Today
• Health beliefs, health behaviors, and behavior change
• Addressing the main goals of interventions
• Social Ecological Framework
• Health beliefs
• Theoretical foundation of interventions
• Why do we need theory to guide interventions?
• What are the most commonly used theories of health behavior?
• When in the process of intervention planning do we use theory?
• Evaluating the impact of interventions
• RE-AIM
• Addictive behaviors
• Eating behavior, exercise behavior
• MHBC, motivational interviewing
Goals of Behavioral Interventions
Demonstrate that
interventions can
cause positive
outcomes
Identify and
understand processes
through which change
occurs (i.e., mediators
or mechanisms of
change)
Identify factors that
cause treatment
effects (i.e.,
moderators of
change)
Approaches to Health Promotion
How do we go about promoting healthy behaviors?
Approaches to Health Promotion
Policy
Individual
Social
Physical
Environmental
Schematic representation
of the ecological
framework for
understanding different
influences on personal
health behaviors
Approaches to Health Promotion
(1) Behavioral and social approaches
- Individually-adapted health behavior changed programs
- Social support interventions in community settings
- Family-based social support
- School-based enhanced health education and practice
(2) Campaign and informational approaches
- Community-wide campaigns
- Mass media campaigns
- Classroom-based health education focused on
providing information
(3) Environmental and policy approaches
Focus on Theory-Based Interventions
Implementation
and evaluation
Design and
planning
Theoretical
foundation
WHY DO WE NEED
THEORY?
Atheoretical Approaches: Motives and
Barriers
• Descriptive
• Typically large-scale surveys of attitudinal
and motivational factors
• Useful for providing baseline data, plotting
trends, or generating ideas and research
directions
• Do NOT explain why individuals hold these
beliefs
Clarification….
• Theory
• A generalized statement aimed at explaining a phenomenon/behavior
• The basis for creating a model
• Model
• Purposeful representation (symbolic, verbal, visual) of reality or a
concept
• Models can serve as the structure for the step-by-step formulation of
a theory
• Framework
• Way of organizing information about the field (e.g., the health onion)
• Similar to paradigms but looser
Some useful definitions…
• Correlate versus Determinant
• Correlate = factor associated with behavior (e.g., age)
• Determinant = factor causally associated with behavior
• strength of association (replicated across studies)
• temporal sequence (precedes outcome)
• dose-response
• conceptually plausible (i.e., must make sense)
Example: …?
Some useful definitions…
• Mediator – intervening causal variable
• on the causal pathway between intervention and intervention
effect/outcome
• explains the mechanism through which the program exerts its
effect
- Example: ?
• Moderator - effect modifier
• a “third” variable that modifies the effect of intervention
- Example: gender-specific effects, …?
• Confounder – factor that predicts outcome but is also
associated with exposure (intervention)
• Example: age, …?
Clarification
• Theories of health behavior
• Linear
• Derived from observational studies
• Mainly explain status, do not predict change in behavior well
VS
• Theories of health behavior change
• Cyclical, dynamic
• Must be tested in experimental context
• Help understand process, goal is to predict change in behavior
Health Behavior Theory
• Only 22.5% of interventions explicitly based on health
behavior theory (Davis et al., 2010)
• Most commonly used theories emphasize individual or
interpersonal factors; physical and social context often
ignored
• Davis at al. (2015)
• Identified 82 theories of behavior with potential for use in health
behavior change
• 4 theories accounted for 174 (63%) of articles
• Transtheoretical Model of Change (TTM; N = 91; 33%)
• Theory of Planned Behaviour (TPB; N = 36; 13%)
• Social Cognitive Theory (SCT; N = 29; 11%)
• Information-Motivation-Behavioural-Skills Model (IMB; N = 18; 7%)
Health Belief Model
(Becker & Maiman, 1975)
The likelihood of behavior depends on the person’s
perception of the severity of health risks and appraisal of the
costs and benefits of taking action.
