Welcome to Engaging Consumers, Providers, and Community in Population Health Programs. This is lecture b. The objective for this lecture is to compare behavior change models. In particular, we want to look at some individual models, as well as some organizational, population, environmental, or what we largely call population ecological models of behavior change. First a few definitions that will help though. Health promotion, this is the process of empowering people to make healthy lifestyle choices and motivating them to become better self-managers. It's worth noting that this isn't just the absence of illness. Health promotion is actually about wellness, happiness, connectedness, having people engaged in their communities in a meaningful and healthy way. We could even go further with the definition and say it is a means of creating shared value and values in the community. Another concept we will define is a theory. And what is a theory? Well, it’s a systematic way to think about how various parts of activities relate to one another. And we often hypothesize that if we change somebody's health behavior, say we have them exercise more, we will have an outcome such as weight loss. And we may even have a secondary outcome such as lower cardiovascular disease rates. And that might be a theory in simple terms. Where we have constructs described, we hypothesis about their relationships and move from there. And then to make those theories easier to understand, we may make models. And these are often graphic or mathematical representations of the constructs and how they interact. So I want to talk about a few different theories. Three in particular. Though I'm going to mention another one in passing. The first is the Health Belief Model. And this has been used by people in public health for many years now, and is worth knowing. And it is very focused on individual's behaviors, their perceptions of their health status, and the ability to change those statuses. It often deals with people's self-efficacy. And one's self-efficacy is the belief that I can actually do something. That I can make the change and realize the outcome that I hope to have happen. A second model is the Transtheoretical Model or the Stages of Change Model. And I'm not going to go into this in depth, but this often describes how individuals move through six stages. The first stage is being aware of a problem. The second stage is wanting to change. Third comes planning to change, that is, making preparations. The fourth stage is action, which is followed by the fifth stage, maintenance. The sixth stage would be termination. So if you think about this as your new year's resolution, you might say, look, it's December. I might want to make a new year's resolution. That sort of is pre-contemplation period. The contemplation period would then involve deciding what sort of new year's resolution you want to make. Is it that you want to go to the gym everyday, lose ten pounds? Something along those lines. Then comes preparation. This is where you go out and buy the gym membership. You actually invest and get your key fob, and hope to go to the gym. Step four would be action. And this is the hard part. Where you actually show up at the gym every morning and make it a reality. And this is where a lot of us tend to fall down on these things. And you might even think about the fifth stage, the maintenance, as being February. When you haven't really made it all that often in January. So you're just going to stop altogether. You cancel the gym membership. Stage six, the termination, and try to think of some other way to loose weight. Another sort of transtheoretical model that many of you would be familiar with is the Kubler-Ross Model, which describes the stages of grief. Denial, Anger, bargaining, depression, and acceptance. We're not going to spend a lot of time on transtheoretical models. Just be aware of them. It's something to think about as you make program plans. And to that end, I'll try to incorporate some of that transtheoretical thought into the Theory of Reasoned Action, Theory of Planned Behavior. This is where we're actually developing programs around activities, to try and get individuals to improve. And the last model is the Chronic Care Model. For many of you who actually work in health systems or in care delivery settings, this Chronic Care Model maybe something you want to consider. Because it talks about how to better coordinate with other parts of the system. So the first model we'll discuss in some depth, is the health belief model. So what are the challenges to find in the health belief model? Well, the first two are the perceptual elements. This is how susceptible you believe you are to a particular illness. You often hear it said about teenagers, for example, that they believe themselves to be invincible. In other words, they have a low perception of their susceptibility to bad outcomes. Particularly things that they view as being way later in life. Things like heart disease and cancers. The perceived severity is also very low because the time when these bad outcomes are going to occur is so far away. So perceived severity is an evaluation of the consequence. Another challenge in the health belief model is the perceived benefits of action. Do I really think that changing the way I act will have some real time discernible benefit to me? And lastly, you have the perceived barriers, in other words, how hard is it for me to make this change? So let's take a longer look at this model presented here as flow chart. And let's move from left to right here. Individual perceptions are on the