Behaviour change strategies

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chapter 7 Behaviour change strategies

INTRODUCTION AND OVERVIEW

It is increasingly being acknowledged that lifestyle factors contribute significantly to virtually all the common chronic conditions encountered in affluent countries. Changing people’s health behaviours, however, is easier said than done, particularly with behaviours that have been ingrained for a long time, or where the motivation for change is mixed. The challenge of behaviour change can also be compounded by addiction, where a person’s upbringing has not fostered responsible or balanced lifestyle choices and where the environment in which one is living works against healthy behaviour change.

AUTONOMY

Being able to successfully change and maintain healthy behaviours relies on more than just receiving health information from a healthcare professional.

Helping people change high-risk behavior will be the key to prevention. To develop more effective prevention programs, we will have to train a new generation of experts who can not only provide people with risk information but also work with them as partners in achieving mutually agreed upon goals.1

Much of the early research into cardiovascular risk factors suggested that, independently of other lifestyle factors, a learned or perceived lack of control or autonomy is a central factor in the development of an illness. Gaining autonomy, on the other hand, is consistently associated with better health outcomes. Control is also intimately linked with stress, because when a person goes through a stressful life-event, having some control over either the event or their attitude to it will buffer the person from the potential for stress in response to the event. This is indicated in many ways, from changes in immune function, blood pressure and gut function to important changes in brain activity. When a perceived lack of control is a consistent state, it has a cumulative effect on emotional wellbeing, allostatic load and behaviour.

To illustrate this point, a study on the association between work stress (job strain and effort–reward imbalance) and the risk of death from cardiovascular disease found a strong association. Over 800 employees were followed up for 25 years. It was found that high job strain (high demands, low job control) led to more than a doubling of the risk of dying from heart disease compared with those with low job strain.2 An effort–reward imbalance (low salary, lack of social approval and few career opportunities relative to efforts required at work) produced a similar effect. Noting the association is interesting. Intervening to mitigate its effects, though, is far more useful.

The ‘control’ associated with higher levels of stress and illness is an uneasy balance between tensions and counter-tensions. The control associated with greater health and self-determination is closely related to self-awareness, mindfulness, emotional regulation and emotional intelligence.

ENABLING STRATEGIES

Behaviour is deeply rooted in attitudes, biology and neurology. It is, however, modifiable when one learns appropriate skills and changes are made to the social environment which are conducive to healthy lifestyle change. Strategies that are aimed at enabling a person to be more autonomous and able to make desired behaviour change are known as ‘enabling strategies’. Having information but not being enabled to translate it into action means that the information is inert.

Much of the time a healthcare practitioner can think it is enough to provide health information and let the case for behaviour change rest on that. Saying, for example, that smoking is bad for one’s health and providing some medical reasons for that will increase the smoking cessation rate over the next year from about 1% to 2%. When enabling strategies are included with the information it is far more effective and, in the case of smoking cessation rates, quit rates can be improved to around 30% or higher. Examples of enabling strategies that will help to facilitate healthy change include: behaviour change skills, motivation, empowerment, health coaching principles, the behaviour change cycle and goal setting. The ESSENCE model (see Ch 6) may also help to give structure to a total lifestyle plan.

MOTIVATION

The first step in enablement is to examine insight and motivation. Nothing happens without insight and motivation—this is just as relevant for the clinician as it is for the patient—and so, for the skilled clinician, the first factor is to raise awareness and enhance motivation.

Our reasons for acting the way we do are often unseen and therefore unexamined. Habits, biases and assumptions are far more influential when we are less conscious. Being aware of our competing motivations for various behaviours is an important first step in being able to understand and change them. Often we don’t consciously examine the pros and cons of continuing to follow a particular path of action. If we eat an unhealthy diet, for example, consciously or unconsciously we will probably be doing so for a variety of reasons. We might, for example, have assumed that:

• diet is not an important health issue
• an unhealthy diet is less expensive than a healthy one
• unhealthy food tastes better
• it would take too much effort to change our eating pattern
• unhealthy food is far more convenient.

If we examined such assumptions more closely, they might not stand up to scrutiny. For example, we might not:

• know how much we are increasing our chances of getting cancer or heart disease by not eating healthy food
• realise that healthy food can cost less than buying ‘fast’ or prepackaged food
• have been creative in using recipes that bring out the good tastes in healthy food
• have realised what it will cost us not to change until we become ill
• have considered that healthy food can be very ‘fast’ to prepare. If in a hurry it can take a lot more time to heat a prepackaged pizza than it takes to pick up a piece of fruit, a handful of walnuts or some dip and rice crackers.

