Members of Pro-Change Behavior Systems, Inc. recently presented to standing room only audiences at the Society of Behavioral Medicine Annual Conference in San Diego. Topics ranged from depression prevention to multiple health risk intervention to smoking cessation. Also presented as part of symposia were findings on theory-based approaches to health interventions across various communication channels and a Transtheoretical Model based approach to health coaching using Computerized Tailored Interventions (CTIs).
The first symposium, organized by Dr. Kerry Evers and entitled “Innovative, Theory-Based Approaches to Health Interventions Across Various Communication Channels,” included overviews of three health interventions being distributed through distinct communication channels. All three interventions utilized a theoretical framework as the centerpiece for content development and offered examples of successfully disseminating innovative, science-based health interventions. The presentation by Dr. Leanne Mauriello reviewed the overarching use of theory in the development of healthy lifestyle and obesity prevention CTIs for student populations.
The second symposium entitled “Disseminating and Implementing Computerized Tailored Intervention Now and in the Future: Who’s Reached and Who’s Not” focused on how new technologies can contribute to health disparities due to the relatively slow diffusion of innovations, particularly to underserved populations. CTIs have growing evidence of efficacy and effectiveness as innovative technologies but also have barriers to reaching those who could benefit from them. Dissemination and implementation research is critical to an understanding of how best to expand the reach and impact of CTIs. Dr. Evers discussed barriers from the industry perspective and strategies for dissemination and commercialization.
Dr. Janet Johnson, presenting for Dr. Deborah Levesque, described a randomized trial of a stage-based CTI for depression in primary care. The treatment produced reliable and clinically significant improvement in level of depression, prevention of major depression among patients experiencing only subclinical symptoms at baseline, and progress to the Action or Maintenance stage among patients in a Pre-Action stage at baseline. Strengths of the Pro-Change approach include its low cost, easy access at home, and foundation in an empirically validated model of behavior change.
Another presentation discussed a study of a brief stage-tailored health risk CTI delivered by Quality Health Solutions, Inc. The study conducted by Pro-Change investigated the prevalence of multiple behavioral risk factors among a set of employees, changes in risk status following the brief stage-matched intervention, and relationships between changes in risk status and worker productivity and quality of life. Dr. Janet Johnson presented evidence supporting relationships between the reductions in behavioral risks and improvements in productivity and quality of life.
The final presentation discussed a meta-analytic study of the effectiveness of Transtheoretical Model (TTM) based smoking interventions over time. The TTM is the theoretical foundation for many diverse smoking cessation interventions, with variable outcomes. Systematic, narrative reviews of the TTM’s efficacy have arrived at conflicting conclusions. The current study found, in general, that participants in treatment conditions were anywhere from 25% to 56% more likely to have quit smoking compared to participants in comparison conditions. Moreover, effect sizes were sustained at long-term 24-month follow-ups. Patricia Castle, M.A. showed that the patterns of effects over time support the efficacy of TTM cessation interventions across a range of settings. Pro-Change’s programs apply TTM tailoring in the manner that produces the best effects.
About the Presentations
“Innovative, Theory-Based Approaches to Health Interventions Across Various Communication Channels,” Kerry E. Evers, Ph.D., Pro-Change Behavior Systems, Inc.; Jay Maddock, University of Hawaii at Manoa; Leanne M. Mauriello, Ph.D., Pro-Change Behavior Systems, Inc. abstract
Abstract: In the past decade the development and testing of health promotion and behavior change interventions have proliferated. Some of the challenges for the future include wider reach, broader dissemination channels, and continued attention focused on promoting science and evidence-based practices. Innovative strategies for integrating theoretical models in the development of health interventions and for designing for dissemination from the start of development are important for the future. The appeal and disadvantages of different communication channels in regard to implementation and practicality need to be considered, as well as recommendations for integration of health interventions across communication channels.
