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Transcript of Michael P. O’Donnell, PhD, MBA, MPH AMSO & His POSSE: A Framework to Develop Effective...
Michael P. O’Donnell, PhD, MBA, MPHMichael P. O’Donnell, PhD, MBA, MPH
AMSO & His POSSE: A Framework to AMSO & His POSSE: A Framework to Develop Effective Organization and Develop Effective Organization and
Individual Behavior Change ProgramsIndividual Behavior Change Programs
What Works Best? What Works Best? Strategy to Develop the FrameworkStrategy to Develop the FrameworkSystematic Benchmarking study
– Good, very good, best programs
Systematic literature reviews– Health impact of programs– Financial impact of
programs
Refining framework
Background C Everett Koop Award
– Health impact– Financial impact
Composite reviews– 1800+ manuscripts
Design/manage programs– 100+ organizations
HUH?HUH?
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Sampling of Theories Sampling of Theories Not to mention the statistics!Not to mention the statistics!Individual level Learning Theories Information processing Health Belief Model Protection Motivation Theory; Extended Parallel
Process Model Theories of Reasoned Action, Planned Behavior, and
Integrated Behavior Model Goal-Setting Goal goal-directed behavior Automatic behavior, impulse behavior, habits Transtheoretical Model of Behavior Change Precaution Adoption Process Model and risk
communication Attribution Theory and Relapse Prevention Communication-Persuasion Matrix Elaboration Likelihood Model Self Regulation
Interpersonal environment Social Cognitive Theory Stigma and Discrimination Diffusion of Innovation Social networks and social support
Multi-level Systems Power Empowerment
Organization level Stage Theory of Organization Change Stakeholder Theory
Community level Coalition Theory Social Capital Theory Social norms Conscientization Community Organization
Society and government level Agenda-building Multiple Streams Advocacy Coalition
Source: Bartholomew LK, Parcel GS, Kok G, Gottleib NH, Fernandez ME, Planning Health Promotion Programs, 3rd 2011, Jossey-Bass
AMSO AMSO Behavior Change Program PortfolioBehavior Change Program Portfolio
Awareness
Motivation
Skills
Opportunity
5%
30%
25%
40%
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Dimensions of Opportunity:Dimensions of Opportunity:Engaging the POSSEEngaging the POSSEP: Peers
O: Organizations
S: State
S: Society
E: Environment
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Applying the AMSO FrameworkApplying the AMSO Framework
Critique existing program Plan a new program Help an individual change habits Examine progress in your own life
Focus on the framework Focus on the framework
Details will become intuitiveDetails will become intuitive
Michael P. O’Donnell, PhD, MBA, MPH © 2010
AwarenessAwareness
Basis of Most Health Education– Health Risk Factors– Benefits of Healthy Lifestyle
What is the Impact of Awareness on Behavior?– eg. tobacco use
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Note: Data from participating states and the District of Columbia were aggregated to represent the United States.Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2003, 2005, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2004, 2006, 2008.
24.2 24.4 24.1 24.4 23.6 24.3 24.7
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1994 1996 1998 2000 2003 2005 2007
Year
Pre
vale
nce
(%)
Trends in Consumption of Five or More Recommended Vegetable and Fruit Servings for Adults 18 and Older, US, 1994-2007
Trends in Prevalence (%) of No Leisure-Time Physical Activity, by Educational Attainment, Adults 18 and Older, US, 1992-2007
Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Educational attainment is for adults 25 and older.Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2002, 2004, 2005, 2006, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2003, 2005, 2006, 2007, 2008.
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vale
nce
(%)
Adults with less than a high school education
All adults
AwarenessAwareness
Basis of Most Health Education– Health Risk Factors– Benefits of Healthy Lifestyle
What is the Impact of Awareness on Behavior?