Health Belief Model (HBM)
Perceived
Susceptibility
Perceived
Seriousness
Perceived
Threat of Disease
Cues to Action
Demographic
Variables
Perceived
Benefits
minus
Perceived
Barriers
Likelihood of Taking
Health Action
Limitations of Health Belief Model
• Illness-avoidance orientation
• Limited use in some behaviors (e.g.,PA/exercise) –
individuals often engage in behaviros for reasons other
than prevention of chronic disease
• May be more useful for explaining avoidance of negative
behaviors rather than engagement in positive health
behaviors
Discussion
• Grandahl et al. (2016)
Self-Determination Theory (SDT)
• Deci & Ryan (1985)
Autonomy
Competence Motivation Behavior
Relatedness
• Individuals possess different types
of motivations but all are related to
three fundamental human needs
Affect
Cognition
Motivation continuum
Self-determined
(autonomous)
Controlling
SDT - Motivation
• Intrinsic
• for the enjoyment of the activity itself
• Integrated regulation
• congruent with the person´s own values and needs
• Identified regulation
• you identify with it (i.e., self-initiated and of some personal
relevance or value)
• Introjected regulation
• wanting to avoid punishment or guilt
• External regulation
• for some external reward or due to pressure to do so (e.g.,
from significant others)
• Amotivation
Theory of Planned Behavior
(Ajzen, 1988)
Exercise behavior can be explained by
• intentions
• subjective norms and attitudes
• perceptions of ability to control behavior
Theory of Planned Behavior (TPB)
• Developed from Theory of Reasoned Action
Attitude
Subjective Norm
Behavioral
Intention
Behavior
Beliefs,
value, likely
outcomes
Beliefs of
significant
others +
motivation to
comply with
such beliefs
Perceived
Behavioral
Control
Perceived
ease or
difficulty of
performing the
behavior
Limitations of TPB
• The model is unidirectional
• Does not account for past behavior
• Focus on social psychological perceptions
• Typically explains more variance in intentions than in
behavior
Social Cognitive Theory
(Bandura,1986,1997)
Behavior
Environmental
factors
Personal
factors
Cognitive,
affective, biological
events
Mediating mechanisms
Fundamental human Beliefs
capabilities
Elements of Social Cognitive Theory
• Goals
• Impediments or barriers
• Outcome expectancies versus self-efficacy
• Outcome expectancies
• Judgments of the likely consequence/outcomes of one’s actions
• Self-efficacy
• people's judgments of their capabilities to organize and execute courses
of action required to attain desired outcomes
Self-Efficacy Theory
Sources
• Mastery experience
(past performance)
• Social experiences
(modeling)
• Verbal persuasion
• Physiological and
emotional arousal
SELF-
EFFICACY
Individual’s beliefs in
his/her capabilities to
successfully carry out a
course of action
(situational specific self-
confidence)
Consequences
• Behavioral choice
• Degree of effort
• Persistence in face of
adversity
Transtheoretical Model of Behavior
Change (TTM)
(Prohaska & DiClemente, 1983)
Exercise behavior can be explained by
• Stages of change
• Processes of change (experiential versus
behavioral)
• Decisional balance
• Self-efficacy (added later by Prohaska et
al., 1994)
TTM
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Adopted from J. Adams & M. White: Br. J. Sports Med. 2003;37;106-114.
Self liberation
Self re-evaluation
Reinforcement management
Helping relationships
Counterconditioning
Stimulus control
Consciousness raising
Dramatic relief
Environmental re-evaluation
Defining Stages of Change
Stage Meeting
criterion
level of PA
Current
behavior
Intention to
meet
criterion
level of PA
Precontemplation No Little or no PA No
Contemplation No Little of no PA Yes
Preparation No Small changes in PA Yes
Action Yes Active for < 6 months Yes
Maintenance Yes Active for > 6 months Yes
TTM Assumptions
Key
During exercise, behavior induction strategies are used
during the different transtheoretical stages. (Prochaska,
DiClemente, & Norcross, 1992)
Matching the intervention to the stage of change is
effective in producing high levels of regular exercise, at
least in the short term.
Health Action Process Approach (HAPA)
(Schwarzer, 2003)
http://userpage.fu-berlin.de/health/hapa.htm
Motivation Phase Volition Phase
Planning
Coping
Self-Efficacy
Outcome
Expectancies
Action Self-
Efficacy
Intentions
Risk
Perception
Physical
Exercise
What does this “two-phase” model mean from an intervention perspective?
Bottom Line
When deciding on the best approach to
encourage INDIVIDUAL behavior change,
maximize exercise adherence and long-term
maintenance of physical activity one must
take into account
…….one’s motivation to change
…….one’s abilities (actual and perceived)
one’s resources and opportunities to change
Behavior Change Wheel (Michie et al., 2011)
WHICH THEORY IS
BEST?
Some Caveats…
• It is unlikely that a single theory will universally explain
physical activity behavior
• Context-specific and population-specific considerations
• Do we need gender-specific theories?
