Applying Theory to Action:
Implementing Best Practices in
Behavior Change
Sara S. Johnson, Ph.D.
Senior Vice President
Pro-Change Behavior Systems, Inc.
[email protected]
Financial Finesse, 2012
What can we learn from health behavior change that might
be applicable to financial well-being?
THE TRANSTHEORETICAL MODEL
Behavior Change
Precontemplation Existing
Contemplation
Behavior
Preparation
What behavior change messages are most
effective for those who need to change?
Maintenance
Action
New Behavior
Behavior has
changed
Key concepts
• Behavior change happens along a continuum
• Individually tailored messages have effects on those who are ready,
getting ready, or not ready to change behavior
• Can have an impact on all participants – and predict future change
© 2014 Pro-Change Behavior Systems, Inc
Stages of Change
Change is a process, not an event
The Transtheoretical Model (TTM) groups the change process into
distinct stages of readiness and provides approaches to help move
people forward through the stages.
Keeping up the Changes
Making Changes
Ready
Getting Ready
Not Ready
© 2014 Pro-Change Behavior Systems, Inc
Maintenance
Action
Preparation
Contemplation
Precontemplation
Precontemplation
Not Yet Ready
Have no intention to adopt
the behavior in the next
six months
Characteristics of Precontemplation
•
•
•
•
•
Cons > Pros
Defensive, Demoralized, In Denial
Resistant
Change experienced as coerced
From 30 to 85% of population at risk
Contemplation
Getting Ready
Intend to adopt the
behavior in the
next 6 months
Characteristics of Contemplation
•
•
•
•
•
•
Pros = Cons
Ambivalent
Lack commitment
Lack confidence
‘Chronic’ contemplation
From 10 to 50% of population at risk
Preparation
Ready to Take Action
Intend to adopt the
behavior
in next 30 days
Already taking small steps
Characteristics of Preparation
•
•
•
•
•
•
•
Pros > Cons
Have a plan
Have taken small steps
Decisive/committed
More confident
“Ideal” participants
From 5 to 35% of population at risk
Action
Recently Changed
Behavior
Adopted the
behavior less
than 6 months ago
Characteristics of Action
• Individuals working to make change
• Individuals may experience strong urge to
revert back to old behavior
• Recycling to earlier stage is common
Maintenance
Changed Behavior
Adopted the behavior
at least 6 months
Characteristics of Maintenance
• Higher self-efficacy
• Dynamic, not static
• Consolidating gains
• Improved coping skills
Change ≠ Action
Stage Progression
Precontemplation
Contemplation
Preparation
PC
C
P
Action
Maintenance
Moving forward at least one stage as much as doubles the chance that
an individual will move to action in the next six months.
Decisional Balance
Benefits
Barriers
Pros & Cons by Stage of Change
Decisional Balance
Pros of Change
Cons of Change
Benefits
Barriers
Perceived Gains
Perceived Losses
Hall, KL & Rossi, JS. (2008). Meta-analytic examination of the strong and weak principles across 48 health behaviors. Preventive
Medicine, 46, 266-274.
Self-Efficacy
Self-Efficacy
Confidence
Degree to which individuals believe they can engage in a
behavior even in tempting situations
DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF. The Process of Smoking Cessation: An Analysis of Precontemplation, Contemplation,
and Preparation Stages of Change. J Consult Clin Psychol. 1991; 59:295-304.
Integration of Stages & Processes of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
Become Informed
Consider Others
Increase Emotional Awareness
Notice the Public Effort
Create New Self-Image
Make Commitment
Get Support
Use Substitutes
Rewards
Manage Environment
Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), 1102-1114.
