Transcript Chapter 2

Planning for Health Behavior
Change Programs
HSCI 533
Lecture 2
New Years Resolutions
This year, I will change X…
Health Behavior
As you all know – successfully adhering to new
years resolutions (changing behaviors) is
extremely difficult!
So then, how does one go about fostering
effective behavior change?
Not simple! Need to undergo a planning
process…
BASIC STEPS
Target health behavior (+/-)
Identify desired outcome (goals/objectives)
Determine what influences it (risk-protective factors)
Conceptually explain why it occurs (theories)
Design an intervention to reach desired outcome
Evaluate its success
A General Model for Program
Planning
Assessing
Needs
Setting
Goals and
Objectives
Developing
an
Intervention
Implementing
the
Intervention
Evaluating
the
Results
Models assist program planners with developing
effective behavior change interventions
Health Promotion Model to Achieve Healthy Behaviors
Needs Assessment
Outcomes
Determinants of Health
•Behavior
Change
Specific risk factors,
diseases, &conditions
Goals/
Objectives
Baseline
Evaluation
Theory
Application
Interventions
•Information
•Programs
•Policies
Monitoring
Conceptual Planning Model
Participatory
Research
4. Evaluate
Program
1. Assess Needs, Assets
of Population
Reassess causes
2. Assess Causes,
Set Priorities
& Objectives
Redesign
3. Design and
Implement Program
*Green & Kreuter, Health Promotion Planning, 3rd ed., Mayfield, 1999.
Health
Behavior
Theory
Selection
A General Model for Program
Planning
Assessing
Needs
Setting
Goals and
Objectives
Developing
an
Intervention
Implementing
the
Intervention
Evaluating
the
Results
Needs Assessment
An initial process to understand…
What types of things help to start (influence) the
health behavior?
Why we continue with a health behavior, even if we
know it is bad/good for us?
How unhealthy behaviors can be stopped or
replaced with healthy ones?
How healthy behaviors can be maintained over
time?
Further Assessment
• Given that multiple factors will be related to the
health behavior, it is important to consider:
• The priorities (importance)?
• What’s most changeable?
More Important
Less
Important
More
Changeable
High priority for
intervention focus
Low priority, except to
show change
Less Changeable
Priority for innovative
program
No intervention
Useful Planning Models
PRECEDE-PROCEED
Provides a comprehensive structure for planners to develop
successful health behavior change interventions
And…it’s one of the best known theoretically grounded
models in health promotion field
PRECEDE: predisposing, reinforcing, and enabling constructs
in educational/ecological diagnosis & evaluation
PROCEED: policy, regulatory, and organizational constructs
in educational & environmental development
Green & Kreuter, 3rd ed
How it Works?
The model begins with an analysis of final consequences
Negative health outcomes
Retrospective explanations are offered relative to causative
factors, categorized as:
Predisposing: antecedent; impact motivation
Reinforcing: antecedent; barriers & vehicles
Enabling: subsequent; feedback & rewards
From an understanding of causative factors (use of theory),
Educational and policy objectives are developed to inform
intervention (program activities)
Program implementation and evaluation follow
<-----------------------------PRECEDE
Phase 5
Administrative &
policy assessment
Public
Health
Phase 4
Educational &
ecological
assessment
Phase 3
Behavioral &
environmental
assessment
Phase 2
Phase 1
Epidemiological
Social
assessment
assessment
Predisposing
Health
education
Reinforcing
Behavior
Health
Policy
regulation
organization
Quality of
life
Environment
Enabling
Phase 6
Implementation
Phase 7
Process evaluation
Phase 8
Impact evaluation
Phase 9
Outcome evaluation
PROCEED-------------------------------->
PRECEDE Framework
Developed in the early 1970s
Four Phases designed to aid in the assessment
(diagnosis) of health concerns for the planning of the
intervention
PRECEDE Phases
Phase 1: Social Assessment
Define health behaviors (problems & priorities)
Consider how such health behaviors affect long-term desired
outcomes
Quality of Life
Happiness
Life Satisfaction
PRECEDE Phases
Phase 2: Epidemiological Assessment
Data gathering step on identified health behavior in terms:
Health impact: disability in functioning, morbidity (illness/disease)
Behavioral impact: consumption, duration/frequency, adherence,
self-care, coping, service utilization
Environmental impact: social (capital/connectedness, crime,
