San Diego State University
College of Health and Human Services
Graduate School of Public Health
Division of Health Promotion
PH 667: Prevention and Control of Chronic Illness
Fall 2010
Class Schedule:
Monday 1:00 p.m. to 3:40 p.m.
Hepner Hall 146
Office hours:
Office Hours: By Appointment
On Campus or at CBEACH
9245 Sky Park, Ct. , #230, San Diego, 92123
Instructor will be available before and after class
instructor: :
Dr. Mary Mulvihill
Phone: 858-775-2257
E-mail: mmulvihill@projects.sdsu.edu
Course Description & Goals
The purpose of the course is to address health promotion strategies for modification of individual
behavioral and social practices to reduce the risk for chronic disease. Accordingly, a major focus will
be modifiable lifestyle behaviors that cut across chronic disease. Within the framework of the socioecological model, basic behavioral strategies relevant to individuals with chronic illness will be taught.
The goal is to equip students to work effectively in an intervention project, clinical care setting, EAP or
worksite wellness program or other setting where individual behavioral intervention with individuals with
chronic illness is required.
Through interactive lectures, discussions of readings, case studies and interactive learning activities,
the course will cover evidence-based, behavioral assessment and intervention strategies applicable to
most chronic illnesses. Students will be trained to apply them across the major domains of moldable
health behaviors for chronic illness prevention and management, including physical activity, dietary
modification, sleep hygiene, and adherence/stress reduction.
Acquisition of the applied behavioral analysis knowledge base and skill set will be emphasized as it is
the foundation for more complex, disease specific interventions. Strategies from motivational
interviewing, including relapse prevention will be included. Cultural and ethical considerations relevant
to individual level behavioral intervention in chronic illness will also be addressed. Psychosocial issues
relevant to chronic illness, such as depression, anxiety, managing pain fatigue, and isolation will be
covered. Issues for family and interface with the health care system will also be discussed.
Students will acquire knowledge of specific chronic illnesses through readings, class discussion, guest
appearances, and by researching and creating a class presentation on a chronic illness of interest,
placed within the framework of the social-ecological model, with emphasis on individual level
behavioral aspects focused on in the class.. There will be a “lab” component with demonstrations, role
play or guest appearances to teach practical skills. In small groups, students will apply those skills and
conduct a behavioral assessment and brief behavioral intervention of a lifestyle-related health behavior
relevant to chronic illness to develop basic competence in practical behavioral intervention strategies
relevant to chronic illness control and management.
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Course Objectives & Teaching Methods
1) Provide an overview of common chronic illnesses and their associated influences within he socialecological framework. Provide an overview of behavioral and psychosocial issues relevant for health
promotion with chronic illness
2) Develop a fund of basic knowledge re the assessment and intervention strategies related to chronic
illness and commonly used in health promotion: smoking cessation, physical activity, dietary, sleep
hygiene, stress reduction (depression, anxiety, pain) and adherence domains common to most chronic
illnesses.
3) Develop an understanding and the basic skills to implement an individualized behavioral
intervention, including theoretically based strategies relevant to intervention with common lifestyle and
illness-related behavioral targets in chronic illness
4) Understand family, peer and medical system level variables and how they impact and interact with t
individual intervention strategies in chronic illness. Understand the chronic illness experience from the
patient’s perspective, including cultural factors that affect diverse groups and how to competently
adjust intervention to accommodate them.
The course is designed around four these four objectives and corresponding teaching and evaluation
methods.
Objectives
Teaching methods
Evaluation
methods
Name and describe the most common types of
 Interactive
 Class
chronic diseases, including prevalence, high risk
lectures
participation
groups, path physiology, medical treatment,
 Discussions of
 Exams
behavioral issues, treatment settings, credible local
readings &
 Individual
and national resources.. Understand influences on
online
presentations
chronic disease within socio-ecological framework.
resources
 Patient
 Presentations
education
Deliver a presentation on an assigned chronic
handout
illness. Create a patient education handout for an
assigned chronic illness incorporating above
features.
Name and describe a selected set of evidence –
based, individual level behavioral assessment and
intervention strategies for modifiable behavioral risk
factors in chronic illness, including physical
activity/fitness, diet, smoking cessation, sleep
hygiene, adherence and stress reduction.