Lessons Learned from Transtheoretical Model
• Behavior change occurs along a continuum
• Individuals have differing levels of readiness
to adopt the behaviors we are trying to
promote
• Matching interventions to different levels of
readiness is more effective than one-size-fits
all interventions or messages
• Certain principles and processes of change
work best at each stage to facilitate progress
PUTTING RESEARCH INTO PRACTICE
Transtheoretical Model Applications
Health
Smoking
Weight
Healthy Eating
Exercise
Stress ManagementBullying Prevention
Depression Prevention
Juvenile Delinquency
Responsible Drinking
Dating Violence
Sun exposure
Organ Donation
Medication Adherence
Domestic Violence
Mammography Screening
Advancing Women
Obesity Prevention Scientists
Sleep
Adoption Readiness
Pain Self-Management
Vocational Rehab/Return
to Work
Child Abuse/Neglect
Social Issues
Other Topics
Continuing Medical
Education
Organizational Change
End of Life Care Planning
Informed Decision Making
Proactive Health
Consumerism
Award-Winning Behavior Change Solutions
LifeStyle Management Suite
•URAC Gold Award for Best Practices in Health Management
•Recognized by the 2012 AHRQ Innovations Exchange
© 2014 Pro-Change Behavior Systems, Inc
Scalable, Mobile-Optimized Solutions
Assess Stage of Change
Stage-Matched Feedback
LifeStyle Management Programs: Smoking
© 2013
Pro-Change Behavior Systems, Inc
LifeStyle Management Programs: Smoking
© 2013
Pro-Change Behavior Systems, Inc
Fully Tailored Text Messages
 Frequency of messages
based upon stage
 Message content tailored to
responses from most recent
computer-tailored
intervention
 Smoking clinical trial found
an 31.6% increase in
efficacy when tailored text
messages were added to
the computer-tailored
intervention
Jordan, P. J., Lid, V., & Evers, K. E. (2012). Cell phone-enhanced expert systems to promote smoking cessation in veterans. Paper presented at the 16th
Annual International meeting and Exposition of the American Telemedicine Association in San Jose, CA, April 29-May 1, 2012.
Intervention Strategies for Precontemplation: Sample Coach Screen
Comparative Outcomes of Interventions
Johnson, J.L., Prochaska, J.O., Paiva, A.L., Fernandez, A.C., DeWees, S.L., and Prochaska, J.M. (2013) Advancing Bodies of Evidence for Populationbased Health Promotion Programs: Randomized Controlled Trials and Case Studies. Population Health Management, 16(6), 373-380.
Physician Staging Algorithm
“Individualized early and aggressive
treatment for Rheumatoid Arthritis”
Includes:
•Understanding RA and its systemic manifestations, the therapeutic targets of
action, safety, and efficacy of biologic agents
•Developing, coordinating, and implementing a treatment plan that includes:
- Administration of pharmacologic agents and use of non-pharmacologic
interventions
- Comprehensive patient education
- Referral to appropriate specialists (e.g., physical therapists, counselors)
•Using objective patient and clinician tools to:
- Recognize suboptimal response to therapy or treatment failure and referring
back to the rheumatologist as needed
- Identify side effects, adverse events, and toxicity resulting from RA therapy
- Monitor disease progression, response to treatment, and QOL
•Collaborating closely with the patient and other medical practitioners to manage
infections and co-morbid conditions, such as cardiovascular disease
Behavior Change Incorporated Into Learning
Increase confidence
Minimize con
Based on this data…
• Presenters were directed to heighten pros and minimize cons
• We measured:
• Change scores between mean of pros vs. mean of cons
• Confidence scores pre vs. post
Including Behavior Change Messages Works: Confidence
Number of confidence messages correlated .71 with
confidence difference scores
– Importance of increasing self-efficacy/confidence:
• Physicians and nurses who have increasing selfefficacy scores are more likely to make stage
progression than those who have stable or
decreasing self-efficacy scores
– Including more messages to increase confidence:
• Facilitates stage progression from Preparation
to Action
• Prevents regression out of Maintenance
The More Clinicians Participate, The Closer They
Move Toward the Performance Improvement
Clinicians participating in 3 or more activities are
more likely to make forward-stage progress than
those participating in a single activity.