homelessness), physical (neighborhood), economic (poverty)
Allows for the establishment of a baseline of health behavior
(prior to intervention)
PRECEDE Phases
Phase 3: Educational & Ecological Diagnosis
Identifies factors that have potential to influence health
behavior change:
Predisposing: Reasons for the behavior – Knowledge,
Attitudes, Beliefs/Perceptions, Skills/Ability
Enabling: barriers & vehicles to the behavior – Peers,
Family, Friends, Media (normative standards)
Reinforcing: feedback & rewards that make the behavior
possible - Availability of resources, Accessibility (services),
Rules/Laws
Enabling Factors
Availability of resources
Accessibility of resources
Laws
Community Commitment
Skills
Reinforcing Factors
Family
Peers
Teachers
Employers
Health Providers
Community Leaders
Decision Makers
BEHAVIOR
Predisposing Factors
Knowledge
Beliefs
Values
Attitudes
Confidence
Health literacy
PRECEDE Phases
Phase 4: Administrative, Policy & Intervention Alignment
Aligns appropriate intervention strategies (guided by
behavior change theories) to address targeted goals and
objectives (desired outcomes)
ABC Model
Health behavior is imbedded in a context; situations that
come before and after the behavior
A
B
C
Antecedents  Behavior  Consequences
Cue or Stimulate
Behavior
Physical events, inner
thoughts/emotions
Consequences
affect whether or not
behavior is repeated
Events that reinforce
behavior or fail to do so
A General Model for Program
Planning
Assessing
Needs
Setting
Goals and
Objectives
Developing
an
Intervention
Implementing
the
Intervention
Evaluating
the
Results
Alice asked, “Would you tell me please, which way I
ought to walk from here?”
“That depends a good deal on where you want to
get to,” said the Cat.
“I don’t much care where,” said Alice.
“Then it doesn’t matter which way you walk,” said
the Cat.
“—so long as I get somewhere,” Alice added as an
explanation.
“Oh, you’re sure to do that,” said the Cat, “if you
only walk long enough!”
—Lewis Carroll,
Alice in Wonderland and Through the Looking Glass
Goals vs. Objectives
Goals
Broad statements of direction – provide a sense
of where we want to go, but they usually do not
provide clear, precise statements of our
destination.
Ex: Goals for Healthy People
Healthy People 2010
defines two overarching
goals for the nation:
Goal 1: Increase quality of
years of healthy life
Goal 2: Eliminate health
disparities
What do we have to do to
reach our goal?
Break broad statements into objectives….
Objectives
Precise statements of intended targets of
change to see desired behavioral outcome
Specified in measurable terms
Considered to be assessment tools b/c they
inform program evaluation
Where to Start…
Take needs assessment information
to guide the formation of
objectives for a behavior change
intervention
Brainstorm about what can be changed
Assess
changeability
Choose Objective
targets
Develop
Baselines
(for each objective)
Establish a Baseline
Monitor the targeted behavior (and
corresponding causal factors  objectives) for
two weeks to understand where you stand with
regards to specified objectives.
What is knowledge level?
What is skill level?
What are attitudes?
What is status of social support?
What is current behavioral pattern?
Importance of Goals &
Objectives in health behavior
change interventions
Health Behavior Change
“If you do not know where you want to go, it is
usually impossible to get there”
Need to be clear about where the somewhere is
in order to:
Design an intervention – clarify what needs to be
done to address health behavior
Evaluate its effects – measure if change has
occurred
Example of General Goals
• At the end of the program, participant will be
able to prepare healthy meals.
• At the end of the program, participant will
reduce the use of non-prescription drugs.
• At the end of the program, participants will
develop good parenting skills.
• At the end of the program, unwanted
pregnancies will be reduced.
Writing Objectives
Begin with the question: “what is the target of
change?...”
…then clearly and specifically state exactly what
you intend to change with the intervention.
Framework to Follow
SMART
Specific (what exactly is being changed and in
whom)
Measurable (% of change to be seen – use a
baseline)
Action (list, describe, indentify, explain)
Realistic (must be achievable)
Time-bound (end of session, end of year)
Suggested Guidelines in Writing Objectives
• Make a rough outline of what you hope to accomplish with
the intervention--Jot down key elements of what you hope
to achieve.
