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%


Dimensions of Opportunity:Dimensions of Opportunity:Engaging the POSSEEngaging the POSSEP: Peers

O: Organizations

S: State

S: Society

E: Environment


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


AwarenessAwareness

Basis of Most Health Education– Health Risk Factors– Benefits of Healthy Lifestyle

What is the Impact of Awareness on Behavior?– eg. tobacco use


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.

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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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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



Awareness

Motivation

5%

30%


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


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


Engage People in ProcessesEngage People in Processes

Wellness committees Market research Mentorships Champions Effective programs

Confidentiality & Transparency


Develop Effective CommunicationDevelop Effective Communication

Consistent with corporate culture Professional Ubiquitous


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.


Provide Effective LeadershipProvide Effective Leadership

Recognize importance of programs Provide appropriate budget Serve as active program champions Be visible program participants


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.


Think about Think about your programyour program



Awareness

Motivation

Skills

5%

30%

25%


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


Goal Setting Goal Setting

Doubles success rates Aspirational, learning & performance goals Expert guidance & personal buy in


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


Self EfficacySelf Efficacy

Belief one can successfully perform behavior

Predicts– Joining program– Completing program– Time to relapse


Behavioral EfficacyBehavioral Efficacy

Belief a behavior leads to desired outcome


Focusing EffortsFocusing Efforts

High

High

Low

LowSelf Efficacy

BehavioralEfficacy


Genetic Predisposition, Physical and Mental Condition

– Athletic ability and experience– “Runner’s High”– Weight– Addiction– Physical disability– Mental illness


Preferred Learning Style Preferred Learning Style by Lifestyle Topic by Lifestyle Topic

Print Telephone Web Individual face to face Group



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


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


Tailoring Tailoring

Motivational readiness to change Level of self efficacy and behavioral efficacy Preferred learning style Genetic predisposition Health status Level of intensity



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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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?


Integrating Behaviors into LifeIntegrating Behaviors into Life

How to overcome barriers How to overcome social influences How to create opportunities



Awareness

Motivation

Skills

Opportunity

5%

30%

25%

40%


POSSE: POSSE: The Dimensions of OpportunityThe Dimensions of Opportunity

P: Peers

O: Organizations

S: State

S: Society

E: Environment


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


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


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


Are you a passive citizen or a policy advocate?Are you a passive citizen or a policy advocate?

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Ohio-minus CuyahogaCountyCuyahoga County


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


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


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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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%

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Lowest Quarter Highest Quarter

Vehicle miles traveled

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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


EnvironmentEnvironmentWill you choose your environment?

Will you shape your environment?

Or

Will your environment shape you?


AMSO & HIS POSSEAMSO & HIS POSSE

Awareness

Motivation

Skills

Opportunity

5%

30%

25%

40%


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


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?


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



Awareness

Motivation

Skills

Opportunity

5%

30%

25%

40%


michael p. o’donnell, phd, mba, mph amso & his posse: a framework to develop effective...

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