Plan and implement a simple, 8 session lifestyle
behavior change project based on principles of
applied behavioral analysis and using motivational
interviewing/relapse prevention strategies.





Interactive
lectures
Guest lectures,
demonstrations
Case studies
Coach’s Toolkit

Class
demonstrations
& role play
Small group
work





Class
participation
Exams
Case study
Coach’s
Handbook
Case study :
Write up of
case study
Write up this case study, including behavioral
assessment, pre and post-test of outcome variable,
self monitoring and feedback graphs (process data),
weekly follow-ups in SOAP format, maintenance
2
plan, client “send off” letter and case summary.
Name and describe peer, family and medical
system level variables relevant to intervention with
chronic illness, and how they interact and impact
individual intervention


Guest speakers 
from each level 
Class
discussion

Exam
Write up of
case study
Presentation
3
Evaluation Methods
Your performance in the course will be evaluated on the following six assignments:
1. Class Attendance & Participation in role plays, behavioral
15 pts
observation and feedback
Due to the hands on learning approach, class attendance is critical as
we will build a skill set gradually over time to give you a foundation for
conducting a competent , individual level, behavioral intervention.
2. Midterm Exams 1 and 2
You will have two closed-book, in-class mid-term exams (see
schedule). These exams are not cumulative, and will consist of
multiple choice, short-answer and discussion questions, covering
primarily lecture material, supplemented by material from readings.
See handout for more information.
25 pts
each
3. Individual Presentation
A 15 minute power point presentation on your assigned chronic
illness topic, pre-approved by the instructor which will cover
epidemiology (high risk groups), path physiology, medical treatment
and behavioral issues pertinent to a specific chronic illness of interest.
A national and local resources page and patient education handout
for the disease-relevant behavioral issues are required to hand out to
the class. See handout for more information
10 pts
4. Individual Behavior Change Case Study write-up
See handout for more information.
Client feedback & evaluation 5 points
5. Coach’s Handbook for Behavioral Intervention
Compilation of all course assessment and intervention forms (content
aides), Coach’s Toolkit guide (process aides) and disease specific
resource sheets and patient handouts (from class presentations) into a
permanent notebook for future reference.
25 pts
Total
Pass/fail
100
Course grades will be assigned as follows based on total points accumulated for the semester:
A
96-100 C+
77-79
A90-95
C
74-76
B+
87-89
C70-73
B
84-86
F
<70
B80-83
Incomplete: Medical emergencies verified by practicing clinicians and limited other emergencies are the
basis for an incomplete.
Course Attendance Policy: Attendance is mandatory, due to the nature of the hands on learning
activities and the shaping model used in the class training. Participation in training activities, such as
role play, demonstrations, guided practice and behavioral observation/feedback will be used as a
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primary method for generating the participation grade for the course. Email instructor if an emergency
arises where you cannot attend class as this affects planning of group activities. Absences for religious
observances: By the end of the second week of classes, students should notify the instructor of
planned absences for religious observances. The instructor will provide appropriate accommodations.
Dat
Content
8/30
Introduction to
course
Models &
frameworks for
understanding
chronic illness
Course Outline & Class Calendar
Special
Assignments
Activities
Review syllabus
Student info sheet
& assignments
Chronic illness
patient interview
Read xxxxx
Readings & Resourc
Clark, NM & M, Giong
by practitioners and p
things ? BMJ, 2000, 3
Bodenhiermer, T. , E.H
Improving primary car
JAMA, 2002, 288, 177
Bodenhiermer, T. , E.H
Improving primary car
part 2. The chronic ca
1914.
Tsai, AC et al. A meta
improve care for chron
2005, 11, 478-88.
9/13
Motivational
interviewing
Behavioral
theories and
behavioral selfmanagement in
the socioecological
framework
Basic behavioral
management :
treatment
planning and self
monitoring in
chronic illness
9/20
:
Guest : Cody
Benedict MPH,
Chronic illness
coach
Cultural
Influences &
disparities in
chronic illness
Lab: CLAS
standards
Select self
management goal
Conduct initial
interview
Conduct Pre-test
of change outcome
Sign up for
individual
presentation topics
Presentation:
Hypertension
Guest Ashley Hall
MPH, CDE,
Diabetes
Educator
,
Type 2 Diabetes
presentation
SM session 1
Set up shaping
hierarchy, initial
goal, contingency
model, self
monitoring
Marlatt, AM, Motivatio
assessment and interv
cessation, pharmacoth
Heijmans, M. & D. De
representations: explo
nature. J. Behav Med,
Betancourt, JR et al. C
care disparities: key p
(Millwood), 2005, 24,
Fisher, EB et al. Ecolo
management: the cas
1523-35.
