Chudley Werch describes an image-based intervention for preventing substance abuse and promoting healthy habits
MOST ADOLESCENTS ARE LIKELY TO EXPERIENCE multiple, co-occurring risk behaviors detrimental to their physical and mental health and personal development, and the combination of these behaviors can exacerbate health risks. However, although there are a plethora of effective interventions for preventing risk behaviors, the majority of evidence-based programs target a single behavior (e.g., cigarette smoking) or behavior category (e.g., substance abuse). There are also many programs shown to promote health-enhancing habits, but again these tend to focus on one area, such as physical activity or healthy eating.
|What we know|
|● The majority of adolescents experience multiple co-occurring risk behaviors.
● The Behavior-Image Model (BIM) can be used to plan brief programs addressing both health risk and health-enhancing habits by targeting positive youth images.
● SPORT is a brief single-session image-based program based on BIM.
● We have shown that SPORT can prevent and reduce substance abuse, while increasing physical activity among adolescents.
Novel interventions that are able to successfully influence co-occurring health behaviors among adolescents and young adults could be more cost effective than single-behavior programs. Multiple-behavior interventions might also be more readily adopted by schools and other youth organizations than single-behavior programs, particularly if they are brief and easy to implement. In addition, expanding the use of effective multiple-behavior interventions could have a greater impact on advancing the practice of evidence-based education for enhancing both mental and physical health than those targeting a single behavior alone.
An image-based approach
Studies have identified social images and future self-images as important factors in the onset and maintenance of a number of health behaviors of young people. We have developed a framework for planning brief, multiple-behavior interventions for youth called the Behavior-Image Model (BIM). BIM emphasizes positive image and behavior content, the idea being that positive social and future self-images can be used to link the prevention of co-occurring risk behaviors with the promotion of health and personal development-enhancing habits. Because images are highly malleable, accessible, and situation sensitive, they can be easily cued, which increases their salience and influence on behavior.
The SPORT program
We have applied BIM to develop a number of brief, image-based interventions that have proved effective for improving multiple health behaviors of adolescents and young adults. The first we created was SPORT, a universal prevention and health program that links participation in sports, exercise, healthy eating, and sleep with alcohol use avoidance. It was developed with funding from the National Institutes of Health and is listed on the National Registry of Evidence-based Programs and Practices (NREPP), and as a Blueprints for Violence Prevention “promising program.” We have conducted several studies evaluating SPORT. In a randomized controlled trial, the program has been shown to prevent and reduce alcohol, cigarette, and marijuana use, while increasing health-enhancing behaviors like physical activity among adolescents, with some outcomes lasting up to a year. Brief multiple-behavior interventions like SPORT typically use a single-session strategy with several components:
Multiple-behavior health screen
The first component of SPORT is a multiple-behavior health screen. The screen consists of items specifically designed to streamline and standardize the collection of data on target health behaviors of adolescents for the purpose of providing tailored feedback and goal setting. This is in contrast to other brief motivational strategies which use screening to identify individuals at highest risk. Since SPORT is a universal intervention, all youth screened are provided with tailored feedback based on their screening responses. Tailoring health communication has been shown to enhance message effectiveness. The screen is self-administered to individuals or groups of youth. It consists primarily of easy-to-complete yes/no questions and takes only a couple of minutes to finish.
The second component of SPORT is a tailored in-person consultation between the adolescent and a designated interventionist or teacher, sometimes referred to as a “fitness specialist.” The consultation uses a standardized script, thereby reducing the need for costly, intensive training, while increasing the probability of the program being implemented with fidelity. Consultations are conducted in a private or semi-private setting to enhance the comfort of the participant. Due to their brief, single-session design, consultations can be implemented in nearly any setting, including schools, youth organizations, community agencies, health clinics, and homes. Colorful graphics and illustrations are shown throughout the consultation, using charts or slides to visually highlight key image content and modeling of health and fitness habits. Consultations take approximately 20 minutes to complete. We have also recently developed a group-administered version of the consultation that can be implemented as a single lesson in a classroom setting to a group of adolescents.
