Some models relevant for planning health promotion programs

1. Some models relevant for planning health promotion programs Ian McDowell March, 2012

2. 1. The ‘Big Five’ Personality dimensions • Extraversion: characteristics such as excitability, sociability, talkativeness, assertiveness, and emotional expressiveness. Extraverted is opposite to introverted ("Would you rather spend an evening with a friend or with a book?") • Agreeableness: attributes such as trust, altruism, kindness, affection: behaviours that promote social interaction. Agreeable can be contrasted with disagreeable (“Are you interested more in other people's feelings or in your own?”) • Conscientiousness: this refers to a person's thoughtfulness, their level of impulse control and goal-directed behaviors. Conscientious people are organized and pay attention to detail. Roughly the opposite of playful. • Neuroticism: a tendency to experience emotional instability, anxiety, moodiness, sadness or irritability. Neurotic vs. stable (“How calm & composed do you remain in stressful circumstances?”)  • Openness, referring to being open to new experiences. Such people are interested in intellectual matters, whether of the imagination or of logic. Related characteristics include insight, having a broad range of interests, being imaginative, intellectual, perhaps witty.

3. Pathways from Personalityto Health Status

4. 2. Health Belief Model Modifying Factors Perceived Susceptibility to Disease · Demographics (age, sex, ethnicity, etc.) · Sociopsychologicalvariables (personality, social class, peer and reference group pressures, etc.)· Structural variables (knowledge about the disease, prior experience of it, etc.) Perceived Severity of Disease Perceived benefits of taking action, minusPerceived barriers to action Perceived Threat of the Disease Cues to Action · Raised awareness (e.g., mass media campaign, newspaper article )· Personal advice (e.g., reminder from health professional)· Personal symptoms· Illness of family member or friend Likelihood of TakingRecommended Health Action

5. 3. Protection Motivation Theory Threat appraisal Vulnerability + Severity of disease Behavior Intentions Coping appraisal Self efficacy + Response efficacy

6. 4. Theory of Reasoned Action Perceived importance of health issue Attitudetoward changing behaviors Perceived effectiveness of recommended action HealthBehavior BehavioralIntentions Beliefs concerning others’ views Subjective norms Motivation

7. 5. Theory of Planned Behavior Behavioral beliefs(importance of thehealth issue &whether the behaviorwill be effective) Attitudetowardrecommendedbehavior Normative beliefs:how do othersview the behaviors? Subjective norms:felt social pressures to act Intentionto act(or not) Behavior Perceived behavioralcontrol Control beliefs:self-efficacy

8. 6. Stages of Change(J. Prochaska, 1985) Pre-contemplation no intention of changing Contemplation intends to act in a realistic time frame (+/- 6 months for smoking) Readiness for action preparing for change in immediate future Action is making, or has made changes Maintenance working to prevent relapse 8

9. StableLifestyle Action Preparation Maintenance Contemplation Relapse Precontemplation 7. Transtheoretical Model (Jim Prochaska, 1985)

10. StableLifestyle Action Preparation Maintenance Contemplation Relapse Precontemplation Preparation: The person is making plans to changein the next month (e.g., has set a quit date). The physician can refer the patient to supportprograms, prescribe nicotine patch, encourage them to set a quit date, etc. Action: The patient has changed.Encouragement & support are the major physician roles:arrange follow-up visits. Maintenance: The patient has practiced thenew behaviour for a monthor more and trying to maintainthe change over the longer term. Contemplation: The person has considered the possibility of changing,but is not ready to actively plan a change. The physician can provide information and encourage them to prepare to actually change. Relapse: Helping with relapse is an importantrole for the doctor; several attemptsmay be required before a behaviouris finally established. Encourage the patient to look on a relapse as gaining experience. Precontemplation: The person does not intend to change the behavior,or is unaware of need to change, or is unwilling to do so. The physician can encourage the patient to think aboutthe behavior and how they would feel about changing.Suggest they talk to their spouse, etc.

11. “Where is the Road Block?”Two models of behavior change Prochaska (1985)Stages of Change Weinstein (1998) Precaution Adoption Process Model MD’s role 1. Unaware of the issue Analyze patient’spersonal risk 1. Pre-contemplation 2. Unengaged by the issue How does she feel? 2. Contemplation 3. Deciding about acting Supply information:pros and cons. 4. Deciding not to act 5. Deciding to act Practical guidance:set quit date, etc 3. Preparation 6. Acting 4. Action Support & aids 5. Maintenance, relapse 7. Maintenance Monitoring 6. Habitual behavior 11

12. 8. Precede-Proceed model Planning phase What can be achieved? What needs to be changed to achieve it? Start Identify the administrative & financial policies needed Identify education, skills & ecology required Identify desirable outcomes: Behavioural, Environmental, Epidemiological, Social Policies Resources Organisation Service or programme components Predisposing factors Enabling factors Reinforcing factors Lifestyle Health status Quality of life Setting up the programme Environment Implementation: What is the programme intended to be? What is delivered in reality? What are the gaps between what was planned and what is occurring? Process: Why are there gaps between what was planned and what is occurring? What are the relations between the components of the programme? Impact: What are the programme’s intended and unintended consequences? What are its positive and negative effects? Outcome: Did the programme achieve its targets? What can be learned? What can be adjusted? Evaluation phase Finish Adapted from: Green L. http://www.lgreen.net/precede.htm (Accessed May, 2009)

13. PRECEDE-PROCEED Framework Phase 5 Administrative Policy Assessment Phase 4 Educational & Ecological Assessment Phase 3 Behavioral & Environmental Assessment Phase 2 Epidemiologic Assessment Phase 1 Social Assessment Predisposing factors HEALTH PROMOTION Behavior & lifestyle Health Education Policy, Regulation, Organization Quality of life Reinforcing factors Health Environment Enabling factors Phase 7 Process Evaluation Phase 8 Impact Evaluation Phase 9 Outcome Evaluation Phase 6 Implementation

14. 9. Social Marketing Social Marketing Cycle 2. Select materials& channels 1. Planoverallstrategy 3. Developinterventionand pretest 4. Implementthe program 6. Use resultsto refineprogram 5. Assesseffectiveness(process &outcomes)

15. The purposes of population health:A model of the various population health perspectives Pophealthpolicies Developing Healthy Policies Developing Delivery Systems Pophealthinterventions Developing Interventions Academicpopulationhealth Analyzing Causes & Predicting Risks Describing Health Issues Interested? Other models on SIM web site: Population health models