Founder Pro-Change Behavior Systems, Inc.

Passing Through the Stages: Passing Through the Stages: Are You Ready for Disease Are You Ready for Disease

Management?Management?

James O. Prochaska, Ph.D.

Director and ProfessorCancer Prevention Research Center

University of Rhode Island

Stages of ChangeStages of Change

PRECONTEMPLATION CONTEMPLATION

PREPARATION ACTION

MAINTENANCE TERMINATION

Intervention IssuesIntervention Issues

1. Recruitment1. Recruitment

2. Retention2. Retention

3. Progress3. Progress

4. Process4. Process

5. Outcomes5. Outcomes

Percent of Smokers by Stage Percent of Smokers by Stage Across Three Different SamplesAcross Three Different Samples

Sample Precont. Cont. Prep. N

Rhode Island 42.1 40.3 17.6 4,1444 Worksites 41.1 38.7 20.1 4,785California 37.3 46.7 16.0 9,534

ORIGINAL IMPACT EQUATIONORIGINAL IMPACT EQUATION

IMPACT = REACH X EFFICACYIMPACT = REACH X EFFICACY

IMPACT = (5% REACH) X (30% ABSTINENCE) = 1.5%IMPACT = (5% REACH) X (30% ABSTINENCE) = 1.5%

IMPACT = (75% REACH) X (20% ABSTINENCE) = 15%IMPACT = (75% REACH) X (20% ABSTINENCE) = 15%

Four Leading Recruitment Strategies

1.1. Persuasive CommunicationsPersuasive Communications

2.2. Positive ReinforcementPositive Reinforcement

3.3. Personal OutreachPersonal Outreach

4.4. Negative ReinforcementNegative Reinforcement

43

45

47

49

51

53

55

Premature Termination

Appropriate Termination

Continuers

PC

T S

core

s

C A M

Stage TransitionsStage Transitions

44

46

48

50

52

54

56

PC Cont Prep Action Maint

ProsCons

Stages by ProcessesStages by Processes

CONSCIOUSNESS RAISINGDRAMATIC RELIEFENVIRONMENTAL REEVALUATION

SELF REEVALUATION

PRECONTEMPLATION CONTEMPLATION PREPARATION

Stages by ProcessesStages by Processes

PREPARATION ACTION MAINTENANCE

SELF LIBERATION

COUNTERCONDITIONINGSTIMULUS CONTROL

REINFORCEMENT MANAGEMENTHELPING RELATIONSHIPS

1. Action-oriented Manuals1. Action-oriented Manuals

2. Stage-Matched Manuals2. Stage-Matched Manuals

3. Stage-Matched Computers & Manuals3. Stage-Matched Computers & Manuals

4. Counselors & Stage-Matched 4. Counselors & Stage-Matched

ComputersComputers

Treatment GroupsTreatment Groups

0

10

20

30

Pretest 6 12 18

Action Manuals

Stage Manuals

Computers+

Counselors+

Assessment Periods

Per

cen

tag

e

0

5

10

15

20

25

30

Counseling

Computer

Baseline

Per

cen

tage

6 months 12 months 18 months

Assessment Periods

Computer vs. CounselingComputer vs. Counseling

PROACTIVE CESSATION WITH PROACTIVE CESSATION WITH ADOLESCENTS IN PRIMARY CAREADOLESCENTS IN PRIMARY CARE

Tailored InterventionsTailored Interventions

23.9%23.9%

Assessment OnlyAssessment Only

11.4%11.4%

Proactive Cessation with Depressed Proactive Cessation with Depressed Patients Patients

Abstinence at 18 MonthsAbstinence at 18 Months

Tailored Tailored Intervention +Intervention +

24.6%24.6%

Assessment Assessment OnlyOnly

19.1%19.1%

Race

0

5

10

15

20

25

30

12 24Assessment (Month)

Po

int

Pre

vale

nce

Ab

stin

ence

White

Black

Age

0

5

10

15

20

25

30

35

40

12 24

Assessment (Month)

Po

int

Pre

vale

nce

Ab

stin

ence

<=24 25-34 35-44 45-54 55-64 65+

Percentage in Action/MaintenancePercentage in Action/Maintenancefor Stress Managmentfor Stress Managment

0

10

20

30

40

50

60

70

Baseline 6 month 12 month 18 month

TreatmentControl

2 significant (p < .001) at 6, 12, & 18 monthsPre-Action at Baseline Only

Risk Factors: Smoking, Avoid High Fat, Regular Exercise Risk Factors: Smoking, Avoid High Fat, Regular Exercise (3x/wk @ 20 min.), Use Sunscreen after 15 min. exposure(3x/wk @ 20 min.), Use Sunscreen after 15 min. exposure