• Ask yourself the following:
When you get done with the intervention: “How will the
participant (you) feel or act, or what new knowledge or
skills will you possess that were not present before the
intervention?”
• Begins with: The [participant]
will be able to . . .Select action verb
list seven dietary recommendations from established
guideline.
avoid frequenting liquor stores saturated in the
neighborhood
Suggested Verbs for Goals and Objectives
Goals
Apply
Appreciate
Commit
Demonstrate
Perform
Synthesize
Analyze
Create
Plan
Know
Use
Conceptualize
Objectives
Arrange
Categorize
Choose
Clean
Compute
Conduct
Construct
Define
Describe
Design
Diagram
Discuss
Drink
Eat
Identify
Itemize
Lead
List
Mark
Match
Name
Operate
Perform
Pick
Position
Report
Show a willingness
Sort
Specify
Underline
Volunteer
Examples of Goals & Objectives
Health Behavior Problem: need to change
unhealthy eating habits
Goal: Reduce risk for obesity
Objective 1: Increase cognitive capacity to avoid
junk food (i.e., thought stopping) (skill)
Objective 2: Increase knowledge of well-balanced
“nutritious” diet (knowledge)
Objective 3: Increase awareness of stress control
(i.e., breathing techniques) (knowledge/skill)
Objective 3: Increase attitudinal awareness of
societal trends and norms of obesity (attitudinal)
Objective 4: Reduce junk food intake (behavioral)
One more thing about Objectives…
•
Can each objective be evaluated? If not,
restate.
• The [participant] will be able to . . .verb
after intervention (as measured against
XX baseline)
Examples
Educational Objective:
By the end of intervention, individuals will know 15
benefits of exercise (baseline: 1 benefit)
Behavioral Objective:
By the end of intervention, individuals will increase
physical activity to 3 times a week (baseline: 0 times).
Educational Objective:
By the end of intervention, individuals will know how to
access resources about diet and internet (baseline: no
access).
Skill Building Exercise
What is your health behavior targeted for
change?
Using SMART way of writing objectives, write at
least 3 intervention objectives that would help
bring about change in this behavior.
A General Model for Program
Planning
Assessing
Needs
Setting
Goals and
Objectives
Developing
an
Intervention
Implementing
the
Intervention
Evaluating
the
Results
Intervention
Total overall strategy
to achieve our
objectives
Vs Method: one
component of the
intervention
Objectives as Drivers of Selection
Interventions (and methods) must be linked
with the objectives they are likely to achieve.
In other words, the objectives should play a
role in driving the selection of all intervention
methods.
Health Behavior Theories as Drivers
Health Behavior theories link objectives and
methods to provide strategies for interventions
 identifying strategies that will bring about
successful behavior change
B/C altering health behavior is extremely
difficult, one must consider foundational
theoretical explanations that describe the
forces that:
Initiate
Maintain
Could replace the behavior
Health Behavior Theories: Depends on X and Y
X?
Y?
THEORIES
(indv, group,
community)
Different theories interpret “X” and “Y”
differently (based on theoretical assumptions
about causation).
Causes Inform Theory Selection
If we think in terms of predisposing,
reinforcing, and enabling factors as
capacities to encourage healthy choices,
then it makes sense to identify theories
to strengthen these capacities.
Example: if a barrier to the performance
of a behavior is tied to deficiencies in
skills, inappropriate attitudes or
inadequate knowledge then theories
containing constructs that emphasize
skill improvement, attitude change, or
increased knowledge should be selected.
Selecting Appropriate Theories
Theories are built upon
a set of constructs
(guiding principles of
behavior) – much like
bricks function as base
units to create
buildings.
As you begin to
analyze the factors
facilitating or hindering
a behavior, guiding
principles or
“constructs” begin to
emerge that relate to
needs assessment
info…
Self-Efficacy
A prominent construct in many health behavior
theories
HBM
SCT
TPB/TRA (perceived behavioral control)
TTM
Definition: A person’s perception of self-control
over his/her behavior
No one-size fits all intervention (or
method)
What is this public health achievement of the 20th Century?
What is the evaluation method to judge this an achievement?