“A Transtheoretical Model-Based Approach to Health Coaching using Computerized Tailored Interventions.” Kerry E. Evers, Ph.D., Sara S. Johnson, Ph.D., Janice M. Prochaska, Ph.D., Pro-Change Behavior Systems, Inc. abstract
Abstract: The World Health Organization (WHO) has estimated that by 2015, world deaths from lifestyle diseases will double unless major efforts are taken to change lifestyle behaviors (WHO, 2007). Computerized Tailored Interventions (CTIs) based on the Transtheoretical Model (TTM) have been shown to be effective for a variety of behaviors. Using assessment data from all of the constructs of the TTM, CTIs often use expert system technology to provide dynamically tailored, individualized feedback to participants. The programs rely on empirically derived decision rules and expert system logic to match intervention strategies to where individuals are in the process of change and facilitate forward stage movement. This theoretically driven, individualized approach has been successful for increasing stress management, exercise, and weight management in home- and worksite-based interventions delivered via print or the Internet in participants’ homes or through their employers. CTI can also enhance the delivery and maximize the effectiveness of telephone coaching sessions, a common communication vehicle for health behavior change and disease management programs that is in high demand among many employers and health plans. The expert system technology that is central to CTIs can increase fidelity of the intervention by replacing traditional clinical decision making on the part of the coach with evidence-based behavior change guidance. The coach is ushered through brief but reliable and valid assessments that are tailored to the individual participant. The expert system can then generate feedback based on empirical decision-making rules. An added advantage of the integration of CTIs into coaching calls is that the participant can interact with the intervention online between sessions to further facilitate progress.
“Randomized Trial of a Stage-Based Intervention for Depression in Primary Care,” Deborah A. Levesque, Ph.D., Deborah F. Van Marter, M.P.H., Janice M. Prochaska, Ph.D., Pro-Change Behavior Systems, Inc.; Robert J. Schneider, Ed.D., Mark R. Bauer, M.D., Harvard Vanguard Medical Associates, David N. Goldberg, M.D., John Stroger Hospital of Cook County; James O. Prochaska, Ph.D., University of Rhode Island. abstract
Abstract: Depression Prevention: Nine hundred and two adults at risk for depression were recruited from primary care waiting rooms and by telephone. The treatment group received a stage-based manual and an individualized printed report in the mail at baseline, and additional individualized reports at 1 and 3 months follow-up. The treatment and control groups were assessed by phone at 0 and 9 months. At nine months with individuals who were in a Pre-Action stage for depression prevention at baseline, treatment group participants were significantly more likely than controls to experience a clinically significant reduction in depression (37% vs. 17%, respectively), to be in the Action or Maintenance stage for depression prevention (70% vs. 55% respectively), and to be taking antidepressant medication if prescribed (71% vs. 50%). Among study participants who were in the Action or Maintenance stage at baseline, the intervention prevented the onset of depression (11% of treatment participants vs. 19% of control participants experienced a new episode of Major Depression during the follow-up period).
“Results of a brief stage tailored health risk intervention and relationship to quality of life and productivity,” Janet L. Johnson, Ph.D. and Patricia H. Castle, M.A. abstract
Abstract: This study looks at behavior change and impacts on quality of life and productivity among employees who participated in a health risk intervention that provided stage targeted messages on multiple health behaviors. Participants who completed an assessment in both 2006 and 2007 included 3492 employees at a Midwestern university. The majority were female (73.1%) and white (92.7%) with a mean age of 42 (sd=10.9). Among those at risk for each behavior at time 1, 25.8% stopped smoking, 34.0% began exercising regularly, 30.3% began eating a healthy diet, 58.8% began effectively managing stress, 52.4% began drinking responsibly, 68.0% began preventing depression at time 2. The behaviors that showed the greatest proportion of people who had not been at risk regressing into at-risk status were exercise (21.4%), fruit and vegetable intake (20.5%), healthy eating (10.8%), and stress management (11.6%). Individuals showed positive change (i.e. reduced risk) on an average of .68 behaviors, t(3491)=43.46, p<.001, d=.74. The negative change (increased risk) averaged .49 behaviors (t(3491)=39.14, p<.001, d=.66). The negative change appears to be driven by the higher rates of new risk for exercise and eating behaviors. By summing the change scores we calculate an average net change of .19 behaviors which represents a small significant improvement in overall behavioral risk status, t(3491)=8.94, p<.001, d=.15. The relationship of behavior change to quality of life and productivity measures were also examined. Among those who were at risk for a behavior at time 1, small improvements on productivity and quality of life were found for those who were not at risk at time 2, (eta-squared= .01 to .07). Similarly, among those who were not at risk at time 1, those who became at risk at time 2 showed small declines in productivity and quality of life (eta-squared=.01 to .07). Behavior change can significantly impact quality of life and productivity. By using stage tailored messages to improve behavior change, quality of life and productivity can also be impacted.