% progressing at Post-Test
Imputed Data
60%
50%
40%
Physicians
30%
Rheums
20%
Nurses
10%
0%
1 Activity
2 Activities
3+ Activities
Achieving the Performance Improvement (Taking Action)
Clinicians participating in 3 or more activities are
more likely to move to Action or Maintenance
than those participating in a single activity.
% moving to A/M at Post-Test
Imputed Data
60%
50%
40%
Physicians
30%
Rheums
20%
Nurses
10%
0%
1 Activity
2 Activities
3+ Activities
Lessons Learned from Applying Theory to Practice
• Effective evidence-based behavior change
interventions can be developed using the
Transtheorterical Model
• Behavior change solutions can be delivered in a
variety of channels:
– Online
– Print
– Coaches/counselors
– Online educational activities
– Seminars & workshops
– Communication campaigns
Lessons Learned from Applying Theory to Practice
• Funding sources include:
– Foundations
– Employers
– Public-private partnerships
LEVERAGING DATA
Depth of Tailoring
One Size Fits All
Targeted
Tailored
Action Oriented
Stage Matched
Stage + Pros + Cons +
Self-Efficacy + 10 Processes
Targeting & Tailoring Continuum
Computer-Tailored Interventions (CTI)
Reliable, valid assessments of most
important behavior change
constructs
Evidence-based,
statistically-derived
decision-making rules
Individualized, tailored
behavior change guidance
Feedback dynamically updated
based on new
assessment data
Measurement Development
•
•
•
•
•
Expert Interviews
Focus groups
Cognitive Interviews
Measure administration
Measure validation
Stage of Change Assessments
• Clearly define the behavior that you are targeting
• Establish rigorous action criteria (e.g. exercise 150
minutes/week, eat 4 1/2 fruits and vegetables per day, set
aside $10 a day to pay down debt, save 10% of income, etc.)
• Ask participants if they are engaging in that behavior
Not intending to in the next 6 months
Intending to in the next 6 months
Intending to in the next month
Already doing it
Been doing it for 6 months
Pros & Cons Assessment Sample
Sample Assessment
Web-based computer-tailored intervention
Data collection/analysis/feedback/assessment
Questions
Tailored
Feedback
Responses
Individuals
Different Levels of Tailoring
Group – Same for all
Targeted
Precontemplation
Contemplation
Preparation
Action
Moderate Tailoring
Full TTM-Tailoring – Computer-Tailored Intervention
Maintenance
What can you do with varying levels of data?
Lots of data?
Tailor content to individual
participant
Some data?
Target message to stage
No data?
Ensure messages appeal to all
5 stages
Lessons Learned from Leveraging Data
• Even in the absence of data, you can assume
your population includes participants in all
stages of change
• Utilizing data to empirically derive decision
rules can enable you to tailor intervention
content to each individual
• Databases can be built and refined over time
HOW HAVE WE BEGUN TO APPLY
THE TRANSTHEORETICAL MODEL
TO FINANCIAL WELL-BEING?
The Debt Diet
TM
• Behavior change program to
help people set aside $10 a
day to pay off debt or build
an emergency fund
• Based on Jean Chatzky’s
book Pay It Down!
• Activities matched to user’s
“stage of change” for setting
aside $10 a day
Stage of Change at Registration
Who Starts Setting Aside $10 a Day?
Precontemplation
Contemplation
Existing Behavior
Preparation
Maintenance
Action
New Behavior
33.3% begin setting aside $10 a day to pay down debt
Who Moves Forward One Stage of Change?
Precontemplation
Contemplation
Preparation
PC
C
P
Action
Maintenance
49.1% move one stage closer to setting aside
$10 a day to pay down debt
Promoting Financial Well-being
Financial Coaching Guide
Financial Coaching Guide
The TTM in Winning Play$
• Action criteria: Increase financial responsibility of
students
• Big challenge is to make action criteria objective and
concrete
Do you ask yourself:
 Can I afford this?
