Evidence-based health and well-being for entire populations.

Multiple Behavior Change

More impact on health and well-being

Pro-Change has long been a leader in providing innovative multiple behavior change programs, which have the potential to offer significantly more impact on health and well-being.

Beginning with the development of the Managing Cholesterol Program, Pro-Change recognized how crucial it was that the fully tailored adherence program be paired with interventions for the other lifestyle behaviors that are key in managing high cholesterol. The results of the initial Small Business Innovative Research (SBIR) funded effectiveness trial exemplify the potential for coaction of behavior change when fully tailored interventions are paired with stage-matched interventions. The treatment group received a full expert system for medication adherence and stage-matched guidance for exercise and dietary fat. The treatment group was 50% more likely than the control to reach Action or Maintenance for all behaviors (Johnson et al., 2006).

The results of Pro-Change’s SBIR-funded, population-based, weight management program add to the support for effective multiple behavior TTM-based interventions. The randomized trial, which included 1277 overweight or obese adults, found significant treatment effects for healthy eating, exercise, managing emotional distress, and untreated fruit and vegetable intake. Participants in the intervention condition who received diet and physical activity interventions lost significantly more weight at follow-up than usual care participants and were significantly more likely to lose at least 5% of their baseline weight.


Exploring innovative options


The success of multiple behavior change is also clear in younger samples. TTM-based multimedia programs for bullying prevention have had similar success in diverse populations (Evers et al., 2007). The trials included 12 elementary schools (40.6% of free lunch eligible); 12 middle schools (48.6% eligible); and 13 high schools (42.3% eligible). The programs had significant effects on three roles related to bullying (i.e., bully, bystander, victim). Overall, the odds ratios indicated that intervention groups were 3-4 times as likely as the control group to progress to Action/Maintenance (i.e., not participate in any role related to bullying) (Van Marter et al., 2006; Evers et al., 2007).

Our multiple behavior change obesity prevention program, Health in Motion, targeted three energy balance areas: increasing physical activity, eating more fruits and vegetables, and reducing TV time. (Mauriello et al., 2010; Driskell, et al., 2008; Velicer et al., 2013). The program was tested in two separate randomized clinical trials with nearly 6,000 adolescents (middle and high school students). Both trials (tested by separate groups and funded by different Institutes) demonstrated that Health in Motion is effective at increasing the targeting energy balance behaviors, reducing overall number of behavioral risks, reducing relapse, and promotion of multiple behavior changes. The middle school trial is noteworthy in two important ways. The follow-up assessment was extended to 36 months, and strong effects of Health in motion influencing energy balance behaviors persisted. Additionally, in that trial Health in Motion was used as a control program for testing a substance use prevention program (decreasing smoking and alcohol). Despite no direct treatment, the energy balance group showed significantly lower smoking and alcohol use than the substance use prevention program. It can be hypothesized that the positive healthy lifestyle messages had a great impact at preventing substance use among adolescents than direct messages against those behaviors.

Within the LifeStyle Management Suite, users participate in a multiple behavior change program, such as Managing High Blood Pressure, or participate in two or more single behavior programs, such as smoking, stress, and exercise.

Pro-Change continues to explore innovative options for maximizing the effectiveness of multiple behavior change interventions while minimizing response burden. Ongoing trials on college student health and healthy pregnancy will provide important data on the utility of optimal tailoring.


Driskell, M.M., Dyment S.J., Mauriello, L.M., Castle, P.H., & Sherman, K.J. (2008). Relationships among multiple behaviors for childhood and adolescent obesity prevention. Preventive Medicine, 46, 209-315. abstract

Evers, K.E., Prochaska, J.O., Van Marter, D.F., Johnson, J.L., & Prochaska, J.M. (2007). Transtheoretical-Based Bullying Prevention Effectiveness Trials In Middle Schools and High Schools. Educational Research, 49(4), 397-414.

Johnson, S.S., Driskell, M.M., Johnson, J., Dyment, S., Prochaska, J.O., Prochaska, J.M., Bourne, L. (2006). Transtheoretical Model intervention for adherence to lipid-lowering drugs. Disease Management, 9(2), 102-114.

Johnson, S.S, Paiva, A.L. Cummins, C., Johnson, J.L. Dyment, S., Wright, J.A., Prochaska, J.O., Prochaska, JM., Sherman, K. (2008). Evidence-based Multiple Behavior Intervention for Weight Management: Effectiveness on a Population Basis. Preventive Medicine, 46, 238-246.

Mauriello, L. M., Ciavatta, M. M., Paiva, A. L., Sherman, K. J., Castle, P. H., Johnson, J. L., Prochaska, J. M. (2010). Results of a Multi-Media Multiple Behavior Obesity Prevention Program for Adolescents. Preventive Medicine, 51, 451-456.

Van Marter, D., Evers, K., Johnson, J., Dyment, S., Prochaska, J.M., and Prochaska, J.O. (November, 2006). Bullying prevention across the school years: effectiveness trial outcomes of Transtheoretical model-based programs for elementary, middle and high school students. Poster presented at the 134th Annual Meeting of the American Public Health Association: Boston, MA.

Velicer WF, Redding CA, Paiva AL, Mauriello LM, Blissmer B, Oatley K, Meier KS, Babbin SF, McGee H, Prochaska JO, Burditt C, Fernandez AC. (2013). Multiple risk factor intervention to prevent substance abuse and increase energy balance behaviors in middle school students. Translational Behavior Medicine, 3, 82-93.

Additional Reading

Prochaska JO. Multiple health behavior research represents the future of preventive medicine. Prev Med. 2008;46:281-285.

Jones, H., Edwards, L., Vallis, T. M., Ruggiero, L., Rossi, S. R., Rossi, J. S. et al. (2003). Diabetes Stages of Change (DiSC) Study. Changes in diabetes self-care behaviors make a difference in glycemic control: The diabetes stages of change (DiSC) study. Diabetes Care, 26, 732-737.

Prochaska, J. O., Butterworth, S., Redding, C. A., Burden, V., Perrin, N., Leo, M. et al. (2008). Initial efficacy of MI, TTM tailoring and HRI’s with multiple behaviors for employee health promotion. Preventive Medicine, 46, 226-231.

Prochaska, J. O., Velicer, W. F., Redding, C., Rossi, J. S., Goldstein, M., DePue, J. et al. (2005a). Stage-based expert systems to guide a population of primary care patients to quit smoking, eat healthier, prevent skin cancer, and receive regular mammograms. Preventive Medicine, 41, 406-416.

Prochaska, J. O., Velicer, W. F., Rossi, J. S., & Goldstein, M. G. (2004). Stage effects in 70 comparisons in a population cessation trial. Addictive Behaviors.

Prochaska, J. O., Velicer, W. F., Rossi, J. S., Redding, C. A., Greene, G. W., Rossi, S. R. et al. (2004). Multiple Risk Expert Systems Interventions: Impact of Simultaneous Stage-Matched Expert System Interventions for Smoking, High-Fat Diet, and Sun Exposure in a Population of Parents. Health Psychology, 23, 503-516.