Today
• Health beliefs, health behaviors, and behavior change
• Addictive behaviors
• Eating behavior, exercise behavior
• MHBC, motivational interviewing
What are health behaviors?
Kasl and Cobb (1966)
Health behavior Behavior aimed to prevent disease
(e.g., eating a healthy diet)
Illness behavior Behavior aimed to seek remedy (e.g.,
to the doctor)
Sick role behavior Activity aimed at getting well (e.g.,
taking prescribed medication)
Matarazzo (1984)
Health-impairing habits Behavioral pathogens
(e.g., smoking, eating a high fat diet)
Health protective behaviors Behavioral immunogens (e.g.,
attending a health check)
Smoking
• Smoking behavior is on the decline but decrease I greater
in men than in women
• Smokers tend to be in the unskilled manual group
• Smokers tend to earn less than non-smokers
• Two-thirds of smokers report wanting to give up smoking
• 58% of smokers say that it would be fairly/very difficult to
go without smoking for a whole day
33%
67%
Yes
No
Components of cigarettes
• Nicotine
• Primary addictive substance, pleasurable
• Acts directly on CNS
• Tars
• Chemicals which are carcinogenic
• Carbon Monoxide (CO)
• CO reduced amount of O2 in blood and places strain on
heart muscle
Smoking and Health
• Smoking is the greatest single cause of preventable
deaths (> 20% of all deaths)
• Half of those who smoke throughout their life will die as a direct result of
their habit
• Half of these deaths will occur in middle age with an average of 21 years
of life lost
• The rest will occur in old age, with around 8 years lost
• Average reduction of life expectancy = 5-9 years
• Smoking contributes to…
• Heart disease
• Cancer
• Stroke
• Influenza and pneumonia
• Chronic bronchitis
• Emphysema
• Peptic ulcers
• Respiratory disorders
• Lower birth weight in offspring
Smoking
- USA
Smoking - UK
Smoking – Global (Ng et al., JAMA, 2014)
Smoking – Global (Ng et al., JAMA, 2014)
Why do people smoke?
• Start
• Social learning (modeling)
• Peer pressure
• 95% begin in teen years
• Know smoking is dangerous but say will stop
• Continue
• Genetic (?)
• Dependence (nicotine-regulation)
• Reinforcement (peers, feeling good, performance)
Treatments for Smoking
• Nicotine-replacement therapy
• Aversion therapies
• Self-management strategies
• Multi-modal approaches
Relapse rate = 70-80% after 1 year
• Factors
• Abstinence-violation effect
• Weight gain (2 pounds)
• Social support
• Intrinsic motivation (better than extrinsic)
• Stress
Helping Smokers
• 5 As (willing to quit)
• Ask about tobacco use
• Advise to quit
• Assess willingness to make a quit attempt
• Assist in quit attempt
• Arrange follow-up
• 5 Rs (unwilling to quit)
• Relevance
• Risks
• Rewards
• Roadblocks
• Repeat
Alcohol Consumption
• The majority of adults have drunk alcohol in the past year
• Men are more likely to drink alcohol than women
• Men are more likely to have drunk on five or more days in the
past week than women
• Men aged 16-24 drink the most
• There are no sex differences in the 24-35 age range
• About 70% of adults drink alcohol at least
occasionally
• about 10% are ‘problem drinkers’ (health damage)
• About 5% are ‘alcoholic’ (alcohol dependence)
• Two vulnerable times
• Teenage years
• Late middle age
Alcohol Consumption - Global
Alcohol Consumption - EU
Why do people drink?