Important Role in Mobilizing Group Support
Michael P. O’Donnell, PhD, MBA, MPH © 2010
AMSO AMSO Behavior Change Program PortfolioBehavior Change Program Portfolio
Awareness
Motivation
5%
30%
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Enhancing MotivationEnhancing Motivation
Embrace people as whole beings Engage people in design and delivery process Develop effective communication Utilize extrinsic and intrinsic incentives Provide effective leadership Tailoring programs (Skill Building discussion) Engage with health assessment
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Embrace People as Whole BeingsEmbrace People as Whole Beings
Focusing on health risk usually does not work
Embrace people as whole beings Help people discover their passions Help people link passions with health Help people make a plan to achieve their goals
Motivational interviewing approach
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Engage People in ProcessesEngage People in Processes
Wellness committees Market research Mentorships Champions Effective programs
Confidentiality & Transparency
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Develop Effective CommunicationDevelop Effective Communication
Consistent with corporate culture Professional Ubiquitous
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Utilize Extrinsic and Intrinsic IncentivesUtilize Extrinsic and Intrinsic IncentivesExtrinsic (Financial) Rewards
- Can push participation from 20% to 90%+- Capture attention, increase participation- Limited long term impact on behavior- Danger of attributing behavior to the incentive vs. intrinsic
benefits
Evolve to Intrinsic Rewards- Life priorities- Self image- Passions- Relationships- Quality of life
Incentives and whole program can be self funded through health plan benefit design. Sec 2705 PPAACA.
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Provide Effective LeadershipProvide Effective Leadership
Recognize importance of programs Provide appropriate budget Serve as active program champions Be visible program participants
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Engage with Health AssessmentEngage with Health Assessment
Health risk questionnaire Biometric screenings
Motivates because it helps people understand the link between lifestyle and health in a personal way.
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Think about Think about your programyour program
Michael P. O’Donnell, PhD, MBA, MPH © 2010
AMSO AMSO Behavior Change Program PortfolioBehavior Change Program Portfolio
Awareness
Motivation
Skills
5%
30%
25%
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Skill BuildingSkill Building
Beyond Why and What to How, When,
Where, With Whom and What If’s Goal Setting Tailoring Utilizing the Best Science Mastering New Behaviors Integrating Behaviors into Life
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Goal Setting Goal Setting
Doubles success rates Aspirational, learning & performance goals Expert guidance & personal buy in
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Tailoring Tailoring
Level of self efficacy and behavioral efficacy Preferred learning style Genetic predisposition Motivational readiness to change Health status Level of intensity
Confidentiality & transparency
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Self EfficacySelf Efficacy
Belief one can successfully perform behavior
Predicts– Joining program– Completing program– Time to relapse
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Behavioral EfficacyBehavioral Efficacy
Belief a behavior leads to desired outcome
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Focusing EffortsFocusing Efforts
High
High
Low
LowSelf Efficacy
BehavioralEfficacy
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Genetic Predisposition, Physical and Mental Condition
– Athletic ability and experience– “Runner’s High”– Weight– Addiction– Physical disability– Mental illness
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Preferred Learning Style Preferred Learning Style by Lifestyle Topic by Lifestyle Topic
Print Telephone Web Individual face to face Group
Confidentiality & transparency
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Motivational Readiness to Motivational Readiness to ChangeChange
– Precontemplation Never 40%– Contemplation Later 40%– Preparation Soon 20%– Action Now– Maintenance Trying to be forever– Termination Probably forever
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Tailoring by Stages of Tailoring by Stages of Motivational ReadinessMotivational Readiness
Precontemplation – Unconditional acceptance– Indirect comments
Contemplation – Enhance Behavioral Efficacy– Enhance Self Efficacy– Expose Social Networks– Aspirational Goal Setting
Preparation– Learning Goal Setting– Enhance Self Efficacy– Enhance Behavioral Efficacy– Introduce to Social Networks
Action– Performance Goal Setting– Skill Building– Engage in Social Networks
Maintenance– Maintain Social Networks– Offer Leadership Opportunities– Reinforce Self Efficacy– Reinforce Behavioral Efficacy
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Tailoring Tailoring
Motivational readiness to change Level of self efficacy and behavioral efficacy Preferred learning style Genetic predisposition Health status Level of intensity
Confidentiality & transparency
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Utilize the Best ScienceUtilize the Best Science
Effects of Integrated Medication and Effects of Integrated Medication and Behavioral InterventionsBehavioral Interventions
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BriefAdvice
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al Lo
ng T
erm
Quit
R
ate
s
Rates doubled with brief advice & triple combining pharmacological and behavioral inventions
Hughes JR. CA Cancer J Clin. 2000; 50: 143-151.
