High Impact Tools for High Impact Tools for Health PromotionHealth Promotion

James O. Prochaska, Ph.D.James O. Prochaska, Ph.D.Director and Professor

Cancer Prevention Research CenterUniversity of Rhode Island

FounderPro-Change Behavior Systems, L.L.C.

The Stages of Change:The Stages of Change:

MaintenanceMaintenance

ActionAction

PreparationPreparation

ContemplationContemplation

PrecontemplationPrecontemplation

Intervention IssuesIntervention Issues

1. Recruitment1. Recruitment2. Retention2. Retention3. Progress3. Progress4. Process4. Process5. 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

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

Pros and Cons of Arranging Pros and Cons of Arranging Follow-up AppointmentsFollow-up Appointments

40

45

50

55

60

PC C P A M

Pros

Cons

T S

core

s

Stage

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

0

5

10

15

20

25

30

ReactiveRecruitment

ProactiveRecruitment

Baseline

Per

cen

tage

6 months 12 months 18 months

Assessment Periods

Proactive vs. Reactive RecruitmentProactive vs. Reactive Recruitment

Percentage in Action/MaintenancePercentage in Action/Maintenance

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

Smoking Point PrevalenceSmoking Point PrevalenceHomeHome

0%

5%

10%

15%

20%

25%

30%

35%

40%

Baseline 12 Month 24 Month

TreatmentControl

% in

Act

ion

and

Mai

nten

ance

Diet Point PrevalenceDiet Point Prevalence(all subjects - PO1 School Adult Sample)(all subjects - PO1 School Adult Sample)

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 PrevalenceHomeHome

0%

5%

10%

15%

20%

25%

30%

35%

40%

Baseline 12 Month 24 Month

TreatmentControl

% in

Act

ion

and

Mai

nten

ance

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%

Impact of Stage-Matched Impact of Stage-Matched ProgramsPrograms

Efficacy X Participation = ImpactEfficacy X Participation = Impact

Individual/Clinic:Individual/Clinic:– 30% X 5% = 1.5%30% X 5% = 1.5%

Public Health/Community:Public Health/Community:– 6% X 75% = 4.5%6% X 75% = 4.5%

Stage-Matched Proactive:Stage-Matched Proactive:– 20% X 75% = 20% X 75% = 15%15%

Population Health ParadigmsPopulation Health Paradigms

Old Paradigm Old Paradigm Complemented byComplemented by New ParadigmNew Paradigm 1. Individualized Patient1. Individualized Patient 1. Entire Populations1. Entire Populations

2. Passive-Reactive Services2. Passive-Reactive Services 2. Proactive Services2. Proactive Services

3. Passive Reactive Patients3. Passive Reactive Patients 3. Proactive Populations3. Proactive Populations

4. Action-Oriented4. Action-Oriented 4. Stage-based4. Stage-based

5. Expert Clinicians5. Expert Clinicians 5. Expert Systems5. Expert Systems

6. Standard Treatment6. Standard Treatment 6. Tailored Treatment6. Tailored Treatment

7. Clinic Based7. Clinic Based 7. Home/Work Based7. Home/Work Based

8. Single Behavior8. Single Behavior 8. Multiple Behaviors8. Multiple Behaviors

9. Single Level 9. Single Level InterventionsInterventions

10. Efficacy Trials 10. Efficacy Trials

9. Multiple Level 9. Multiple Level

Interventions Interventions

10. Effectiveness Trials10. Effectiveness Trials