• Start
• Social learning (modeling)
• Peer pressure
• Continue
• Dependence
• Reduce social anxiety
• Tension relief
• Reinforcement
Addictive Behavior
• Psychological theories
• Social learning perspective
• (1) classical conditioning; (2) operant conditioning; (3) observational
learning; (4) cognitive processes
• Biological theories
• Disease perspective
• Addiction
• Social theories
• Social reinforcement
• Social identity
Addictive Behavior
• Results of the interaction of person factors and the
environment
https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction
Addictive Behavior
Treatments for Alcohol Abuse
• Detoxification
• Alcoholics Anonymous
• Psychotherapy
• Aversion therapies
Addictive Behavior
• Stage-based models
used widely in addiction
treatment programs
• Relapse prevention and
coping strategies key
parts of addiction
treatment programs
MOST
• Multiphase Optimization STrategy
• Inspired by engineering principles
• Framework for development, optimization, and
evaluation of behavioral/biobehavioral interventions
(BBIs)
• Desiging BBIs that meet cirteria for
• Effectiveness (does it do more good than harm?)
• Efficiency (does it avoid waisting time, money, and other
valuable resrouces?)
• Economy/Scalability (does it offer a good value and can it be
implemented widely with fidelity?)
• ….that is optimization criteria
Collins LM, Murphy SA, Nair VN, Strecher VJ. Ann Behav Med. 2005 Aug;30(1):65-73.
www.methodology.psu.edu
MOST
• Which combination of intervention
components is the most effective?
• Content
• Adherence
• Fidelity
• Factorial or fractional factorial
experiments
• Main effects
• Interaction/synergistic effects
Collins LM, Murphy SA, Nair VN, Strecher VJ. Ann Behav Med. 2005 Aug;30(1):65-73.
www.methodology.psu.edu
Sexual Behavior
Robinson et al. (2002)
• Discussion about sexual
behavior has evolved from
focus on its biological
functions, to focus on
pleasure, to focus on sex as
risk behavior for STDs and
unplanned pregnancy
• Challenging behavior to
study because it involves
• Intrapersonal factors
• Interpersonal factors
• Sex as interaction;
role negotiation
• Situational factors
Physical Activity and Diet
Diet
Diet
• Factors impacting eating behavior
• Exposure
• Social learning (peers, parents, media)
• Associative learning (rewarding eating behavior, food as reward)
• Parental control
• Theories of eating behavior (TPB, SCT)
• Weight preoccupation, body dissatisfaction and body
image
• Dieting vs. Overeating
• Intense debate over the most appropriate diet
Physical Activity
Conceptual Human Movement Framework
Pettee & Morrow (2010). Measurement of Active and Sedentary Behaviors: Closing the Gaps in Self-report Methods. NIH, Bethesda MD (July 21, 2010).
Human
Movement
Attributes
Energy
expenditure
Physical
Fitness
Metabolic rate
(basal, resting)
Thermic effect
of food
PA related EE
Behavior
Physical
Activity
Occupational/
School
Household/
Caretaking/
Domestic
Transportation
Leisure
Sitting
Media Use
Non-occupational
school
computer use
Sleeping
Occupational/
School
Sitting while
driving/riding
Sedentary
Activity
Discretionary
Non-discretionary
Cardiorespiratory
Fitness
Muscle Fitness
(strength vs. endurance)
Body Composition
Flexibity
Balance &
Coordination
Obesity Prevalence
Among U.S. Adults
BRFSS, 2000, 2005, 2009
Can physical activity save us
from the obesity epidemic?
Content source: National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation
National Center for Chronic Disease Prevention & Health Promotion
Behavioral Risk Factor Surveillance System
National Center for Chronic Disease Prevention & Health Promotion
Behavioral Risk Factor Surveillance System
1988–2008 No Leisure-Time Physical Activity
Trend Chart
National Center for Chronic Disease Prevention & Health Promotion
Behavioral Risk Factor Surveillance System
National Center for Chronic Disease Prevention & Health Promotion
Behavioral Risk Factor Surveillance System
Participated in 150 minutes or more of Aerobic Physical Activity
per week
National Center for Chronic Disease Prevention & Health Promotion
Behavioral Risk Factor Surveillance System
Participated Muscle Strengthening exercises more than twice per
week
National Center for Chronic Disease Prevention & Health Promotion
Behavioral Risk Factor Surveillance System
Participated in enough Aerobic and Muscle Strengthening exercises to
meet guidelines
Objective Physical Activity Surveillance
(Accelerometry)
Troiano et al. (2008)
• 42% of children ages 6-11 yr obtain the recommended 60
min x d(-1) of physical activity
• only 8% of adolescents achieve this goal
• Among adults, adherence to the recommendation to
obtain 30 min x d(-1) of physical activity is less than 5%.