One way of clarifying and galvanising motivation is to use the cycle of behaviour change model, which is described in more detail later in this chapter. Another way is for the patient to write down on a piece of paper all the costs and benefits of making or not making a particular change. An example is given in Table 7.1.

TABLE 7.1 Costs and benefits of changing or not changing behaviour to include regular exercise

  Changing Not changing
Benefits
• More vitality
• Better mood and less anxiety
• Weight control
• Less likely to become ill (infections, heart disease, cancer, dementia etc)
• Social interaction
• Sustainable performance
• Sense of achievement

• Comfortable
• Easy
• Time for other things

Costs
• Takes money
• Out of comfort zone
• Requires effort
• Time taken from other things
• Might injure oneself
• Low vitality
• Lowered mood and greater anxiety
• Weight problems
• More likely to become ill (infections, heart disease, cancer, dementia etc)
• Have to take time away from other things for being ill
• The cost of being ill
• Less social interaction
• Poorer performance
• Sense of not taking on challenges

Having done this, the next step is to look at the things standing in the way of healthy change and then to consider how valid or fixed they are. Take cost as an example. The preferred form of exercise might be skiing, but this is not very accessible and has a high financial cost. But exercise can also be relatively inexpensive—walking is an example. Furthermore, exercise can reduce a significant financial and time burden by reducing the likelihood of becoming ill and needing time off work. Rather than costing money, it is likely to save money. In truth, being sedentary may be the far more expensive option. A similar process can be followed for each factor, such as tiredness—exercise increases energy and vitality. If there is a concern about injury then it will be important to choose a form of exercise suitable for the person’s current age and level of fitness—what is appropriate for a 20-year-old may not be appropriate at age 50.

The aim of such an exercise is to help remove the influence of inhibitors of the behaviour and to emphasise the enhancers. If such an exercise is undertaken in a creative and unbiased way, it is likely that there will be far fewer barriers to healthy change.

EDUCATION

In the healthcare setting, education can be enormously empowering. Having an education is protective against a whole range of illnesses, not just because a person has factual health information they would not otherwise have had, but because a person who has had an education often feels more confident, is able to weigh up options and make decisions, and can ask questions and seek alternatives. Therefore, one of the most enabling things that can be done for a person is not just to educate them in the form of providing information but also to foster their self-empowerment, self-governance and problem-solving abilities. This can be implemented by the general practitioner, and also through community-based programs.

ENVIRONMENT

Enabling strategies also need to be supported by an environment that is conducive to healthy change. Providing someone with information and skills related to smoking cessation will help them to quit, but if that person is subjected to a constant barrage of pro-smoking marketing messages, if they are regularly exposed to passive smoking in the workplace, and if their family and friends are not supportive of the change, then that person’s ability to remain a non-smoker will be seriously undermined. Similarly, if a person wanted to increase their level of exercise, then having a safe environment to exercise in, access to adequate facilities and parks, and supportive people to help maintain the change, will make them much more likely to maintain the new behaviour. Thus, no matter what behaviour change we wish to make, choosing and enhancing our social and physical environments carefully is an important part of the change process.

PSYCHOLOGICAL FACTORS

A number of psychological factors are important enabling strategies. These factors include stress management, attention regulation and emotional regulation. These will be dealt with in the mind–body chapter (Ch 8).

PROCHASKA DICLEMENTE CYCLE OF BEHAVIOUR CHANGE

The Prochaska DiClemente cycle of behaviour change is a model initially developed to explain the steps we go through in changing a behaviour. It has been used widely in health and psychology settings for various behaviours, although it was initially applied to smoking cessation. It is applicable to almost any behaviour and can be adapted as such. The steps in the process are outlined in Figure 7.1 and below.

image

FIGURE 7.1 Prochaska DiClemente cycle of behaviour change

The model simply acknowledges the fact that we go through different stages in making any change in behaviour. The cycle begins even before we first think about the behaviour, and continues until the new behaviour eventually becomes established or maintained. It also embraces the fact that behaviour often relapses.

The stages are self-explanatory but there are some important points to remember when implementing the process. Early in the process it is important to determine which stage a person is in. Knowing the stage helps one to tailor questions, direct information, enhance motivation and provide skills relevant to that stage. Trying to encourage action, for example, before a person has clarified their motivation will be inappropriate and is almost certain to fail. The art is to move through the stages from where the person is currently and in a way that is suitable for their needs and motivation.