 Is this purchase in line with my values and
life goals?
 If I can’t afford this and it is not consistent
with my values and goals, why am I buying
it?
Majority Are in Pre-Action Stages
Lessons Learned from Applying the TTM to Financial Well-Being
• Initial efforts suggest we can assess readiness to
change financial behaviors
• Beginning to gather data will enable the
development of targeted and tailored behavior
change solutions for various delivery channels
BUT WAIT! WHAT DO I DO NOW?
Applying the TTM to Your Initiatives
• Ask yourself:
– Does the promotion of your program appeal to individuals
in all stages of change?
– Do your current or planned initiatives address participants
in all five stages of change?
– How can you incorporate behavior change messages and
strategies that will meet the needs of your whole
population?
– Is it possible to assess stage of change or other behavior
change variables to tailor interventions?
– Can stage of change be a component of your evaluation?
What Do You Do with Precontemplators?
• Goal: Engage them in the change process
• Key Strategy: Increase the Pros
– Encourage participants to list their own “pros” of the
behavior(s) on which they are working. How will they
benefit from setting aside money to pay down debt,
following a budget, saving, or investing? What’s in it for
them?
– Point out additional benefits specific to them
– Provide a list of benefits
– Encourage participants to look for more
– Encourage participants to create a Top Ten List of the
benefits that matter most to them.
What Do You Do with Contemplators?
• Goal: Overcome ambivalence
• Key Strategy: Make the Pros Outweigh
the Cons
– Ask participant to name most significant con(s)
– Acknowledge changing does have costs, but
avoid debate about whether change is “worth it”
– Ask participant to shrink cons by:
 Comparing them to growing list of pros
 Asking how important they are relative to pros
 Challenging themselves to counter the cons
More About Contemplation
• Don’t encourage Contemplators to take
action – but rather to start to prepare
• Encourage small steps
Key Behavior Change Strategy for Preparation
• Goal: Help the patient move to Action
• Key Strategy: Encourage participant to
make strong commitment by:
– Setting a specific start date, rather than
wait for a magic moment
– Sharing commitment with others
– Creating a specific “Action Plan”
– Writing down the plan, start date, etc.
Key Behavior Change Strategy for Action
• Goal: Keep it up!!
• Key Strategy: Encourage participant to get
support by:
– Seeking support from others, especially those who are
already doing what they are working on
– Being as specific as possible about the type and
amount of encouragement they need
– Making changing financial behaviors a family affair
– Starting a “money group”
– Seeking out professionals as needed
Key Behavior Change Strategy for Maintenance
• Goal: Make new behavior a life-long habit
• Key Strategy: Use Substitutes
• Encourage participant to:
– Replace negative thoughts with positive
thoughts
– Plan ahead to deal with difficult situations
(e.g., unexpected emergency expenses)
– Have a plan for dealing with slips rather than
giving up
Final Question: How Ready Are You?
How ready are you to implement programs that embody
the principles of the Transtheoretical Model that we
discussed today?
 I don’t plan to in the next 6 months (Precontemplation)
 I plan to in the next 6 months (Contemplation)
 I plan to in the next month (Preparation)
 I have been for less than 6 months (Action)
 I have been for more than 6 months (Maintenance)
Resources
• Changing for Good: James Prochaska
• Prochaska, J.O., DiClemente, C.C., & Norcross, J.C.
(1992). In search of how people change:
Applications to addictive behaviors. American
Psychologist, 47(9), 1102-1114.
• Prochaska, J.O., Johnson, S.S., & Lee, P. (1998). The
Transtheoretical Model of behavior change. In
E.Schron, J. Ockene, S. Schumaker, & Exum, W.M.
(Eds.), The handbook of behavioral change, second
edition. New York: Springer.