Best Science for Tobacco Treatment
Meta-analyses of 27 different topics Combined approaches: Brief MD advice+ behavior therapy +
medication Minutes of therapy: 300 Number sessions: 8 Type and number of staff: 2-3 including one physician Medication type: outcomes by medication Behavioral therapy type: outcomes by type
Treating Tobacco Use and Dependence: 2008 Update, Fiore, et al, HHS
Best Methods for Weight Control?
?
?
?
?
?
?
?
?
Workplace Health PromotionOverall Processes
What Works in Worksite Health Promotion: Systematic Review Findings and Recommendations from the Task Force on Community Preventive Services
Robin E. Soler, Nicholaas Pronk, Ron Goetzel
American Journal of Preventive Medicine
Volume 38(2) Supplement 2, February, 2010
The Community Guidehttp://www.TheCommunityGuide.org/worksite
Scope of ReviewScope of Review
Health Assessment with Feedbackvs
Health Assessment with Feedback Plus Intervention
Incentives and Competition to Reduce Tobacco Use Smoke-free Policies to Reduce Tobacco Use Point of Decision Prompts to Increase Stair Use
Health Assessment with Feedback
ConclusionConclusion: Insufficient evidence to recommend
ReasonsReasons: Small effect size Small number of studies (32) Poor study design
Health Assessment with Feedback Plus Intervention* ConclusionConclusion: Strong evidence of effectivenessTobacco use (30) - 1.5 % pp prevalence - 2.3 % consumptionDietary fat consumption (11) - 5.4 % pp prevalenceBlood Pressure control (31) - 4.5 % pp prevalenceCholesterol management (36) - 6.6 % pp prevalence - 4.8 mg/dlAbsence from work (10) - 1.2 days/year less
ConclusionConclusion: Sufficient evidence of effectivenessSeat belt use (10) - 27.6 % pp prevalenceHeavy drinking (9) - 2.0 % pp prevalencePhysical activity (18) -15.3 % pp prevalenceHealth risk score (21)Medical utilization (7)
ConclusionConclusion: Insufficient evidence of effectivenessFitness (9) positive outcomes small effect sizes, multiple measuresBody composition (27)- BMI (8) -.5 BMI unit consistent findings- Weight (17) -.56 pds small effect size- Fat (6) -2.2 % small effect size
ConclusionConclusion: Not effectiveFruit and vegetable consumption (8) minimal changes observed
*Numbers of studies are shown in parentheses ( )
Mastering New BehaviorsMastering New Behaviors
Translating skills into practice Forming new habits
How long does it take for new skills to become established habits?
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Integrating Behaviors into LifeIntegrating Behaviors into Life
How to overcome barriers How to overcome social influences How to create opportunities
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Think about Think about your programyour program
Michael P. O’Donnell, PhD, MBA, MPH © 2010
AMSO AMSO Behavior Change Program PortfolioBehavior Change Program Portfolio
Awareness
Motivation
Skills
Opportunity
5%
30%
25%
40%
Michael P. O’Donnell, PhD, MBA, MPH © 2010
POSSE: POSSE: The Dimensions of OpportunityThe Dimensions of Opportunity
P: Peers
O: Organizations
S: State
S: Society
E: Environment
Michael P. O’Donnell, PhD, MBA, MPH © 2011
Posse:A large group with a common interest..Merriam Webster..Merriam WebsterYour crew, your hommies, people who (sometimes) have your back…Urban Dictionary…Urban Dictionary
P:P: PeersPeers
Most important influence groupMost important influence group
- Close friends
- Close co-workers
Michael P. O’Donnell, PhD, MBA, MPH © 2011
Social Networks and LifestyleSocial Networks and Lifestyle Design: Framingham Heart Study; longitudinal observational
study Sample: 12,067 people, 3 generations
– 53% women 47% men– 21-70 years, mean 38– 0-17 years of education, mean 13.6
Measures: Biometrics including BMI– All 1st order relatives– At least one close friend– Neighbors– 1973,1981,1985,1989,1992,1997,1999,2003
Obesity, smoking, depression, alcohol
Christakis, NEJM, 357;4;2007Michael P. O’Donnell, PhD, MBA, MPH © 2010
Probability That an Ego Will Become ObeseBecome Obese According to the Type of Relationship with an Alter Who May Become Obese in Several Subgroups of the Social Network of the
Framingham Heart Study
Christakis NA, Fowler JH. N Engl J Med 2007;357:370-379
Likelihood & degrees of separation1: 45%2: 20%3: 10%
Geographic separationEffect maintained 0,.26,1.5,3.4,9.3,471 miles
Probability That a Subject Will Quit SmokingQuit Smoking According to the Type of Relationship with a Contact Who Quits Smoking, in the Social Network of the Framingham Heart Study
Christakis NA, Fowler JH. N Engl J Med 2008;358:2249-2258
O:O: OrganizationsOrganizations Employer
– Health promotion program– Smoke free campus, hiring smokers– Absenteeism, health plan, compensation– Nurturing vs. toxic mission and management– Safety hazards/protections – Cafeteria, walkable campus, fitness center
Faith Community– Norms, mission, messages– Access to programs
Schools, especially for families with children Clubs Others?
