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Using the Stages of Using the Stages of Change Model to Select Change Model to Select
an Optimal Health an Optimal Health Marketing TargetMarketing Target
Paula Diehr, Ph.D.Paula Diehr, Ph.D.
Health Marketing Research Health Marketing Research CenterCenter
CDC Center of Excellence CDC Center of Excellence
Biostatistics and Health ServicesBiostatistics and Health Services
SPHCM University of Washington SPHCM University of Washington
GoalGoal
Use Stages of Change model Use Stages of Change model to determine the best to determine the best intervention target to intervention target to decrease population smokingdecrease population smoking
Same target suggested by Same target suggested by health marketing principles?health marketing principles?
OutlineOutline Stages of ChangeStages of Change Data – estimate probability of changing stagesData – estimate probability of changing stages Probabilities Probabilities Multi-state life table Multi-state life table Expected number of years spent in Expected number of years spent in
MaintenanceMaintenance Hypothetical Interventions – alter 1 probabilityHypothetical Interventions – alter 1 probability Best intervention – most years in Maintenance Best intervention – most years in Maintenance Compare to Health Marketing recommendationCompare to Health Marketing recommendation Smoking ExampleSmoking Example
Stages of Behavior ChangeStages of Behavior Change(Prochaska, Transtheoretic (Prochaska, Transtheoretic
Model)Model) Pre-contemplation Pre-contemplation
(not even thinking about stopping smoking)(not even thinking about stopping smoking) ContemplationContemplation PreparationPreparation Action (short-term smoking abstinence)Action (short-term smoking abstinence) Maintenance (long-term smoking Maintenance (long-term smoking
abstinence)abstinence)
Stages of Change ModelStages of Change Model
ContPrecont Prep MaintAction
+ Never Smoker+ Never Smoker
ContPre Prep MaintAction Never
ContPre Prep MaintAction Never
Dead
Pre NeverNeverPrep
+ Dead+ Dead
Transition Probabilities (2 Transition Probabilities (2 Yrs)Yrs)
t1/ t2t1/ t2 PrePre ContCont PrepPrep ActAct MainMaintt
NeveNeverr
PrePre .63.63 .16.16 .05.05 .10.10 .06.06 00
ContCont .37.37 .29.29 .12.12 .11.11 .11.11 00
PrepPreparar
.24.24 .24.24 .26.26 .12.12 .14.14 00
ActioActionn
.08.08 .12.12 .06.06 .14.14 .59.59 00
MainMaintt
.01.01 .01.01 .01.01 .02.02 .95.95 00
NeveNeverr
.001.001 .001.001 .002.002 .004.004 .04.04 .95.95
Transition Probabilities (2 Transition Probabilities (2 Yrs)Yrs)
t1/ t2t1/ t2 PrePre ContCont PrepPrep ActAct MainMaintt
NeveNeverr
PrePre .63.63 .16.16 .05.05 .10.10 .06.06 00
ContCont .37.37 .29.29 .12.12 .11.11 .11.11 00
PrepPreparar
.24.24 .24.24 .26.26 .12.12 .14.14 00
ActioActionn
.08.08 .12.12 .06.06 .14.14 .59.59 00
MainMaintt
.01.01 .01.01 .01.01 .02.02 .95.95 00
NeveNeverr
.001.001 .001.001 .002.002 .004.004 .04.04 .95.95
Transition Probabilities (2 Transition Probabilities (2 Yrs)Yrs)
t1/ t2t1/ t2 PrePre ContCont PrepPrep ActAct MainMaintt
NeveNeverr
PrePre .63.63 .16.16 .05.05 .10.10 .06.06 00
ContCont .37.37 .29.29 .12.12 .11.11 .11.11 00
PrepPreparar
.24.24 .24.24 .26.26 .12.12 .14.14 00
ActioActionn
.08.08 .12.12 .06.06 .14.14 .59.59 00
MainMaintt
.01.01 .01.01 .01.01 .02.02 .95.95 00
NeveNeverr
.001.001 .001.001 .002.002 .004.004 .04.04 .95.95
Multi-State Life Table (age Multi-State Life Table (age 40)40)
Life Expectancy=36 yrsMaintenance=26 yrs
Public Health Public Health InterventionsInterventions
People move among stages with People move among stages with certain probabilitiescertain probabilities
Can improve population health Can improve population health (reduce smoking) by changing the (reduce smoking) by changing the probabilitiesprobabilities
Suppose we could change one Suppose we could change one probabilityprobability
Which probability should we change?Which probability should we change?
