This panel explored applications of the transtheoretical model (TTM) of health behavior change to evaluations of public awareness activities. Dr. Michael Rohr and Dr. Mark Robbins are collaborating on efforts to develop the TTM for evaluation activities in the organ donation community. Dr. Robbins is currently consulting on a project funded by the Health Resources and Services Administration (HRSA), Division of Transplantation, to develop tools to measure stages of behavior change in college-aged students to gauge the effectiveness of organ donation awareness programs. Together these presentations represented the first challenge of this conference, that is, how to strengthen evaluations of public awareness activities.
These presentations focused on applying the five stages of behavior change identified by Prochaska et al. to organ donation, i.e.:
- pre-contemplation: the person has not thought about donating organs
- contemplation: the person has thought about donating organs
- preparation: the person has made phone calls or requested information about organ donation
- action: the person has taken action to express his/her wishes about organ donation, e.g., signed a donor card, talked to a lawyer, or discussed wishes with family
- maintenance: the person may occasionally remind or reinforce statement of wishes to family members.
To develop this model for organ donation activities, Robbins et al. developed a structured family consent survey to interview next-of-kin who either did or did not consent to donate organs. The survey was designed to measure: 1) stage of change, 2) decisional balance, and 3) potential processes of change. The information from the survey can be used to target specific processes of change to promote advances towards the action phase and, ultimately, to increase the likelihood of consenting to donate. One limitation of this survey has been its small sample size of non-donor families. As indicated by the panel, this sample size needs to be strengthened to improve the validity of the survey findings.
The TTM could be used to guide the assessment of programs such as the Georgia Coalition’s "Life Takes Guts" college campus awareness initiative, presented by Von Roebuck, Chair of the Georgia Coalition. Based on the theory that values are chosen during the years 18-24 that guide adulthood decision making, Roebuck and his colleagues at the Coalition have implemented a college-level campaign for organ donation awareness and donor card signing. The campaign involves a variety of campus celebrities, food, local media, and other "attention grabbers" for students. The Coalition supported 5 campus programs in the first year, 10 campuses in the second year, and will support 15 campus programs in 1998. In some cases, the college campuses are taking over the program themselves. The Coalition has reached approximately fifty-percent of the students in Georgia, and is evaluating the awareness of students and their level of intent to donate. Over the past few years, the number of tissue and organ donors has increased in Georgia, perhaps due to this and other programs. The primary evaluative concern identified for this effort is the difficulty of measuring a causal link between the "Life Takes Guts" program and Georgia’s organ donation rates.
Conference participants expressed concern that the TTM needs to be further tested in the organ donation community, particularly given the contrast between the acute nature of organ donation and such chronic health behavior change models as smoking cessation. Suggestions included the following.
- A more effective survey instrument needs to be developed due to the logistical problems associated with administering detailed surveys to grieving families. To make the TTM more useful, concise surveys similar to the SF-36 quality of life questionnaires need to be developed. The survey results need to be reliable, reproducible, and able to be more readily administered in this difficult setting.
- To test the TTM more fully across its stages of behavior change, the survey should be given to a much bigger non-donor sample to improve the validity of results. With an oversampling of donor families, the results are likely to be skewed towards the action phase.
- The evaluation of the "Life Takes Guts" program could be improved by combining elements of the TTM. Measures could be taken of how many students were previously aware of organ donation activities, and the extent to which this intervention prompted progression through the stages of change. In addition, surveys could be taken and analyzed by class to see if the on-campus interventions moved students through stages of change as they advanced from being freshman to seniors. The Coalition could conduct pre- and post- surveys, tracking the classes by year and the number and types of impressions the classes have experienced. The college campus population is unique in that it is a relatively contained audience that allows for this type of tracking.
- The application of the TTM to this program should be expanded from the individual as the unit of analysis to the family. The family is most often the decision-making unit in these cases, and needs to reach the action stage in order to consent to donate. Parents’ weekends on college campuses may offer an appropriate opportunity to implement surveys of families.
- More efforts need to be made to analyze why the donation rate in Georgia has increased, to better identify potential causes of the increase. For example, if the increase in donations resulted primarily from a change in the consent rate, then it is more likely that the college and religious programs in Georgia may have affected the consent rate. On the other hand, if the increase in donations resulted primarily from an increased referral rate, then it is possible that the programs did not have as big an impact. To determine specifically what caused a family to consent to donate, surveys should be administered at the time of consent to determine what influenced that family’s decision.