Employers need to leverage or overcome the influence of Employers need to leverage or overcome the influence of other organizationsother organizations
Michael P. O’Donnell, PhD, MBA, MPH © 2011
S: the “State”S: the “State” National policy
– Agriculture, transportation, education policy– National campaigns: SBWG, national HP strategy– Support for health research– Integration of wellness into Medicare & insurance policy– Social safety net– Tobacco policy
State policy– Smoke free workplace laws, quitline coverage– Gun safety laws– Speed limits, helmet policies– Medicaid eligibility and scope of services
Local policy– Smoke free public places– Tobacco excise taxes– Restaurant ingredients & labeling– Local campaigns – Active transportation options– City planning, zoning, pollution control
Michael P. O’Donnell, PhD, MBA, MPH © 2011
Are you a passive citizen or a policy advocate?Are you a passive citizen or a policy advocate?
0.0
5.0
10.0
15.0
20.0
25.0
30.0
2003 2004 2005 2006 2007 2008 2009
USA
Ohio-minus CuyahogaCountyCuyahoga County
Michael P. O’Donnell, PhD, MBA, MPH © 2010
Smoking Rates, Cleveland, Ohio & US, 2003-2009
S:S: SocietySociety Broad cultural norms
– Fitness & sports: 25,000 finished US marathon in 1976, 507,000 in 2010– Second hand smoke: annoyance in 1980, deadly in 2011– Smoke free workplaces: rare in 1980, the norm in 2011– Vegetarian diet
Ethnic norms– Expressing emotions– Significance of food– Asking for help and helping others– Eg. Cultural value of familismo, respeto, simpatia and personalismo
make Hispanic/Latino families want to protect their families from second hand smoke BUT reluctant to ask neighbors to refrain from smoking
Celebrity role models– Oprah weight loss and gain– Starlets pursuit of perfect body– Actors smoking in movies– Miss Universe Sushmita Sen (India), 1994
Michael P. O’Donnell, PhD, MBA, MPH © 2011
Baezconnde-Garbanati, AJHP, 2011
E:E: EnvironmentEnvironment Assess to smoke free clean air
– At work– Restaurants– Public spaces
Access to nutritious affordable food– Cafeteria at work– Neighborhood stores
Opportunities for physical activity
Michael P. O’Donnell, PhD, MBA, MPH © 2011
Designing Activity-Friendly Buildings
• If the average person spent only one more minute per day going upstairs, they would burn an extra 2900 kcal per year, or .8 pounds.
• For only 2 minutes per day, that’s more than 1.5 pounds per year.
Source: Jim Sallis Ph.D., San Diego State University
Typical American gains 2 pounds per year after college
The Impact of Sprawl on Health and Behavior
Urban Sprawl Utilitarian walking Leisure time
walking Increases BMI Increases in BP
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Low Sprawl Average High Sprawl
Minutes Walked
Source: Ewing et al. (2003) AJHP
The Effect of Mixed Use on Obesity
Participants were divided into four groups based on the level of land use mix
Each quartile increase in land use mix was associated with a 12.20% reduction in the odds of being obese.