PRE-CONTEMPLATION

Pre-contemplation is the time before a person has even begun to think about changing a behaviour. For example, a smoker presents to a doctor with a cold but has not yet thought of giving up, and may not have made many connections between their smoking and their tendency to get upper respiratory tract infections. Obviously, no change is possible until the person has begun to think about change, and so the doctor might help the patient to make the link between their smoking and the acute illness they have presented with. Many anti-smoking advertisements are also aimed at making people think about their habit. They are motivating people to consider the next stage by raising awareness and modulating emotion and attitude.

CONTEMPLATION

Contemplation is when the person first starts to think about changing the behaviour. Contemplation can take a short time (seconds) until the behaviour changes, or it can be long (years or even decades). In our example above, the GP may mention that smoking is contributing to the person’s tendency to get colds as well as putting them at risk of other illnesses. This is ‘opportunistic’—that is, waiting for the opportunity to present itself rather than being proactive. Such prompts can also be included in a more structured way, for example by using computer prompts or medical guidelines about screening all patients for smoking. In the contemplation phase it is important to examine what motivates the behaviour. Motivation is always particular to the individual, and so exploring this needs to be done in a patient-centred way. For example, for a young professional, having a cold may be relevant because time off work is a major inconvenience. Concern about lung cancer or heart disease may not be important for a 20-year-old, but saving money, sporting performance, attractiveness to the opposite sex and accelerated ageing of the skin might be. If the patient is interested in proceeding, then this process can be supported with further discussion, information, reading materials and other aids.

PREPARATION

The preparation stage is when a person takes steps to put things in place to help ensure that the behaviour change is more likely to be successful. This can include accessing information about how to stop smoking by phoning the QUIT Line, or informing the family that a ‘quit date’ has been set, or planning which places to avoid once having stopped smoking. At this time the person may also be developing the enabling strategies that will help them to maintain the desired behaviour after action has taken place. Care needs to be taken in this stage, and failure to recognise this can lead to a lack of success.

ACTION

In the action stage, the person is implementing the new behaviour. For example, they have thrown away the cigarettes and are not smoking. A supportive environment is very important in this stage if the behaviour is to be maintained, and this includes avoiding situations and places that are likely to activate the old behaviour. The tendency to revert to the old unhealthy behaviour is strongest in the initial stages. Like going uphill, it takes effort and it is easy to roll down again if one loses focus.

RELAPSE

With some habits, relapse can occur a number of times until lasting change is finally achieved. It is very useful not to see ‘relapses’ as ‘failures’ but to reframe them as learning opportunities. If a person has reverted to the old behaviour then it will be for a reason. Stress, overwork and emotional upsets are the most common reasons for relapse but other factors can also come into play. Perhaps they may have lost focus, or become complacent that the old behaviour wasn’t an active issue any longer, or perhaps they didn’t pay attention to the environmental issues. The important thing is not to dwell on a perceived failure but, rather, to learn what brought about the relapse in order to make future attempts more likely to succeed. Dwelling on failure saps energy and disheartens. To learn a useful lesson is to make something good out of an otherwise negative situation. Although relapse takes the person back to the start of the cycle, they will generally move through the preliminary stages a lot more quickly and easily than was the case the first time around.

MAINTENANCE

The maintenance stage is where change, having been made, becomes long-term. The initial establishment of the behaviour has been passed and the new behaviour takes relatively little effort to maintain. Provided the motivation remains clear and the benefits of the new behaviour pattern are obvious, there will tend to be few problems. Again, complacency and stress are common reasons for relapse. For example, ‘I’ll just have one cigarette’ can quickly become a full-blown reactivation of the old habit. Reactivation of dormant thought patterns and neural pathways can take place quite quickly. An old behaviour pattern can return with surprising force, even after many years.

SMART GOAL-SETTING

If one decides to make a healthy change, it is worth considering a way of setting goals that will help them to be realised. Setting unrealistic goals, for example, can be discouraging and can perpetuate negative patterns of thought. Being SMART about setting goals can be very helpful. The SMART approach is widely used and can be applied for setting goals related to any behaviour. The SMART acronym stands for:

Specific
Measurable
Attractive
Realistic
Time dependent.

Often, goals are not achieved because one or other of these issues was not attended to. A goal is harder to attain and progress is harder to measure if it is vague or ill-defined. For example, one might aspire to the goal of ‘exercising more’, but what does that mean? How much exercise? How often? What type of exercise? If a goal is not specific then the person never really knows whether they are achieving it. It is easy to think that we are doing better or worse than we really are. A specific goal would be something along the lines of, ‘I plan to walk around the park (three kilometres) four evenings per week’. This is specific—it gives the type, duration and frequency of exercise. With a specific goal set, the person can then measure how well they are doing in relation to it. As one goal is attained, a new and more ambitious goal can be set.