0

1

2

3

4

Number ofNumber ofRiskRiskFactors in Factors in PreparationPreparationAmongAmong3,6163,616Current Current SmokersSmokers

Number inPreparation

Stage

63%

27%

8%

2%0%

Point Prevalence Smoking CessationPoint Prevalence Smoking Cessation

0%

5%

10%

15%

20%

25%

30%

35%

Baseline 12 Month 24 Month

Per

cent

in A

ctio

n/M

aint

enan

ce

Expert System

Assessment Only

Diet Point PrevalenceDiet Point Prevalence

0%

5%

10%

15%

20%

25%

30%

35%

40%

Baseline 12 Month 24 Month

TreatmentControl

% in

Act

ion

and

Mai

nten

ance

Sun Point PrevalenceSun Point Prevalence

0%

5%

10%

15%

20%

25%

30%

35%

40%

Baseline 12 Month 24 Month

TreatmentControl

% in

Act

ion

and

Mai

nten

ance

TWO YEARS OF PRIMARY TWO YEARS OF PRIMARY CARE COUNSELINGCARE COUNSELING

I.I. No effects on any of the four target behaviorsNo effects on any of the four target behaviors

II.II. No increased effect on four behaviors treated No increased effect on four behaviors treated effectively with TTM-tailored interventionseffectively with TTM-tailored interventions

TWO YEARS OF WORKSITE TWO YEARS OF WORKSITE CAMPAIGNCAMPAIGN

I. No effects on any of the multiple targeted I. No effects on any of the multiple targeted behaviorsbehaviors

II.II. No increased effect on multiple behaviors No increased effect on multiple behaviors treated effectively with TTM-tailored treated effectively with TTM-tailored interventionsinterventions

Diabetes Self Management Outcomes: Diabetes Self Management Outcomes: Percent in Action or Maintenance at 12 MonthsPercent in Action or Maintenance at 12 Months

II.

SMBG

A. Canada

B. Hawaii

I. Smoking:

A. Canada

B. Hawaii

III.

Diet

A. Canada

B. Hawaii

Treatment Assessment

26 % 15 %

25.9 % 15.9 %

40.6 %

24.1 %

31.8 %

11.5 %

38% 25 %

28 % 18%

Co-variation: The increased probability of Co-variation: The increased probability of progressing to action on a second behavior progressing to action on a second behavior (e.g. diet) when individuals have (e.g. diet) when individuals have progressed to action on an initial behavior progressed to action on an initial behavior (e.g. smoking).(e.g. smoking).

Co-variation in Co-variation in Odds Ratio Odds Ratio

Control GroupControl Group .85 .85TTM Intervention GroupTTM Intervention Group 3.443.44

ADHERENCEADHERENCETreatment Success by GroupTreatment Success by Group

Pre-action at BaselinePre-action at Baseline

0%

10%

20%

30%

40%

50%

60%

70%

Baseline 6 mo 12 mo 18 mo

ADHERENCEADHERENCERegression from A/M by GroupRegression from A/M by Group

Post-action at Baseline Post-action at Baseline

50%55%

60%65%70%

75%80%85%90%

95%100%

Baseline 6 mo 12 mo 18 mo

Exercise Staging – Adherence Group Exercise Staging – Adherence Group Progression to A/M by Group Progression to A/M by Group

(pre-action at baseline)(pre-action at baseline)

0%5%

10%15%20%25%

30%35%40%45%50%

Baseline 6 mo 12 mo 18 mo

% in

A/M

Dietary Fat Staging – Adherence GroupDietary Fat Staging – Adherence GroupProgression to A/M by Group Progression to A/M by Group

(pre-action at baseline)(pre-action at baseline)

0%

5%

10%

15%

20%

25%

30%

Baseline 6 mo 12 mo 18 mo

% i

n A

/M

Multiple Behavior Change Strategies

I. Sequential

II. Simultaneous: Modular

III. Simultaneous: Co-variation

IV. Simultaneous: Integrative

A. Bullying Prevention

B. Pro-active Health Consumer

NEW IMPACT EQUATIONNEW IMPACT EQUATION

IMPACT = REACH X EFFICACY IMPACT = REACH X EFFICACY

X (X ( BEHAVIORS CHANGED) BEHAVIORS CHANGED)