left. And these perceptions really depend on people's awareness of two elements. Their susceptibility to a disease. Number one, their susceptibility to a disease. And two, how serious they think that disease is. Say for example, you're a middle-aged man. So we can also take in some of these modifying factors appearing in the middle of the chart. The demographic variables. And you come from a socioeconomic background, where it's not unusual for people to have cardiovascular disease, heart attacks, and other illnesses. So you might perceive yourself to have elevated susceptibility. How serious you consider the disease is another important component. Because it is the two elements taken together, perceived susceptibility, and perceived seriousness, that factor into your overall perception of disease threat. Which appears in the box in the center of this model. As mentioned earlier, there are modifying factors above and below the total perceived threat of disease. And those modifying factors include demographic characteristics. In cancer for example, it is well known that women who have a mother, an aunt, a grandmother, or sister who has had breast cancer have elevated susceptibility to the disease. And breast cancer's a very serious illness that's received a lot of attention. So women with those modifying factors are likely to perceive breast cancer to be very serious. Therefore, their perceived threat of that disease is likely to be very high. You'll notice that I mentioned a couple of cues to action, which fall under modifying factors in the center of the chart. This model which originally appeared in Health Education Quarterly many years ago, has been modified to include social media. More and more we see things like Facebook and other media campaigns that connect us, such as Twitter. Really helping to increase our awareness, and give a more accurate perception of threat. But there are other forms of cues to action. You may get a postcard from your dentist reminding you that it's time to get your teeth cleaned. A family member or friend may get ill, and make you think about it. Those sorts of things. The other parts of the health belief model that are important fall under likelihood of action, which appears on the right-hand side of the chart. And the first action has to do with decision making. And this is where you look at your perceived benefits and subtract the barriers to action. This is really sort of a cost benefit analysis. And it involves deciding whether doing what needs to happen to improve health is worth the cost of doing it. In other words, is it worth it to me to get up every morning and go to the gym and pay gym fees in order to lower my risk of cardiovascular disease? And taken together, these factors will determine the likelihood of my taking an action. So you'll notice that the arrows are flowing in a very particular order. It's my overall perception of threat. The middle box, coupled with the cost benefit analysis of action, that will factor into my likelihood of taking an action. The theory of planned behavior or TPB, served those of us in public health very well for many years. There are a few benefits of this for the constructs you need to know. And these are very similar to what you just saw in the health belief model. It's a perception of your behavioral control, the likelihood that engaging in an activity will lead to a desired outcome. And this has another important component which is my perceived power. Do I really think that I can change my health or the condition I live in? Here's how this model, which has been slightly modified looks. But rather than simply having two factors acting on my intention, as in the health belief model. I now have three. And the first is this subjective norm. Are there people in my community engaged in healthy behavior whom I should be modeling myself after? So, if you live in a community where everybody's jogging, riding their bikes to work, eating salads at lunch, using the stairs. If there's all that type of subjective and social norming happening around you, it may have a fairly dramatic effect on your planned behaviors. It may even influence your attitude toward behaviors. Lastly, the other leading element is perception of behavioral control. The belief that I can actually make the necessary change. And you'll see that these first three elements, the subjective norm, attitude toward the behavior, and perceived behavioral control, feed into one's intention. That is, my desire to do it. And then that intention, once it gets strong enough, or my desire is high enough, will result in a behavior. You may notice that one of these early constructs is actually having a deleterious effect on actual behavior. In other words, your perception that there aren't good biking paths, jogging paths, local gyms, or healthy food options, may be very real. You may live in a community that's a food dessert. Where healthy foods are not readily available. And that has a very real impact on behavior. The other big set of models are ecological models. And these involve trying to change the operation, the environment around individuals. So individual models are good for identifying program needs to impact the individual. As a planner, you need to consider the individual. But you also need to consider the environment. Can people actually access the things they need to improve their health? One example is putting healthy dining options on fast food restaurant menus. And this is something we've seen more and more in recent years. So why use a socio-ecological or an environmental model to change behavior? Well, human