Measurable

If a specific goal is set, it can be measured much more easily. Measuring progress towards attaining goals helps one to gauge progress in an objective fashion. Measuring progress can also provide encouragement by recognising progress towards the goal, or it can provide a reality check. It can also help us to modify a goal, if appropriate, by either stepping it up or cutting it back. In the exercise example above, a person might find that they have been able to walk around the park only three times per week, not four. On that basis they can decide whether they need to increase their effort or perhaps reduce the goal if it is unrealistic.

Attractive

If a goal is not attractive or enjoyable, it won’t be maintained in the long term. If, for example, the person does not enjoy the form of exercise they have chosen, they will not maintain it for long, certainly not past the point where their initial enthusiasm has died down. In this case, they would either need to find a way of making that form of exercise attractive—for example, by running with friends or in beautiful parks, or playing a team sport—or choose a different form of exercise. With the right form of exercise a number of goals can be realised within one activity—increasing social interaction at the same time as doing exercise, for example. It is best to choose exercise that we enjoy, is appropriate to our age and fitness and suits our life situation. A noisy gymnasium might not be appropriate for an older person, or an expensive sport might not be right for someone with limited income. It is also useful to consider that a number of things can make a goal ‘attractive’. A goal can be attractive because the activity is pleasurable, but equally it can be the end-product, rather than the means of achieving it, that is attractive. For example, a person may wish to pursue a certain career but may not find the effort, sacrifice and study along the way all that pleasant. Persevering, however, may help them develop a great deal of character and resilience in a way that taking the pleasant option would never have done.

Realistic

If a goal is unrealistic, or not achievable, then a sense of discouragement and failure may arise when the goal is not realised. This may even be despite the fact that an enormous amount of progress has been made. So, for example, a plan to quickly go from no exercise to running every day is unlikely to be achievable or sustainable. If there has been a recurrent attitude of thinking of oneself as a failure, then that attitude will have been reinforced. So a modest but achievable goal is often a far better foundation upon which to build than a more far-reaching goal. Realistic goals can certainly be built upon steadily as they are achieved. The initial goal may be modest, and revised a month later, at which time a slightly higher goal is set. A month later it can be revised again. In this way a goal that might have seemed unrealistic at an early stage can be achieved in the longer term via a series of smaller, realistic goals. Some people intentionally set very high goals in order to extend their performance because they thrive on the challenge. As long as the goal is not dangerous, that can also be a valid way of working towards a goal for those with high confidence and a resilient sense of self. For such people, not meeting a high goal is not a sign of defeat but is a motivator to rise to a challenge or make further effort.

Time dependent

It is useful for a goal to have a specific time frame rather than being too open-ended. This can increase focus and maintain motivation. For example, a person may aim to be fit enough to compete in a fun run in 6 months’ time. As such it can help a person to stay focused and not become complacent. This helps us to make our goals specific, map our progress, provide incentive and keep goals realistic.

SMART goal-setting activity

In using the above model, a patient might like to set a SMART goal for themselves. It can be done as an intellectual exercise but in order for it to have more meaning it needs to be related to a goal that really matters, a goal that the person has a desire to implement. The goal could be anything—it could, for example, relate to:

• exercise
• change of diet
• weight control
• study
• learning a skill
• getting over a phobia
• renovating the house.

BASK

Any educational intervention relates to behaviours, attitudes, skills and knowledge. As has been mentioned, simply thinking that knowledge or information is going to change behaviour is generally a false assumption. The most powerful way to change behaviour is through a shift in emotion and attitude, supported and directed by knowledge. BASK is an acronym:

• Behaviour is what a person does.
• Attitudes are what a person believes.
• Skills are what a person can do.
• Knowledge is what a person understands.

Interventions can be directed at any or all of the above dimensions. The Ornish program (which will be described in detail in the chapters on heart disease (Ch 25) and cancer (Ch 24)) is a good example of a program that contains all these aspects contained in BASK. That is largely why the program is so successful.

Interventions directed at the wrong aspect of BASK will tend to be ineffective. For example, it is little use giving knowledge where there is an attitudinal problem preventing change. In such a case the attitude needs to be dealt with first. The knowledge will not translate into action while that barrier is in place. In advertising aimed at smoking cessation, increasing knowledge is only a secondary aim, whereas the primary aim is to make a negative emotional and attitudinal association between smoking and wellbeing. Put another way, most of the time a person already knows the basic principles of what is healthy and what isn’t, but reasons other than knowledge are maintaining the unhealthy behaviour. Doctors too often interpret patient education as only giving factual information, and this is one of the main reasons that giving advice on behaviour change frequently does not result in action.