Diabetes Prevention P
incidence of T2DM wi
2002, 346, 393-403.
5
Glasgow, R. E. et al. A
key to successful diab
2004, 27, 477-490.
9/27
Guest : Melissa
Stephens,
American Lung
Association
SM session 2
skills training,
guided practice,
implement rewards
Clark, NM & MA Valer
in educational interven
Resp Rev, 2003, 4k 3
Toelle, B. G. and FS r
management plan for
Cochrane Database S
Asthma in
children
presentation
Guendelman, S. et al.
self-management beh
randomized trial of the
and asthma diary. Arc
20.
RAMP website
10/4
10/1
1
Behavioral
assessment and
intervention for
sleep hygiene,
Symptom-related
insomnia
Adherence in
chronic illness,
scope of the
problem, problem
solving common
challenges
10/1
8
Impact of chronic
illness on family
members,
Caregiver strains
Family
interventions in
chronic illness
Means MK, Lineberge
JD..Nonpharmacologi
Options Neurol. 2008
SM session 3
Problem solve
barriers, build self
efficacy, look for social Becker PM. Pharmacolog
supports in everyday
treatments of insomnia.. N
life
Presentation :
HIV
SM session 4
Graphic feedback
system, adv.
Reward system,
social support
strategy
Midterm Exam 1
Session 5 –
shaping,, set up
practice relapse
Guest : Polster
Breast Clinic,
Scripps Memorial
Hospital, Breast
Buddy program
Session 9 – wrapup, summary of
progress,
maintenance plan,
send off letter
Presentation:
Breast cancer
Osterberg, L. & T Blas
NEJM, 206, 353, 487-
Rubin, RR. Adherence
J Med. , 2006, 118, Su
Matire, LM et al. Is it b
member ? A meta-ana
for chronic illness. , H
Lim, JW & Zebrack, B
chronic illness. A critic
J Qual Life Outcomes
6
10/2
5
Anxiety influences
in chronic illness
Anxiety-specific
targets such as
uncertainty, pain,
procedures,
behavioral
challenges
11/4
Depression
influences in
chronic illness
Guest Lamaire,
Palliative Care
program, San
Diego Hospice
Presentation
Chronic pain
Presentation:
Bipolar
Behavioral
strategies for
addressing
depression &
fatigue in chronic
illness
11/1
1
Lou Ryan
Practice relapse
implementation
Behavioral change
project
Session 6- process
practice relapse,
prepare for
relaxation
procedure
Guided relaxation
script
Session 7 –
behavioral
relaxation protocol
Session 8 – Final
treatment session.
Prepare maintenance
plan.
Robinson L. Stress an
1990 Dec;25(4):935-4
Huntley A, White AR,
asthma: a systematic
Feb;57(2):127-31. Re
Sims SE. Relaxation t
patients cope with the
review of the literature
91. Review
Chapman The vital lin
depressive disorders.
pA14..
Addressing the needs
illnesses: the case of
Manag Care, 2004, 10
-
Compose “send –off”
letter
Conduct post test
11/1
8
11/2
5
Mindfulness-based
strtegies
Steve Hickman
Presentation:
Behavior Change
Write-ups due
Feedback from
clients/co-coaches
11/3
0
12/6
West Wireless
Midterm Exam 2
7
8
PH 667, Fall 2008
Class Assignments
Overall Objective:
Integrate existing and new knowledge and skills in health promotion relevant to individuals with
chronic illness, using the behavioral and socio-ecological framework.. Be able to apply that knowledge
on a practical level with modifiable behavioral commonly targeted in individuals with choric illness for
risk reduction, prevention and control of their disease. .