“The Use of Theory in Developing Interactive Interventions to Promote Healthy Lifestyles among Student Populations,” Leanne M. Mauriello, Ph.D., Carol O. Cummins, M.Ed., M.L.I.S., Karen J. Sherman, B.A., & Sharon J. Dyment, M.P.H., Pro-Change Behavior Systems, Inc. abstract
Abstract: As the rates of obesity increase and the consequences become more severe, the successful promotion of healthy lifestyle behaviors to student populations becomes ever more important. Risk factors for chronic disease begin in childhood, adolescence, and young adulthood, and consequently, prevention efforts must begin early. Interactive technologies are a promising means for developing and disseminating health behavior change interventions on a population basis to students. With improved program retention, wider reach, and less reliance on staff for delivery, interactive technologies offer a cost-effective means of delivering interventions. In addition, youthful users enjoy the appeal and interactivity of such programs. Despite the benefits, to date there has been a lack of effective evidence-based, theory-grounded interactive interventions for youth in the areas of obesity prevention and healthy lifestyle promotion. Innovative, multiple behavior, theory-based, interactive interventions are in development for student populations, ranging from elementary school to college populations. The Transtheoretical Model (TTM) guided the development of each of these interventions, including the development of measures, the creation of tailored feedback messages, the selection of images, and the design of interactive components such as online workbooks, videos, and testimonials. It is important to carefully and thoroughly utilize a theoretical framework throughout all aspects of intervention development.
“A Meta-Analytic Study of TTM Smoking Cessation Interventions,” Patricia H. Castle, M.A., Pro-Change Behavior Systems, Inc.; Colleen A. Redding, Joseph S. Rossi, University of Rhode Island. abstract
Abstract: Smoking causes 35% of all cancers, 33% of all heart attacks and strokes, and 90% of COPD. In spite of its risks, 22% of the population still smokes. These facts underscore the importance of population-based smoking cessation interventions. The Transtheoretical Model (TTM) is the theoretical foundation for many diverse smoking cessation interventions, with variable outcomes. Systematic reviews of the TTM’s efficacy have arrived at conflicting conclusions. This study compared effect sizes across 24 randomized controlled trials (including a combined sample size of N=27,190) of TTM cessation treatments using meta-analytic procedures to examine the 24-hour point prevalence smoking abstinence rates across time. These 24 studies were conducted in a range of community (37.5%), school (4.2%), and health care (58.3%) settings; most targeted smoking only (91.7%), many used proactive recruitment strategies (79.2%), and more than half were conducted outside the U. S. (62.5%). Intervention modalities ranged from counseling (41.9%) to computer-based expert systems (32.3%). Most comparison groups were usual care (79.2%) and the remainder were assessment only (20.8%). Odds ratios (OR) and 95% confidence intervals were computed revealing a series of significant pooled ORs over time ranging from 1.25 – 1.56 across time points ranging from 1 month to 24 months. Overall effect sizes were larger for studies that used (1) three/four TTM constructs compared to one/two constructs, and (2) a computerized tailored expert system modality compared to counseling. In general, participants in treatment conditions were anywhere from 25% to 56% more likely to have quit smoking compared to participants in comparison conditions. Moreover, effect sizes were sustained at long-term 24-month follow-ups. These patterns of pooled effect sizes over time support the efficacy of TTM cessation interventions across a range of settings.