about what other people think
about the behavior and the motivation to comply with those other people
(referents). |
Social-Cognitive Theory
|
|
|
|
Self Efficacy |
|
Peoples beliefs that they can exert
control over their motivation and behavior and over their social environment
(people doubt this) |
|
|
|
Outcome Expectation |
|
What you think will happen if you take
a certain action |
Elaboration Likelihood
Model
|
|
|
Promote central processing |
|
(not peripheral processing). |
|
This takes work. Results in long
lasting behavior change. |
Theories
|
|
|
Explain how variables work together to
influence health behaviors |
|
|
|
Variables are threat, efficacy and
barriers |
|
|
|
|
|
(Detail is beyond the scope of this
class) |
Slide 9
Approaches
|
|
|
Describe different steps to increase
the persuasiveness of a health risk message |
|
|
|
Stages of Change Model & Social
Marketing are approaches |
Stages of Change Model
|
|
|
Prochaska & DiClemente 1992 |
|
|
|
Characterized by incremental steps,
relapse, and sustainability |
|
|
|
Not a linear progression, rather a
spiral with relapses |
Slide 12
The Stages
|
|
|
Pre-contemplation |
|
Contemplation |
|
Preparation |
|
Action |
|
Maintenance |
Precontemplation
|
|
|
|
|
Denial |
|
|
|
No perceived problem |
|
|
|
No association of problem with behavior |
Contemplation
|
|
|
|
|
Realistic assessment of one self |
|
|
|
Unable to confront problem or behavior |
Preparation
|
|
|
|
|
|
|
Actively gathering information in
preparation for behavior change |
Action
Maintenance
|
|
|
|
|
Constant vigilance to avoid relapse |
|
|
|
Remember behavior related illness are
always potentially “chronic!” |
Levels of Prevention (3)
|
|
|
|
Primary |
|
Aimed at those who have not started a
risk behavior |
|
|
|
Secondary |
|
Aimed at those who do not exhibit
chronic behavior |
|
|
|
Tertiary |
|
Aimed at Treatment & Maintenance |
Elements of Prevention (4)
|
|
|
Education |
|
Treatment |
|
Public Policy |
|
Law Enforcement |
Education
|
|
|
Limit demand by providing information |
|
Changing attitudes and beliefs |
|
Providing skills (examples) |
|
Changing behavior |
Treatment
|
|
|
|
|
Removal physical & environmental
conditions that contribute to behavior (AA, NA) |
|
|
|
Psychological and physical hooks |
|
|
Public Policy & Law
Enforcement
|
|
|
|
|
Courses of Actions pursued by the
government |
All the levels
&
Elements of Prevention
Where can we apply Stages
of Change Model?
|
|
|
|
|
|
All levels of prevention |
|
Primary |
|
Secondary |
|
Tertiary |
|
|
|
Two elements of prevention |
|
Education |
|
Treatment |
Categorize the Behavior
|
|
|
|
|
Addictive Behavior (physical &
psychological) |
|
Tobacco use (Nicotine) |
|
Drug abuse (Heroine, crack, cocaine) |
|
Alcohol abuse (ETOH) |
|
|
|
High Risk Behavior (psychological hook) |
|
Over eating/ under exercising |
|
Violence |
|
Unsafe practices |
|
Injury related |
|
Sex related |
|
|
Techniques for Stage
Placing
Take an Excellent Health
History
|
|
|
“The Techniques of Skilled
Interviewing” (NO THREATS) |
|
|
|
Active listening |
|
Adaptive questioning |
|
Nonverbal communication |
|
Facilitation |
|
Echoing |
|
Empathetic responses |
|
Validation |
|
Reassurance |
|
Summarization |
|
Highlighting Transitions |
Understand the Difference
|
|
|
|
|
|
Illness |
|
How the patient experiences the
symptoms |
|
|
|
Disease |
|
The explanation the clinician brings to
the symptoms |
The 4 A’s
|
|
|
Ask |
|
Advise (personalize) |
|
Assist |
|
Arrange |
|
|
|
How does the patient react? |
Be Informed!