ContPre Prep MaintAction Never
Dead
Pre NeverNeverPrep
Disparities PerspectiveDisparities PerspectiveProb=0.1610% Higher
ContPre Prep MaintAction Never
Dead
Pre NeverNeverPrep
Prevention PerspectivePrevention Perspective
Prob=0.0410% Lower
Social Marketing Social Marketing PerspectivePerspective
SM uses marketing principles to SM uses marketing principles to achieve specific behavioral goalsachieve specific behavioral goals
Principle 1 --- Low-hanging fruit Principle 1 --- Low-hanging fruit Target the markets Target the markets mostmost ready for ready for
changechange Principle 2 --- Customer relationship Principle 2 --- Customer relationship
management (customer loyalty)management (customer loyalty) Cheaper to keep a current customer than Cheaper to keep a current customer than
to get a new oneto get a new one
ContPre Prep MaintAction Never
Dead
Pre NeverNeverPrep
““Low Hanging Fruit”Low Hanging Fruit”Prob=0.5910% Higher
ContPre Prep MaintAction Never
Dead
Pre NeverNeverPrep
““Customer Relationship Customer Relationship Mgmt”Mgmt”
Prob=0.0210% Lower
Which Intervention is Which Intervention is Best?Best?
Improve each transition probability Improve each transition probability by 10%by 10%
Calculate new multi-state life tableCalculate new multi-state life table Calculate expected years spent in Calculate expected years spent in
MaintenanceMaintenance Compare interventionsCompare interventions Choose intervention that gives the Choose intervention that gives the
most years spent in Maintenancemost years spent in Maintenance
Transitions and Transitions and InterventionsInterventions
PrePre ContCont PrepPrep ActAct MainMaintt
NeveNeverr
PrePre .63.63 .16 .16 (1)(1)
.05.05 .10.10 .06.06 00
ContCont .37 .37 (2)(2)
.29.29 .12 .12 (3)(3)
.11.11 .11.11 00
PrepPrep .24.24 .24 .24 (4)(4)
.26.26 .12 .12 (5)(5)
.14.14 00
ActAct .08.08 .12.12 .06 .06 (6)(6)
.14.14 .59 .59 (7)(7)
00
MainMaintt
.01.01 .01.01 .01.01 .02 .02 (8)(8)
.95.95 00
NeveNeverr
.001.001 .001.001 .002.002 .004.004 .04 .04 (9)(9)
.95.95
Hypothetical InterventionsHypothetical Interventions## Transition probability to be improvedTransition probability to be improved
00 Status QuoStatus Quo
11 Precontemplation Precontemplation Contemplation Contemplation (Disparities)(Disparities)
22 Precontemplation Precontemplation ContemplationContemplation
33 ContemplationContemplationPreparation Preparation
44 ContemplationContemplationPreparationPreparation
55 PreparationPreparationActionAction
66 PreparationPreparationActionAction
77 ActionActionMaintenance (Low Hanging Maintenance (Low Hanging Fruit)Fruit)
88 SmokerSmokerMaintenance (Customer Maintenance (Customer Relationship )Relationship )
99 Ever SmokersEver SmokersNever Smoker Never Smoker (Prevention)(Prevention)
RESULTS RESULTS DatasetDataset
11 22 33
Initial Distribution:Initial Distribution:
All PrecontemplationAll Precontemplation 77 77 77
All ContemplationAll Contemplation 77 77 77
All PreparationAll Preparation 77 77
All ActionAll Action 77 77 77
All MaintenanceAll Maintenance 77 88 88
Baseline (no Never)Baseline (no Never) 77 77 77
All Never SmokersAll Never Smokers 99
Baseline + NeverBaseline + Never 99
DatasetDataset 11 22 33
Initial Distribution:Initial Distribution:
All PrecontemplationAll Precontemplation 77 77 77
All ContemplationAll Contemplation 77 77 77
All PreparationAll Preparation 77 77
All ActionAll Action 77 77 77
All MaintenanceAll Maintenance 77 88 88
Baseline (no Never)Baseline (no Never) 77 77 77
All Never SmokersAll Never Smokers 99
Baseline + NeverBaseline + Never 99
Summary of ResultsSummary of Results
Intervention 7 (low hanging fruit) is Intervention 7 (low hanging fruit) is usually the best if population of interest usually the best if population of interest is ever smokersis ever smokers
Intervention 8 (customer relationship) is Intervention 8 (customer relationship) is usually best if all in Maintenance at age usually best if all in Maintenance at age 4040
Intervention 9 (prevention) if population Intervention 9 (prevention) if population of interest includes many never smokersof interest includes many never smokers
Social marketing principles worked!Social marketing principles worked!
What Stage to Target?What Stage to Target? Current Smokers (Precont, Contemp, Current Smokers (Precont, Contemp,
Prep) Prep) Smoking Cessation (#1-5) Smoking Cessation (#1-5) Never bestNever best
Former Smokers (Action, Maintenance)Former Smokers (Action, Maintenance) Relapse Prevention (#6, 7, 8)Relapse Prevention (#6, 7, 8) Best if population is former Best if population is former or currentor current
smokerssmokers Never Smokers Never Smokers
Primary prevention (#9) Primary prevention (#9) Best if population has many never smokersBest if population has many never smokers
Why not current Why not current smokers?smokers?