Individually-adapted PA interventions
• Key elements
• Goal setting & self-monitoring progress towards goals
• Social support
• Positive reinforcement (self-rewards, positive self-talk)
• Self-regulation skills (problem solving, developing skills to prevent
relapse)
• Kahn et al. (2002)
• Foster et al. (2005) – Cochrane review
• Stricter criteria for selection of intervention studies (RCTs)
• Smaller but positive effects
• Highlighted usefulness of telephone and printed educational
materials
Multiple Behavior Change Research
•Efforts to promote two or more health behaviors
•The interrelationships among health behaviors and
interventions designed to promote change in more than
one health behavior at a time
•Presents a unique set of challenges
• theoretical, methodologic, intervention, statistical, and funding
issues
Rationale for MHBC Research
Approximately half of all causes of mortality in the United
States are linked to social and behavioral factors such as
smoking, diet, alcohol use, sedentary life-style, and accidents.
Yet less than 5% of the approximately $1 trillion spent annually
on health care in the United States is devoted to reducing risks
posed by these preventable conditions. Behavioral and social
interventions therefore offer great promise to reduce disease
morbidity and mortality, but as yet their potential to improve the
public’s health has been relatively poorly tapped.
— Institute of Medicine
Rationale for MHBC Research
• The major causes of morbidity and premature mortality in
the US (heart disease, cancer, and stroke) influenced by
multiple health risk behaviors (including smoking, alcohol
abuse, physical inactivity, and poor diet)
• In the US, only 3% of adults meet all four health behavior
goals of being a nonsmoker, having a healthy weight,
being physically active, and eating 5 or more fruits and
vegetables a day (Reeves & Rafferty, 2005)
Rationale for MHBC Research – cont.
•Clustering of unhealthy behaviors
• In the US, the majority of adults meet criteria for two or more risk
behaviors (Fine et al., 2004; Pronk et al., 2004)
•92% of smokers exhibit at least one additional risk
behavior (Fine et al., 2004; Klesges et al., 1990; Pronk et
al., 2004)
•9 out of 10 overweight women at least two eating or
activity risk behaviors (Sanchez et al., 2008)
Rationale for MHBC Research – cont.
•Success in changing one or more lifestyle behaviors
may increase self-efficacy to improve risk behaviors
individuals have low motivation to change
• Gateway behavior to overall healthy lifestyle?
•Limited contact opportunities for health promotion –
should aim for interventions that could simultaneously
improve multiple risk behaviors
•Interventions targeted at single risk behaviors, even if
effective, will be limited in their impact
Methodological Issues in MHBC
•Design issues
• How many behaviors to target at once?
• Specific combinations of specific behaviors? Are some
more compatible than others?
• Differential motivation to change different behaviors
• Implications for timing? Introduce behaviors at the same
time or sequentially?
Hyman et al. (2007)
• Is sequential presentation of stage of change–based
counseling to stop smoking, reduce dietary sodium
level, and increase physical activity by at least 10 000
pedometer steps per week more effective than
simultaneous counseling?
• African Americans (N=289) with hypertension, aged 45
to 64 years, initially non-adherent to the 3 behavioral
goals, were randomized:
(1) 1 in-clinic counseling session on all 3 behaviors every 6 months,
supplemented by motivational interviewing by telephone for 18 months;
(2) a similar protocol that addressed a new behavior every 6 months;
(3) 1-time referral to existing group classes (“usual care”).