• Existing theories should be scrutinized and revised based
on available evidence
• This is a very slow process
• Efforts for transtheoretical paradigms
• Theoretical Domains Framework (Cane et al., 2012, Michie et al.,
2005)
Common Mistakes When Using Theory
• Focusing program too narrowly for expected outcomes
• Selecting too few constructs (or only at one level of influence)
– a program should be based on important influences on
behavior
• Focusing too broadly in relation to the resources available
• Failure to consider the particular situation and target group
• Using constructs from theories without considering
implications (should aim for multiple levels if influence)
• Overreliance on familiar methods and strategies
• Overreliance on a favorite theory
• Dismissing theory and relying on experience or intuition
How to Select a Theory
• The social or health problem at hand (what are the
needs?)
• The behavior(s) to be targeted
• Health behavior theory as blueprint identifying salient antecedents
of behavior
• The target population and their needs
• Context in which the intervention will take place
PLANNING MODELS CAN PROVIDE GUIDEANCE IN A
SYSTEMATIC WAY
STARTING WITH NEEDS ASSESSMENT
Approaches to Health Promotion
Policy
Individual
Social
Physical
Environmental
Schematic representation
of the ecological
framework for
understanding different
influences on health
behavior
A Shift from a Clinical to a Public Health
Approach
Clinical/Medical Approach
• stresses convenience &
efficiency of the provider
• “waiting” approach –
individuals must look for
programs that meet their needs
• serve mostly active and healthy
(or patient populations)
• takes place in structured
settings
Community-based Approach
• multi-level public health orientation
• “seeking” approach – active
approach to collecting and
disseminating information to allow
for tailoring to individual needs
• target all segments of population,
especially those who would
particularly benefit (i.e., those at
risk)
• takes place in “real-life”
environment
• Seeks to instill changes in social
networks and structures,
organizational norms, policies
Applying the RE-AIM Framework to
Health Behavior Interventions
• RE-AIM originally developed to evaluate the public health
impact of health promotion efforts and potential for
dissemination and sustainability
• Today interventionists use this framework in the planning
phases of interventions to maximize their public health
impact and long-term effectiveness
Applying the RE-AIM Framework to
Physical Activity Interventions
Central questions
• How well does research translate into practice?
• What is …Robustness
• What is …Translatability
• What is …Public health impact
• Individual level
• Institutional (or Setting) level
RE-AIM
Determine if acceptable program/policy will:
• Reach large numbers of people, especially those who can benefit most
• Be widely adopted by different settings using available “channels” of
delivery
• Be consistently implemented by settings and staff members reflective of
local community
• Produce relevant, replicable, long-lasting effects (with minimal negative
impacts) at reasonable cost
RE-AIM as a planning model: Designing for
dissemination
Klesges, et al Ann Beh Med 2005;29:S66-75.
RE-AIM – cont.
R
E
A
I
M
Reach
Effectiveness
Adoption
Implementation
Maintenance
Increase
Increase
Increase
Increase
Increase
Glasgow, Klesges, Dzewaltowski, et al., Ann Behav Med, 2004
RE-AIM Dimensions
Dimension Definitions
REACH
1. Participation rate among potential
target group(s)
2. Representativeness of participants
in terms of social, demographic,
and health characteristics
EFFICACY/
EFFECTIVENESS
1. Effects of intervention on primary
outcome of interest
2. Impact on quality of life and
negative outcomes
3. Robust outcomes (similar effects
among targeted groups)
Clarification of Terms
• Efficacy
Does the treatment/intervention cause an effect?
Does the treatment/intervention work under ideal
circumstances?
• Effectiveness
Does the treatment/intervention work under real-life
circumstances?
RE-AIM Dimensions (cont.)
Dimension Definitions
ADOPTION
1. Participation rate among possible
settings and contexts
2. Representativeness of participating
settings, intervention staff
IMPLEMENTATION
MAINTENANCE
1. Extent intervention was delivered
as intended in protocol
2. Time & cost of intervention
1. Longer-term effects > 6 months
(Individual)
2. Impact of attrition on outcomes
(Individual)
3. Sustained delivery or modifications
of intervention (Setting)
Some Challenges…
Reach
• Not studying a relevant, high-risk, or representative
sample
• Remedy?
Efficacy or Effectiveness
• Not thoroughly understanding outcomes or how they
come about, e.g., no knowledge of mediators,
conflicting or ambiguous results, or inadequate
control conditions to rule out alternative hypotheses
• Remedy?
Some Challenges – cont.
Adoption
• Program not ever adopted or endorsed — or only
used in academic settings
• Remedy?
Implementation
• Protocols not delivered as intended (type III error)
• Remedy?
Maintenance
• Program or effects not maintained over time
• Remedy?
RE-AIM Resources
If we want more evidence-based
practice,
we need more practice-based
evidence.
L. W. Green, 2004
More information on RE-AIM at www.re-aim.org
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
• PA as a gateway behavior to overall health full 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
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