Exams
You will have two closed-book, in-class mid-term exams (see schedule) designed to assess your
competence in the basics of individual level behavioral intervention in chronic illness. . These exams
are not cumulative. They will consist of multiple choice, short-answer and discussion questions,
covering primarily lecture material, supplemented by material from readings and online resources
assigned in class.
Individual Presentation and Patient Handout on a Chronic Illness
A 15 minute power point presentation on your assigned chronic illness topic, pre-approved by the
instructor which will cover the following aspects of the chronic illness : epidemiology (high risk
groups), pathophysiology, usual medical treatment and behavioral challenges. A portion of the talk
should address ways of coping with specific disease –related behavioral challenges. One slide
should list national level resources, such as national disease associations and one slide should list
local resources pertinent to the chronic illness.
A double sided or trifold (brochure format), color patient education handout for the disease-which
may include relevant behavioral issues and resources useful to clients. is required This will be
handed out to the class for future reference and to be placed in your Coach’s Handbook. This will
be evaluated based on the appropriateness and usefulness of the content and on the accessibility
and “look” of the document, including relevant visuals.
Class Participation & Attendance
Because of the “hands on” nature of the learning activities, class attendance and participation are
crucial. We will use demonstrations, role plays, and small group learning activities to teach practical
aspects of applied behavioral strategies. This is an excellent way to get some guided practice and build
your self-efficacy, though it does require some courage and willingness to make mistakes and allow us
all to learn along with you.
Because of the small group nature of the case study/behavioral change project, it is crucial that all
group members be present each week. Your absence affects the other group members as well as
course planning for in class learning activities. Each week will build on the week before, so if you miss
class, you will miss a key building block in your skill set.
Previous students have noted that these activities, though difficult at first were among the most
effective learning experiences they had. Each of you comes into the class at a different level
depending on your background, so improvement in skills is the important part. Your willingness to jump
in and try out new skills in class will be part of your grade. .
Behavior Change Project (conducted in groups of 3)
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This is an 8 session basic behavioral intervention conducted with an individual member of your
class as a “client” and another member as a co-coach. The target behavior is a lifestyle behavior
(physical activity, diet, sleep hygiene or adherence issue similar to what might be needed with a
chronic illness client. Some class time will be given to this project but not every week. You are
expected to meet face to face with your group weekly , supplemented by email and phone contact
as needed to keep the project on track every single week. During Spring Break if all is going well, you
may meet by phone.
The intervention begins with an assessment and a pre-test, ideally of an objective outcome variable..
A self monitoring system needs to be set up to track the behaviors you are facilitating change with,
which gets reviewed each week. These may be the same or different the outcome variable. Based on
assessment inf, treatment planning is done.
A conceptual model of the behavioral contingencies is constructed and a shaping strategy or
hierarchy is planned by the coach with the assistance of the co-coach, and collaboration with the client.
Small, achievable goals are set in a gradual progression with appropriate extrinsic rewards.
Each week the weekly feedback form is filled out, which guides you through the assessment of
ongoing barriers, benefits, rewards administered, skills training delivered and education provided. Each
week the client is given feedback and the shaping strategy is adjusted for their needs to optimize
progress. Care is taken to provide reinforcement of progress, timely salient rewards, reframing
and problem solving of difficulties, and support for development of self-efficacy. The
development of social support in the person’s everyday environment is critically important so the
behavior will continue to be reinforced after coaching ends. As treatment progresses, a token
economy system of rewards can be set up if desired. Coach’s should provide interim social support
via phone/email/text as needed during the intervention.
Two specialized behavioral intervention protocols are delivered in the latter part of the intervention. The
practice relapse allows the assessment and the learning of how to handle a relapse from the new
behavior should it occur. During the debriefing from this, skills and supports needed to help the person
get back on track are identified so that the client is prepared when it happens after coaching. A
behavioral relaxation strategy is identified in consultation with the client that may be effective for
them. The coaches plan a protocol using the behavior science literature, develop a script, and deliver
the intervention to the client to support optimal stress management and deal with anxiety-related
barriers relevant to their behavioral change process.
At the end of “treatment”, a post-test is done as part of the post-treatment assessment and compared
to the pre-test. In addition, behavioral data collected during the treatment, especially improvements
from session 1 to 7 are quantitatively, summarized across all relevant parameters. Graphic feedback
may be very useful in addition. The progress of the client is summarized, in person with them and in a
brief written summary report (samples on BB) to me. Use the outline provided on BB. Qualitative
feedback from the client is also solicited, and this is combined with input from the coaches to form a
summary of ALL positive behavior changes as well as remaining challenges and recommendations.