The primary end point was the proportion in each arm that met at least 2
behavioral criteria after 18 months.
Hyman et al. (2007) - results
•At 18 months, only 6.5% in the simultaneous arm,
5.2% in the sequential arm, and 6.5% in the usualcare
arm met the primary end point
•Results for single behavioral goals consistently
favored the simultaneous group
• At 6 months, 29.6% in the simultaneous, 16.5% in the
sequential, and 13.4% in the usual-care arms had
reached the urine sodium goal
• At 18 months, 20.3% in the simultaneous,16.9% in the
sequential, and 10.1% in the usual care arms were
urine cotinine negative
King et al. 2013
• Four intervention groups: a sequential exercise-first
group, a sequential diet-first group, a simultaneous group,
and a control group
• 12 months interventions; 4 months in between sequential
behaviors
• Telephone-based counseling (SCT, TTM); control received
stress management advice
• The behaviors presented first, showed
greater improvement in sequential
interventions (suppression effect of
“diet first” on physical activity)
• In simultaneous group, changes in both
behaviors comparable, the size of the
effect similar to that of “first behavior” in
the sequential group
Fruit & Vegetable Intake Calorie Intake from Sat. Fat
MVPA
Methodological Issues in MHBC
•Measurement issues
• Separate or composite measures?
•Data analysis
•Theory testing across behaviors
•Participant burden
Behavior Change from the Perspective of
Motivational Interviewing
Motivational interviewing is a directive, client-centered
counseling style for eliciting behavior change by helping
clients to explore and resolve ambivalence.
Source: http://www.motivationalinterview.org/
Miller WR, et al. Motivational Interviewing, 2nd ed. Guilford Press; 2002.
Berger B. Motivational interviewing helps patients confront change. Available
at:http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Phar/nov99relationships.cfm
&pub_id=8&article_id=450.
The Spirit of Motivational Interviewing
•Collaborate with the patient
•Evoke their readiness to take action (elicit “change talk”)
•Develop patient’s autonomy to take responsibility for their
own health
Behavior change can be facilitated
but not coerced.
Strategies for Successful Interaction
with Patients
Elicit-Provide-Elicit
• Menu of Strategies
The Five Principles
• READS
Helpful Tools
• Readiness Rulers
• The Envelope
Rollnick S, et al. Health Behavior Change: A Guide For Practitioners. Churchill Livingstone; 2003.
Berger B. Motivational interviewing helps patients confront change. Available at:
http://www.uspharmacist.com/oldformat.asp?url=newlook/files/Phar/nov99relationships.cfm&pub
_id=8&article_id=450
Strategies for Successful Interaction
with Patients
ELICIT-PROVIDE-ELICIT
• The good things and bad things
• What do they like and dislike about the proposed
changes?
• What is their representation of the illness and its
treatment?
• Do they agree with the NP/MD?
• Do they believe they can do what is asked? What
will help?
• What are the barriers?
• IS THE PATIENT READY FOR THE CHANGE?
Five Principles of MI
•Express empathy
•Develop discrepancy
•Avoid argumentation
•Roll with resistance
•Support self-efficacy
Building Motivation
• Explore ambivalence and build motivation
(1) Open-ended questions
(2) Reflective listening
(3) Affirmations
(4) Summaries
(5) Elicit self-motivational statements (change talk)
Readiness to Change: Eliciting Change
Talk
“If I handed you an envelope, what would the message inside
have to say to get you to ________?”
Building Motivation
• Goal is to get patient/client to articulate:
• The steps I plan to take are:
• Challenges that may interfere:
• How I will handle these challenge
• I’ll know my plan is working if:
MHBC Challenges
•Timing of treatment
•Measuring changes in multiple behaviors
•Theory testing across behaviors
•Participant burden