The difference in weight for an average 5’ 10” white males in the lowest quartile of mixed use and the highest quartile of mixed use was 10 pounds.
Frank, L., Andresen, M., and Schmid, T., Obesity Relationships With Community Design, Physical Activity, and Time Spent in Cars. American Journal of Preventive Medicine. June 2004.
Daily steps are higher among adults who commute by train instead of car
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Ave
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aily
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Wener RE, Evans GW. A morning stroll: Levels of physical activity in car and mass transit commuting. Environment and Behavior 2007; 39(1): 62-74.
Pedometer data collected from over 100 New Jersey train and car commuters revealed that those who commuted by train walked 30% more steps a day and were 4 times more likely to meet recommended 10,000 steps daily than car commuters.
Driving is a risk factor for obesity
10%
14%
27%
18%
0%
5%
10%
15%
20%
25%
30%
Lowest Quarter Highest Quarter
Vehicle miles traveled
% o
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(BM
I>30
)
Lopez-Zetina J, Lee H, Friis R. The link between obesity and the built environment. Evidence from an ecological analysis of obesity and vehicle miles of travel in California. Health & Place 2006; 12(4):656-664.
A study of 33 California cities found that adults who drove the most had obesity rates (27%) that were three times higher than those who drove the least (9.5%).
The Impact of Driving and Walking on Obesity
Every additional 30 minutes spent driving per day translates into a 3% increase in the odds of being obesity
Every additional Kilometer (.6 miles) walked translates into nearly a 5% reduction in the odds of being obese
Frank, L., Andresen, M., and Schmid, T., Obesity Relationships With Community Design, Physical Activity, and Time Spent in Cars. American Journal of Preventive Medicine. June 2004.
OpportunityOpportunity
Genetic Predisposition, Physical and Mental Condition– Athletic ability– “Runner’s High”– Weight– Addiction– Physical disability– Mental illness
Natural Environment
Santa Cruz: body surfing & cycling Michigan: indoor swimming & X country
skiing Seoul: hiking in the mountains Pittsburgh: crew
Michael P. O’Donnell, PhD, MBA, MPH © 2010
EnvironmentEnvironmentWill you choose your environment?
Will you shape your environment?
Or
Will your environment shape you?
Michael P. O’Donnell, PhD, MBA, MPH © 2011
Think about Think about your programyour program
Michael P. O’Donnell, PhD, MBA, MPH © 2010
AMSO & HIS POSSEAMSO & HIS POSSE
Awareness
Motivation
Skills
Opportunity
5%
30%
25%
40%
Michael P. O’Donnell, PhD, MBA, MPH © 2010
FOCUS ON THE FRAMEWORKFOCUS ON THE FRAMEWORK
What is stalling change What is stalling change at a personal level?at a personal level?
Think of a behavior or health issue you or associate “should” be addressing but are not
Clarify role: Active listener or stalled changer Reflect on why you are not addressing it
– Lack of Awareness– Lack of Motivation– Lack of Skills– Lack of Opportunity
Michael P. O’Donnell, PhD, MBA, MPH © 2010
How well does your program help How well does your program help your employees improve?your employees improve?
Think about a health behavior or condition that has not improved very well through your wellness program
Clarify role: Active listener or program analyzer Review how you scored your program on AMSO Framework Discuss areas that you would like to improve your program
– What changes would have the most impact?– What changes are you most able to change?– What is your plan for areas with greatest impact that you are able
to change?
Michael P. O’Donnell, PhD, MBA, MPH © 2010
How well does your program help How well does your program help your employees improve?your employees improve?
Think about a health behavior or condition that has not improved very well through your wellness program
Clarify role: Active listener or program analyzer How well does your program do each of the following?
– Enhance Awareness– Motivate Change– Convey Skills– Provide Opportunity
Michael P. O’Donnell, PhD, MBA, MPH © 2010
AMSO AMSO Behavior Change Program PortfolioBehavior Change Program Portfolio
Awareness
Motivation
Skills
Opportunity
5%
30%
25%
40%
Michael P. O’Donnell, PhD, MBA, MPH © 2010