A behavioral maintenance plan is developed to address the client’s individual needs over time after
intervention, which should include solutions to barriers and other individualized tips, short and long
term goals, short and long term reward strategy and social support plan related to the target behavior.
This plan is written up and given to the client to keep for future reference and turned in to me. To wrap
up, the plan should be accompanied by a “send off” letter – a brief personal note from the coaches
that summarizes their progress and process throughout and provides motivation and inspiration for
their future success.
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Coach’s Handbook for Behavioral Intervention in Chronic Illness
Compilation of all course assessment and intervention forms (content aids), Coach’s Toolkit guide
(process aids) , disease specific resource sheets and patient handouts (from class presentations) into
a permanent notebook, such as a binder for future reference. You may choose to include selected
class lectures and presentations but this is not required. Inclusion of the basic lectures on smoking
cessation, fitness/PA, diet, and sleep is recommended.
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Other Administrative Issues
Course Assignments
 All written assignments must be typed using Microsoft Word or a similar word processing program.
In addition to spelling, grammar, and writing style, your work will be evaluated based on
professional appearance (examples of non-professional appearance: crinkled pages, stains, poor
staple job)
 Oral presentations should lose PowerPoint or an equivalent program. As health communication
includes media design, professional appearance and the “look” of a project will be part of its
evaluation.( Examples of this include appropriate visuals, color scheme, font, backgrounds and
ease of reading text)
 Assignments are not to be emailed, but can be turned into the class’s Digital Drop box on BB. Feel
free to email me with any questions or concerns, however.
 You are strongly encouraged to keep computer backups of your work to avoid losing information
and time.
 If you have an Authorization for Accommodations form that indicates a need for academic
accommodations, please let me know so we can discuss this. Student Disability Services is located
in Calpulli Center, Suite 3100 (third floor), (619) 594-6473 and (619) 594-2929 (TDD/TTY)
Academic Integrity
Academic dishonesty is an affront to the integrity of scholarship at SDSU and a threat to the quality of
learning. Violations of academic integrity are noted in the SDSU Statement of Student Rights and
Responsibilities:
2.1 Cheating shall be defined as the act of obtaining or attempting to obtain credit for academic work
by the use of dishonest, deceptive, or fraudulent means. Examples of cheating include, but are not
limited to (a) copying, in part or in whole, from another’s test or other examination; (b) discussing
answers or ideas relating to the answers on a test or other examination without the permission of the
instructor; (c) obtaining copies of a test, an examination, or other course material without the
permission of the instructor; (d) using notes, cheat sheets, or other devices considered inappropriate
under the prescribed testing condition; (e) collaborating with another or others in work to be presented
without the permission of the instructor; (f) falsifying records, laboratory work, or other course data; (g)
submitting work previously presented in another course, if contrary to the rules of the course; (h)
altering or interfering with the grading procedures; (i) plagiarizing, as defined; and (j) knowingly and
intentionally assisting another student in any of the above.
2.2 Plagiarism shall be defined as the act of incorporating ideas, words, or specific substance of
another, whether purchased, borrowed, or otherwise obtained, and submitting same to the University
as one’s own work to fulfill academic requirements without giving credit to the appropriate source.
Plagiarism shall include but not be limited to (a) submitting work, either in part or in whole, completed
by another; (b) omitting footnotes for ideas, statements, facts, or conclusions that belong to another; (c)
omitting quotation marks when quoting directly from another, whether it be a paragraph, sentence, or
part thereof; (d) close and lengthy paraphrasing of the writings of another; (e) submitting another
person’s artistic works, such as musical compositions, photographs, paintings, drawings, or sculptures;
and (f) submitting as one’s own work papers purchased from research companies.
3.0 Academic and Punitive Sanctions: Cheating and plagiarism in connection with the academic
program at The University may warrant two separate and distinct courses of disciplinary action that
may be applied concurrently in response to a violation of this policy: (a) academic sanctions, such as
grade modifications; and (b) punitive sanctions, such as probation, suspension, or expulsion.
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