December 29, 2008

STAGES OF CHANGE

Tobacco recovery for severe mental illness makes progress despite challenges from Ohio’s declining economy

—by Paul M. Kubek and Matthew K. Weiland

Columbus, OH—A significant cutback in funding for tobacco-cessation programs in the State of Ohio has negatively affected efforts to reduce illnesses and healthcare costs associated with the use of harmful tobacco products. Yet, the Ohio Tobacco and Recovery Project, developed for people with severe mental illness, continues to make progress toward a service model that will stand the test of time and create positive results for Ohio residents. A recent national survey has found that while tobacco use in the general population has declined in many states over the last 10 years, tobacco use in Ohio has not declined.

The Project team has developed a "getting-started guide" for its consultants, trainers, and evaluators to help organizations begin to implement the model. The team has also completed baseline fidelity assessments at five community-based behavioral healthcare organizations (see sidebar), with additional reviews anticipated at other organizations over the next few months. All of these organizations have expressed a commitment to addressing tobacco use among the consumers they serve. The fidelity assessments provide information about how closely an organization's services and policies fit the Ohio Tobacco and Recovery stages-of-change model and provide steps for fidelity action plans, which guide the implementation process.

BASELINES & ADVOCACY

The baseline fidelity assessments have found that consumers and service organizations are having difficulty accessing medications for tobacco cessation. The Ohio Departments of Health (ODH), Mental Health (ODMH), and Alcohol and Drug Addiction Services (ODADAS) are interested in working with healthcare institutions in the state to make medications more readily available, especially to underserved populations such as people with severe mental illness.

THE ADVISORY COMMITTEE

The advisory committee for the Project is comprised of representatives from over 27 different organizations who continue to collaborate actively and passionately. Committee members include advocacy groups, healthcare and behavioral healthcare organizations, charitable foundations, national experts, and Ohio State Departments of Health, Mental Health, and Alcohol and Drug Addiction Services. The committee meets quarterly in Columbus, most recently in November.

THE FIDELITY MEASURE

“The feedback will help us move more efficiently toward our goal of developing an evidence-based practice. . . . We are evaluating the evaluation instrument, and, in doing so, we are gaining knowledge about the implementation process that will make our consulting services that much more effective.”

—Debra Hrouda, MSSA (’94), LISW-S

The fidelity measure is a 19-item instrument that represents all of the core components of the model. It combines components of the evidence-based Integrated Dual Disorder Treatment (IDDT) model, items from existing tobacco-cessation models, and items that were not present in other models to help people with severe mental illness address their tobacco use. These components were identified by the project development team through a comprehensive review of relevant literature and consultations with nationally known cessation-program developers, including Carlo C. DiClemente, PhD, professor of psychology at the University of Maryland-Baltimore County, who is co-creator of the Transtheoretical Model of Change (stages of change) and Jill Williams, M.D., associate professor of psychology and director of the Division of Addiction Psychiatry, UMDNJ-Robert Wood Johnson Medical School.

The fidelity measure helps organizations implement the model and helps evaluators provide feedback to the organizations to guide the progress of implementation. It also helps assure consistency of implementation across organizations located in communities throughout the state. The consistency is essential for evaluating treatment outcomes, and attributing outcomes to the new intervention. The outcomes and fidelity data will help evaluators determine over time whether the Ohio Tobacco and Recovery stages-of-change model is an evidence-based practice. This process typically takes several years and will likely include changes in the fidelity measure, based upon outcomes and feedback from evaluators and service providers involved in the implementation and fidelity-assessment processes.

"A perfect model on paper doesn't mean anything if it won't work in the real world," says Debra Hrouda, MSSA ('94), LISW-S, associate director of research and evaluation at the Center for EBPs and manager of the Ohio Tobacco & Recovery Project. "If the components of the model are not useful to the people doing the work in the field, then what's the point? We've done our homework and have come up with a model based on the best available evidence to address this important issue with this special, under-served population. So we're very confident about what we've got. Yet, we don't want to stop there. That's why we need the outcomes and fidelity data so we can tweak and perfect the model and the measure as we move forward."

In addition to gathering consumer outcomes and conducting fidelity reviews, Hrouda explains, the Ohio Tobacco and Recovery Project has developed an online survey to gather feedback from evaluators about each item on the fidelity measure. This way we can evaluate the measure as well as the model. It is based upon a method developed by Gary Bond, PhD, Chancellor's Professor at Indiana University-Purdue University Indianapolis.

"The feedback will help us move more efficiently toward our goal of developing an evidence-based practice," Hrouda says. "We feel it's a smart way to do implementation. We are evaluating the evaluation instrument, and, in doing so, we are gaining knowledge about the implementation process that will make our consulting services that much more effective."

STAGES OF CHANGE

Many tobacco cessation models in the United States are designed for people who are ready to take action to quit. Yet, research conducted by DiClemente and his colleagues since the 1980s, as well as others, demonstrates that people typically go through five stages of change (pre-contemplation, contemplation, preparation, action, maintenance) when replacing unhealthy habits with healthy ones. The Ohio model was designed specifically to offer interventions for people in all stages of change. It's especially important for people diagnosed with severe mental illness, because research shows that more than 70 percent use tobacco products (e.g., cigarettes, chewing tobacco) and that they die approximately 20 to 25 years earlier from potentially tobacco-related illnesses than people in the general population.

"Think for a moment about a typical tobacco user," says Hrouda. "He may have heard tobacco is bad for you but has not experienced any bad effects. In fact, he may report only the positives he perceives to come from tobacco-for example, ‘It helps me relax' or ‘It helps me think clearer'. That same person may complain about some negatives in his life-for example, ‘I don't have enough money to do what I want to do'. But he might not make the connection between this and tobacco.

"So this person may not even think about reducing or eliminating tobacco unless presented with information relevant to his personal life by people he knows and trusts. Our model is intentionally designed to help people weigh the pros and cons of tobacco use in hopes that awareness of the cons will eventually win. Our model can help people tip their decisional balance toward contemplation, preparation, and action and, therefore, quit successfully."

Hrouda emphasizes that addictive behaviors do not change or stop overnight, that movement toward abstinence typically occurs gradually over time and that relapse is likely to occur. This is especially true with people who have severe mental illness, because symptoms of mental illness and one's lifestyle are often complicating factors in the process of abstinence.

Hrouda concludes that the Ohio Tobacco and Recovery stages-of-change model acknowledges this and responds to it by providing ongoing support and encouragement to people trying to achieve healthier habits.


CONTACT US

Service organizations and systems that are interested in the Ohio Tobacco & Recovery stages-of-change model are encouraged to contact the following:

Patrick E. Boyle, MSSA, LISW-S, LICDC
patrick.boyle@case.edu


Paul M. Kubek, MA, is director of communications/technology-transfer product development and Matthew K. Weiland, MA, is technology-transfer product development specialist/producer at the Center for Evidence-Based Practices at Case Western Reserve University.