Life Table ExampleLife Table Example Precontemplators do move on to Precontemplators do move on to
higher stages under the status quo higher stages under the status quo Quitting smoking is easy. I’ve done Quitting smoking is easy. I’ve done
it a thousand times.it a thousand times. Interventions to help quitters stay Interventions to help quitters stay
quit had more long-term quit had more long-term effectivenesseffectiveness
LimitationsLimitations DataData
3 different datasets have complementary 3 different datasets have complementary weaknessesweaknesses
Data optimistically biased? (sensitivity Data optimistically biased? (sensitivity analyses)analyses)
GenderGender Started at age 40 – younger of interestStarted at age 40 – younger of interest Real interventions Real interventions
improve >1 transition probabilityimprove >1 transition probability might change other probabilities by might change other probabilities by
changing normschanging norms Cost effectiveness not discussedCost effectiveness not discussed
ConclusionConclusion Support for smoking prevention and Support for smoking prevention and
relapse prevention rather than for relapse prevention rather than for smoking cessationsmoking cessation
Health Marketing principlesHealth Marketing principles Heartless?Heartless? Agreed with “optimum” intervention from Agreed with “optimum” intervention from
Stages of Change ModelStages of Change Model Even for the worst-off smokers Even for the worst-off smokers
(Precontemplators)(Precontemplators) Support for the use of Health Marketing Support for the use of Health Marketing
Principles to target smoking interventionsPrinciples to target smoking interventions
FutureFuture
Are these findings true for other Are these findings true for other behaviors?behaviors?
Younger age? Sex?Younger age? Sex? ProbablyProbably More and better smoking dataMore and better smoking data Data on stages of change for other Data on stages of change for other
behaviorsbehaviors
The EndThe End
3 datasets3 datasets CHPGP CHPGP
N~10,000 2-year transitionsN~10,000 2-year transitions age-specific estimates of changeage-specific estimates of change all stages all stages Poor operationalization of Precontemplation and Poor operationalization of Precontemplation and
ContemplationContemplation MartinMartin
N~500 6-month transitionsN~500 6-month transitions No “Preparation” or “Never”No “Preparation” or “Never”
PizacaniPizacani N~500 2-year transitionsN~500 2-year transitions No follow-up data for Action, Maintenance, No follow-up data for Action, Maintenance,
NeverNever
Sensitivity AnalysesSensitivity Analyses
Rate of smoking initiation lowerRate of smoking initiation lower Rate of relapse from Maintenance higherRate of relapse from Maintenance higher Rate of remaining in Precontemplation Rate of remaining in Precontemplation
higherhigher .63.63.85.85
Different objectivesDifferent objectives Survival, partial credit for lower stagesSurvival, partial credit for lower stages
Different time horizons – 4 yrs, 10 yrsDifferent time horizons – 4 yrs, 10 yrs
Three DatasetsThree Datasets Wagner E, et al: The evaluation of the Kaiser Wagner E, et al: The evaluation of the Kaiser
Family Foundation's community health Family Foundation's community health promotion grants program (promotion grants program (CHPGPCHPGP ): Overall ): Overall design. design. J Clin Epidemiol 1991; J Clin Epidemiol 1991; 4444:685-699. :685-699. [N [N = 10,000, all stages]= 10,000, all stages]
MartinMartin RA, et al: Latent transition analysis to RA, et al: Latent transition analysis to the stages of change for smoking cessation, the stages of change for smoking cessation, Addict. Behav 1996Addict. Behav 1996; ; 21:67–80. 21:67–80. [N = 500, [N = 500, missing stages]missing stages]
PizacaniPizacani B, et al: A prospective study of B, et al: A prospective study of household smoking bans and subsequent household smoking bans and subsequent cessation related behaviour: the role of stage cessation related behaviour: the role of stage of change. of change. Tob Control. 2004Tob Control. 2004; 13:23-28. ; 13:23-28. [n=500, missing stages][n=500, missing stages]
Table 1, Stage Table 1, Stage DefinitionsDefinitionsStage CHPGP Martin Pizacani
Time between waves
2 yrs 6 months 21 months
Stage: Precontemplation No quit attempts
in past year No plans to quit in next 6 months
Not thinking of quitting
Contemplation 1-2 quit attempts in past year
Serious plans to quit in next 6 months
Thinking of quitting in next 6 months
Preparation 3+ quit attempts in past year
n/a Thinking of quitting in next 30 days and at least one quit attempt in previous year
Action Abstained for < 1 year
Abstained for < 6 months
Abstained for < 90 days
Maintenance Abstained for > 1 year
Abstained for > 6 months
Abstained for > 90 days
Never-Smoker Smoked < 100 cigarettes in lifetime
n/a Smoked < 100 cigarettes in lifetime
(Dead) (Dead) (Dead) (Dead)
3 datasets (cont.)3 datasets (cont.) Dataset CHPGP Martin Pizacani 1st Survey Year (approx) 1991 1996 2004 Number of survey waves 3 5 2 Time between waves 2 yrs 6 months 21 months Loss to f/u (wave 1-2) 40% 50% Mean Age 52 40 45 % male 41 32 50 # of Persons 5553 545 565 # of transitions 9622 565 Baseline Distribution: Precontemplation .118 .143 .169 Contemplation .059 .446 .192 Preparation .034 .091 Action .031 .147 .006 * Maintenance .247 .264 .213 * Never-Smoker .511 .328 * * Not tracked