Number of Cigarettes
5,000
4,000
35%
3,000
22%
2,000
1,000
0
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
Cigarette Consumption and Major Historical
Events—United States, 1900-2000
Broadcast
Ad Ban
1st World Conference
on Smoking and Health
5,000
1st Great American Smokeout
Nicotine
Medications
Available Over
the Counter
Master
Settlement
Agreement
Fairness Doctrine
Messages on TV
and Radio
1st SmokingCancer Concern
Surgeon General’s
Report on
Environmental
Nonsmokers’
Tobacco Smoke
Rights
1st Surgeon
General’s Report
Number of Cigarettes
4,000
End of WW II
3,000
2,000
1,000
Movement
Begins
Great Depression
0
1900
1910
1920
1930
Source: USDA; 1986 Surgeon General's Report
1940
1950
1960
1970
Federal
Cigarette
Tax Doubles
1980
1990
100-Percent Smokefree Ordinances, by Year of
Passage
Number of
Ordinances
18
Workplace
Restaurant
Restaurant and Workplace
16
14
12
10
8
6
4
2
0
1985
1986
1987
* Through September 1992.
Source: National Institutes of Health, National
Cancer Institute (1993). Smoking and Tobacco
Control - Monograph 3. Major Local Tobacco
Control Ordinates in the U.S.
1988
US Dept. of Health and Human Service. Public Health
Service, National Institutes of Health. NIH Publ. No. 933532.
1989
1990
1991
Year
1992*
Tobacco Vending Machine Ordinances
Number of
Ordinances
(Cumulative)
180
Total Ban
Partial Ban
160
140
120
100
80
60
40
20
0
1985
1986
1987
* Through September 1992.
Source:
National Institutes of Health, National Cancer Institute (1993).
Smoking and Tobacco Control - Monograph 3. Major Local Tobacco
Control Ordinates in the U.S.
US Dept. of Health and Human Service. Public Health Service, National
Institutes of Health. NIH Publ. No. 93-3532.
1988
1989
1990
1991
Year
1992*
Comprehensiveness
In trying to isolate the essential components of
complex interventions, none could be shown to
stand alone
Any combination of methods was more
effective than the individual methods
The more components, the more effective
The more components, the better coverage
A General Model for Program
Planning
Assessing
Needs
Setting
Goals and
Objectives
Developing
an
Intervention
Implementing
the
Intervention
Evaluating
the
Results
PROCEED Framework
Developed in the 1980s
Last 4 phases (5-8) act as a guide for the
implementation and evaluation of the developed
intervention
Phase 5: Implementation
Phase 6: Process Evaluation (monitoring of
inputs/intervention delivery)
Phase 7: Impact Evaluation (immediate, observable
effects - short-term outcomes)
Phase 8: Outcome Evaluation (long-term outcomes)
Application of Information to Guide
Interventions
Theories
Strategies
Outcome
Skill Building Training
HMB
Education
Social Support
TRA
SCT
Motivational Training
Reminders
Social Support Group
Improved Health
Behavior
Process Evaluation
Concerned with what one hopes to accomplish during
the intervention to achieve the desired outcome
(behavioral change)
Process of monitoring how well implementing and
adhering to the specific intervention (AKA: fidelity)
Whether we are totally successful, partially successful
or unsuccessful –must have a clear picture of what was
done and not just what we hoped would be done in
order to evaluate our results
Monitoring What?
Keep track of how you are doing with respect to
the specified objectives (as they are measurable).
Document throughout implementation (daily,
weekly)
Log what is delivered or what is received
Track progress (in meeting specified activities)
Information makes it possible for intervention
adjustments
Phase 8: Impact Evaluation
Focuses on the immediate
observable effects of a
program (awareness,
knowledge, attitudes,
skills, and behaviors)
leading to the intended
outcomes of a program
Improved health behavior
Outcome evaluation
Focuses on the end result of a program
generally measured by improvements in overall
morbidity (illness)
Determines whether the intervention met the
stated goals
Considerations
Need to ensure that efforts to effect behavioral
change, factor in environmental and social
constraints…
The Environmental Imperative
Environments provide opportunities
Environments provide cues
Environments enable choices
Social environments reinforce positive
behavior and punish negative behavior
Legal penalties and financial incentives can
be built into environments
Putting it all together
Developing a physical activity
promotion program
Latina women living in inner-city communities
In Class Activity
Pair up to consider the following case:
Ms. Smith is a 45 year old Latina women who is overweight and
has problems managing her Type II diabetes. She receives a
very small retirement income. She lives off the 110 freeway (in
Vernon) having no access to safe walking areas or parks in the
neighborhood. She also expresses that her very large family
(many of whom still live with her) requires a lot of her time for
providing childcare.