Applying the
Stages of Change Model
"Individual
Applications"
|
|
|
Individual Applications |
|
& |
|
Societal Applications |
Smoking Cessation
Tobacco Facts
Tobacco kills more people
than all of these causes of death combined:
|
|
|
|
|
Car crashes |
|
AIDS |
|
Suicide |
|
Homicide |
|
Illicit Drug use |
|
Alcohol |
"One in every five
deaths..."
|
|
|
One in every five deaths in the |
|
United States |
|
is smoking related |
"On average smokers
die"
|
|
|
On average smokers die |
|
about seven years earlier than
nonsmokers |
"Cigarette smoke
contains 4,000 chemicals"
|
|
|
Cigarette smoke contains 4,000
chemicals |
|
|
|
43 known carcinogens |
|
|
|
401 highly toxic substances |
|
|
|
Examples of poisons: carbon monoxide,
cyanide, formaldehyde |
Why Smoke?
|
|
|
|
|
Psychological & Physical |
|
Hooks |
Nicotine is Not
Addictive?!
Commercial Break
CEO’s of Big Tobacco
Congress 1994
Smoking Cessation
|
|
|
|
|
|
|
An individual Application |
Living Well . . . Tobacco
Free
|
|
|
|
|
Presented by the American Cancer
Society Eastern Division Inc. |
|
|
|
Refer to the book for Stages of Change
Page |
Four Program Components (encompass
the elements of prevention)
|
|
|
Tobacco Education |
|
Clearing the Air |
|
Freshstart ** |
|
Staying off smoking ** |
Freshstart Sessions
(encompass the stages of change)
|
|
|
Understanding Why and How (contemplation
& preparation) |
|
Managing the First Few Days (Action) |
|
Mastering the Obstacles (Action) |
|
Staying Quit and Enjoying it Forever (Maintenance) |
Smoking Cessation
CDC recognizes Tobacco
Cessation as one of the ten greatest public health achievements of the 20th
Century
Where have we begun to
succeed as a society?
|
|
|
Public Policy & Law Enforcement |
|
elements of prevention |
Legislation
|
|
|
1964 Surgeon general established
advisory committee on Tobacco which suggested relationship to cancer in
writing. |
|
|
|
1965 Federal Cigarette Labeling and
Advertising Act requiring surgeon general’s warning on all packs. |
|
|
|
1971 all broadcast advertising was
banned. |
|
|
|
1990 smoking banned on all interstate
buses and domestic airline flights lasting six hours or less. |
|
|
|
|
More legislation
|
|
|
1992 Synar Amendment passed: federal
law that requires all states to adopt legislation that prohibits the sale and
distribution of tobacco products to people under age 18. |
|
|
|
1994 attorney generals of 4 states sued
big tobacco. Settlement in
Mississippi, Florida, Texas. Recouped
millions for smokers medical bills. |
|
|
|
1995 Bill Clinton announced FDA plans
to regulate tobacco, especially sales to minors |
|
|
|
1998 6.5 billion dollar settlement in
Minnesota. Public knowledge of deceit. |
|
|
|
Set back in 1998- Senate rejected MCain
bill to raise taxes and change policy |
|
|
Achievements
|
|
|
Smoking prevalence rates among adults
aged 18 years and older decreased from 42.4% in 1965 to 24.7% in 1997 |
|
|
|
1.6 million deaths were postponed,
saving more than 3 million person-years of life |
|
|
BUT
|
|
|
Since 1990 smoking prevalence among
adults is virtually unchanged |
|
|
|
Adolescent smoking increased 28.3% from
1991 to 1997 |
|
|
|
Second hand smoke is still a big
problem |
Where do providers fall
short?
|
|
|
Only 15% of smokers who saw a provider
in the past year were offered assistance with quitting |
|
|
|
Only 3% were given a follow up
appointment to address this topic |
|
|
|
Only 9% of managed care organizations
have fully implemented the guidelines for coverage |
Smoking Cessation Clinical
Practice Guideline, 2000
|
|
|
Effective treatments exist (psychiatric
hook) |
|
|
|
Every patient who uses tobacco should
be offered treatment |
|
|
|
Strong dose-response relationship,
effectiveness increases with intensity of treatment |
|
|
|
Treatment is insured & clinicians
are reimbursed (far from 100%) |
|
|
|
Pharmacotherapy (physical hook) |
|
|
|
Clinically effective and cost effective |
As a society, we are SLOWLY
changing our behavior
|
|
|
Providers |
|
Legislators |
|
Consumers |
|
Big tobacco (because they have to!) |
Weight Loss
Examples
|
|
|
“Practical Clinical Behavioral
Treatment of Obesity,” by Ingela Melin & Stephan Rossner (2003) refer to
the article for Prochaska reference #15 |
|
|
|
“The Therapeutic challenge: behavioral
changes for long-term weight maintenance,” by Westehoefer (2001) |
Westhoefer’s Stages
|
|
|
Problem consciousness (contemplation) |
|
Attitudinal change (preparation) |
|
Behavioral change (Action) |
|
Behavioral trial (Action) |
|
Behavioral stabilization (Maintenance) |
Are the programs effective?