behavior is difficult to change. And it takes a lot of things pushing on us, not just on typically, to make those changes happen. So what are some of the components of the social-ecological model? Well, there are the intrapersonal components. If you hang around with people who are getting up and going to the gym, chances are you'll get up and go to the gym too. Then there is the perceived environment. In the past, people often said that California was a healthy place to live. People perceived Californians as being healthier for a variety of reasons. That they spend lots of time out in the sun surfing, jogging, wanting to look like movie stars, those sorts of things. So the behaviors themselves are an active living domain. Behavior settings, we mentioned that at some great length. And the policy environment. And this is not trivial. So now we're getting further, and further away from the individual you'll see. And do we have good policies? Does your local government promote parks, bike paths, other healthy options in the community? So here's the ecological model as it's often depicted with concentric eclipses. At the center are intrapersonal characteristics. And furthest out is the policy environment, which takes all types of policy such as zoning, healthcare, transportation, and media regulations into consideration. Just inside the policy environment is the environment in which people are living. The behavioral setting as we might call it. The behavior setting includes factors such as walkability, recreational opportunities, and a social climate. Moving inward, you'll find active living domains. And this is really where you're going to get into the nitty gritty of where people work, where they live, and how they get back and forth to those places. Even more internal to the person, is their perception of that environment. Is this environment a healthy one? Am I safe? Is it attractive? Are there conveniences that I can take advantage of? And lastly at the center, there's interpersonal well-being. Am I happy, well-balanced, and leading the life that I want? Note that the information environment, the social and cultural environment, and the natural environment are all important. The last model we'll talk about just briefly is the chronic care model. And this is something for those of you who work in a health system, or doctor’s office, or an any way engaged in patient care. This is something on which we're often working if you’re in private sector. So, what's the chronic care oriented system? Well, it reviews interventions in other conditions to see how we can change the way we are currently practicing the delivery of services within our organizations. There are many examples. Non-physician team members or physician extenders give patients more contact with people operating a support toward improving their care. Planned encounters are a way to increase the number of activities in which people have the opportunity to change their behavior. And that flows directly into modern self-management support, through tools like personal health records. And the watches that tell us to get up and exercise, and track how many steps we take, those sorts of things. Then there's intensification of treatment. Often we've been encouraged to keep people out of the hospital, and we have perhaps discharged patients prematurely, in order to reduce what we used to call length of stay. We may want to intensify or lengthen those treatments in some instances. Again, care management for high risk patients, it's not just my part that matters. I need to understand how often caregivers, and how other organizations in the community are interacting with this patient, to make sure that we are coordinated in a way that's effective. And electronic registries. These are tools that let us know when somebody has a particular chronic illness that we should be aware of and helping them manage. So, here's a graphic depiction of the chronic care model. The big oval represents the greater community. What are its resources? How does public policy affect how we deal with individuals? And then we have the health system itself, represented by a smaller circle that's completely contained within the community. And you might ask within your community, whether there's self-management support. And by the way, that may occur within and outside the health system. You might also ask whether the health system is integrated. Is there a delivery system design that ensures that patients discharged from the hospital are receiving proper followup care? Then there's decision support. For example, you might want to know whether a doctor's office has tools that can recommend that a person be prescribed one drug over another, under a certain set of conditions. What sorts of aftercare do they deserve, etc. And all of that is dependent on people's Clinical Information Systems, Electronic Medical Records, etc. Do these tools actually support better decision support and integration? And all of those things in the ovals at the community and health system levels, feed down into having informed, activated patients. And a prepared, proactive practice team. If you have all of those things, you'll actually have improved outcomes. This concludes lecture b, of engaging consumers, providers, and community in population health programs. So in summary, theories and models can be very helpful in helping you design your patient engagement program. Both and the individual and ecological perspectives should come to bear as you make those designs. And in particular, you may have more control over ecological elements of your engagement program.