As a public health professional charged with helping Ms. Smith
manage her diabetes…what do you need to consider?
Formative evaluation & baselines
for outcome evaluation
Determinants of Health
Phase 5
Administrative &
policy assessment
Phase 4
Educational &
ecological
Points of the assessment
Phase 3
Behavioral &
environmental
assessment
Causal Chain
Theory
Public
Health
Predisposing
Health
Problem
Scope
Reinforcing
Behavior
Health
Interventions
Self Study of
Needs
Risk Factors
Health
education
INPUTS
Phase 2
Phase 1
Epidemiological
Social
assessment
assessment
Policy
regulation
organization
Environment
Quality of
life
OUTPUTS
Enabling
Risk Conditions
Objectives
*Using
Phase 6
Baselines Implementation
Activities
Phase 7
Process evaluation
Ongoing
Monitoring/Data
Collection
Phase 8
Impact evaluation
Measurement/Data
Collection
Phase 9
Outcome evaluation
Data Analysis: Are
Objectives met?
Activity Feedback
Individual-level health behavior factors may include:
Increase her knowledge about the disease
Change her attitudes
Increase her “self-efficacy”
Group level health behavior factors:
Identify family constraints and encourage family social support
of changed practices (diet, exercise)
Ecological level health behavior factors:
Ms. Smiths’ environment is important to consider, in terms of
addressing: low income, lack of access
These factors will guide the selection of health behavior theories to
inform interventions (which will look different, depending on the
factors).
Summary
Selecting or writing the appropriate educational goals
and objectives is important for any health education
program.
The selection of an objective should always consider
the resources available to achieve that objective.
A needs assessment is an important step to take before
selecting or writing objectives or selecting methods.
Summary
Goals may be general, but objectives must be specific
and measurable.
In writing objectives, the educational purposes
(outcome) must be considered.
All domains should be considered if adequate time and
resources are available.
More on Interventions
How do you change health behavior?
Health Education – a major tool of health
promotion
Health Education Defined
Aimed at bringing about behavioral changes in
individuals, groups, and larger populations from
behaviors that are presumed to be detrimental
to health, to behaviors that are conducive to
present and future health
Simonds, 1976
Health education can facilitate
behavior change in:
Individuals
Groups
Larger Populations
Changing Individual Behavior
Modification of individual behavior – on a oneon-one basis
Clinical or counseling setting
Examples: Mother receiving consultation on
how to BF newborn baby; planned parent hood
education on STD prevention
Changing Group Behavior
Attempts to change the health behavior of
multiple individuals in a group
community setting, school
Examples: Learning healthy eating habits by
participating in weight management program;
BF support group
Behavior Change in Larger Populations
Community level behavior change attempts to
change the health behavior of larger
populations
Tranfat ban in California restaurants
Examples: Learning healthy eating habits by
participating in weight management program
Example…
Health Education Practice Concerned with
factors that hinder health behavior change
Since the 1990s many public schools have
stopped having regular PE classes.
What health behavior are schools hindering?
What type of health education intervention
might be implemented to address this concern?
Broader Definition of Health
Education
Includes…
Policy
Advocacy
Campaigns
Policy Examples…
Policies related to maternity leave
Norway: 42 weeks with full pay or 52 weeks with
80% of salary
Flexible part time work is available for women after
giving birth with income supplemented by
maternity benefits
Women are entitled to 1 to 1.5 hour breaks to
return home to BF or bring child to work
Soda ban
Junk food ban in vending machines
Advocacy Examples…
BF promotion among working mothers
Mothers against drunk driving
Campaign Examples…
Reducing HEP B Risk
Other approaches
Community Mobilization: persuading
community members to attend or participate in
activity planned by health educator
Community organization: mobilize (coordinate
resources) to solve a mutual problem or pursue
mutual goals (community forums)
Networking: important fxn of health promotion
– to accomplish mutually set objectives
Coalition building: group of organizations to
pursue common goal related to health
Advocacy: working for political, organizational
change on behalf of interest group