|
|
|
|
Westenhoefer says, yes and no. |
|
“Isolated changes of single behaviors
will not suffice for long-term success, but more complex changes of many
behaviors and perhaps life-style as a whole are necessary for long-term
weight maintenance.” |
|
Meal rhythm and frequency, quality of
food, meal situations, restriction of food |
|
Melin & Rosner don’t have patient
data. |
|
But they do feel that they changed the
attitudes of the health care personnel.
“850 nurses, dietitians and other health care personnel have been
educated – overall these participants find their education and supervisions
meaningful and valuable.” |
|
|
Why does this research seem
inconclusive?
Weight Loss
Levels of Prevention
|
|
|
|
|
Education (little has been done) |
|
Fast food healthy choices |
|
Public schools |
|
|
|
Treatment |
|
For Profit “Diets” |
|
Weight Watchers |
|
Atkins |
|
LA weight loss |
|
|
|
Public Policy & law enforcement |
|
Schools: California (has ban in place)
& New York |
|
17 states (NY) have “sin taxes” on soda
& junk food |
|
What if things were different? Will
Doritos get sued? |
|
|
|
|
Safer Sex
|
|
|
Individual Applications |
|
? |
Abstinence
Safer Sex
|
|
|
Societal Applications |
|
|
|
(Because people have sex with somebody
else) |
|
|
|
|
ESID
|
|
|
Experimental Social Innovation and
Dissemination (1977) Fairweather & Tornatzky |
|
|
|
Behavior Change Model Variant for
Societal implications carried out traditionally by scientists |
|
|
|
“HIV, Sex, and Social Change: Applying
ESID Principles to HIV Prevention Research,” By Fernandez, et al. (2003) |
|
|
|
|
ESID parameters
|
|
|
Must address a pressing social issue |
|
Be guided by humanitarian values |
|
Include representative of the affected
community |
Why?
|
|
|
|
|
In 1989 68% of all adult/adolescent
AIDS cases were of MSM |
|
|
|
Not because they are homosexual, but
because of their high risk behavior. |
ESID Principles
|
|
|
|
|
|
Adoption of an idea with verification
of peer support |
|
|
|
“Opinion Leaders” |
|
Safe Sex Endorsers |
|
Behavior Change Advocates |
|
Chosen by bartenders |
Results at 2 months
|
|
|
25% decrease in unprotected anal
intercourse |
|
30% decrease in unprotected receptive
anal intercourse |
|
16% increase in condom use |
|
18% decrease in proportion of men with
more than one partner |
Results after 1 Year
|
|
|
|
|
65% decrease in unprotected anal
intercourse |
|
50% increase in condom use |
In conclusion
What’s in common?
|
|
|
Ownership of the problem |
|
Group support |
|
Program longevity |
|
“Life Savors” |
|
Facilitators |
|
Harm reduction |
|
No vaccines, limited pharmacology Tx |
|
Fatality when not adhered to |
What is Different?
|
|
|
Unfortunately, |
|
you can’t use a condom in stages |
Complementary Medical
Interventions
|
|
|
|
Pharmacotherapy |
|
Methadone maintenance |
|
Nicotine gum, patch, nasal spray,
Zyban, clonidine |
|
|
|
Surgery |
|
“Stomach stapling” Gastric Bypass
Surgery |
|
|
|
Alternative Therapy |
|
Acupuncture |
|
Hypnosis |
|
Herbal Therapy |
Changing Behavior of
Providers
|
|
|
Increases ownership of a societal
behavior problem |
|
|
|
Shares the burden of the problem
behavior |
|
|
|
Validates a behavior as a problem |
|
|
|
Makes a difference |