Positive image content
Content found in the consultation is designed to promote an active and fit lifestyle and image, and emphasizes the conflict between this and using alcohol and drugs. First, the interventionist provides feedback tailored to screening items cueing individual behavior-image linkages, increasing the importance of subsequent image and behavior content. Positive feedback is presented congratulating those who responded that they engaged in any of the health-enhancing behaviors, or avoided alcohol use, while neutral (i.e., non-negative) feedback encourages adopting positive behaviors and avoiding alcohol for those who respond that they are not currently doing so. Next, messages are presented that highlight the positive images associated with engaging in each of the health-enhancing -behaviors and avoiding alcohol use. For example, “Sports and physical activities are fun, help you look trim and strong and feel good about yourself, give you lots of energy, and can help you do better in school.” Lastly, parallel messages are presented showing how drinking alcohol interferes with achievement of positive behavior, while avoiding risk behaviors like alcohol use supports positive image and behavior goals. For example, “An active lifestyle and alcohol do not mix. Using too much alcohol can hurt your performance in sports and have a negative impact on your health and relationships. Avoiding alcohol, along with regular exercise, is key to keeping a fit, trim, and healthy body.”
Multiple-behavior goal plan
After administering the screen and conducting the tailored motivational consultation, a multiple-behavior goal plan is provided to participants. The goal plan can be implemented individually or to a group. It is designed to increase awareness of positive behaviors and images as norms and values, and improve goal setting and behavior monitoring self-regulation skills. The goal plan provides adolescents with an opportunity to make a public commitment to change behaviors. First, the interventionist presents concrete behavior change recommendations related to each of the targeted behaviors. Next, the interventionist requests that the participant sign the goal to avoid alcohol and drug use during the next 30 days to maintain an active, healthy lifestyle and image. In addition, youth are asked to identify another health habit to improve. Then they are asked to select one or more behavioral strategies to help them achieve their goals. These “health and fitness tips” include, for example, giving oneself small rewards for making behavior improvements. Lastly, participants are instructed to take the contract home and post it for monitoring throughout the month. Combined, the components of SPORT take approximately 45 minutes to implement. SPORT can be re-administered as a booster to maintain initial program effects. We also include parent flyers which can be sent home to reinforce SPORT program content and enhance parent–child communication about healthy adolescent behaviors and image.
Evidence-based programs that effectively impact multiple co-existing risk behaviors among youth and young adults are needed. The Behavior-Image Model is an emerging conceptual framework for planning brief interventions that link the prevention of risk behaviors, such as substance use, with the promotion of health and personal development-enhancing behaviors, like physical activity, by targeting positive social and future self-images. SPORT is a brief single-session image-based multiple-behavior program based on BIM. Its brevity and standardization permit it to be easily implemented as a stand-alone or supplementary intervention to enhance both the physical and mental health of adolescents in a cost-effective manner.
About the author
Chudley Werch is the president of Brief Programs for Health and a visiting scientist at Mayo Clinic in Jacksonville. He conducts research and development on brief positive-image-based multiple-behavior interventions for preventing substance abuse and improving the health of young people.
Werch CE et al (2005), A Multi-health Behavior Intervention Integrating Physical Activity and Substance Use Prevention for Adolescents. Prevention Science, 6(3), 213–26.
Werch CE (2007), The Behavior-Image Model: A Paradigm for Integrating Prevention and Health Promotion in Brief Interventions. Health Education Research, 22(5), 677–90.
Werch CE et al (2008), Efficacy of a Brief Image-based Multiple Behavior Intervention for College Students. Annals of Behavioral Medicine, 36(2), 149–57.
Werch CE et al (2011), Brief Integrative Multiple Behavior Intervention Effects and Mediators for Adolescents. Journal of Behavioral Medicine, 34, 3–12.