JOURNAL KEEPING

Keeping a journal is a powerful way of following progress, gaining insight and reinforcing change. A variety of studies suggest that keeping a journal about important issues is therapeutic in itself, particularly for dealing with emotional issues. For a journal to be of real use it needs to be about events and issues that are important to the person.

HEALTH PROMOTION3

Health promotion is powerful, effective, and cheap! (Dr Rob Moodie)

The health of individuals and communities depends on many determinants. Health is affected not only by our genetic endowment and physical risk factors, but also by such things as:

• socioeconomic status
• social supports
• level of education
• employment (or lack of it)
• culture
• mental health
• physical environment.

As already mentioned, simply providing information without attending to the social, economic, cultural and physical environment will be ineffective and potentially wasteful of resources.

An example will help to put this into a practical context. The road toll among young males is a major health issue and is largely contributed to by alcohol abuse, speeding and other risk-taking behaviours. To help young males avoid binge drinking, drink-driving and speeding requires that attention be paid to the attitudes and skills of young males. Young males, for example, are prone to impulsivity, a feeling of immortality and over-confidence, all at a time of gaining newfound freedom. This confluence of circumstances and psychological factors predisposes them to risk. To succeed in reducing the road toll among this group requires legislation (laws on speeding, alcohol consumption and drink-driving), changes to alcohol advertising, increasing the price of alcohol, and social marketing aimed at changing attitudes to drink-driving. It also requires the providing of alternatives to drinking excess alcohol (e.g. making water available in clubs and pubs) as well as adequate public transport. Such strategies work, and save a huge amount of social, emotional and economic waste.

The individual practitioner has an important role to play in reinforcing key health messages, whether it be opportunistically or in a systematic way.

A population approach to health promotion is far more cost-effective than treating individuals. This is well illustrated in the reduced rates of many infectious diseases through immunisation. Illnesses such as measles are uncommon now. Polio is rare. Smallpox has been eradicated. Other examples of major health promotion successes include:

• tobacco control
• reducing road trauma
• HIV/AIDS control
• skin cancer prevention.

Now fewer than 17% of adults smoke, whereas the figure was around 72% among males in the middle of the twentieth century.4,5 The effects of this change will be increasingly felt in coming generations as the rates of smoking-related illnesses decline. In developed countries, road tolls have more than halved over the past 30 years.6 This is despite a doubling of the population and an even larger increase in the number of cars on the road. The number of new HIV/AIDS cases diagnosed per year has dropped significantly in most developed countries, due largely to public campaigns promoting safe sex and harm minimisation among drug users being strongly reinforced by healthcare practitioners. Skin cancer rates—most importantly the rates of malignant melanoma—have plateaued in recent years in places where sunburn rates have been reduced. In Victoria, Australia, for example, there has been a 60% decline in weekend sunburn rates over the past 20 years.7 Sun-smart campaigns have been implemented not just through medical practices but also in schools and via social marketing.

VicHealth figures suggest that, per life year gained, the cost of smoking prevention is approximately 1/500th that of treating lung cancer. In Australia, the treatment for AIDS in the early 1990s cost over $46 000 per life year gained, whereas it only costs $185 per life year gained when the money is spent on preventing HIV infection.8

Effective health promotion depends on a number of factors, and these are outlined below.9

• Good background data and information— not only do we need to know such things as which health problems are prevalent and who they affect, but also how effective any interventions or programs are. Good epidemiological data, unbiased research and evidence are therefore vital in helping guide community initiatives as well as clinical practice.
• Clear and sensible policy, legislation and regulation— the policies of organisations and political parties can support or undermine any attempts to implement effective strategies. Positive examples of using legislation to enhance health include laws on the promotion of tobacco, drink-driving laws, enforcing speed limits, and laws promoting the wearing of seatbelts. Other topical areas being considered include such things as limiting the marketing of unhealthy foods to children, drug harm minimisation strategies and genetic testing.
• Quality communication—communication and advocacy can make or break health promotion initiatives. This can include education, enhancing motivation, changing attitudes, improving cooperation, and providing practical information about available services.
• Well-trained and diverse professionals—welltrained healthcare professionals are essential in ensuring that health promotion initiatives are well planned and effectively delivered in the community. Those involved with implementing health promotion can include doctors, nurses, counsellors and services providing screening, marketing, education and business support, as well as sporting bodies, arts bodies, police, media and local government. General practitioners are a vital link in the chain, and health promotion activities can be informed by up-to-date guidelines and screening schedules produced by the professional colleges.
• Community involvement—health promotion is implemented through the community, by the community and for the community. Without community engagement, inspiration and support, any initiative will be far less effective and will waste resources. General practitioners can play an important role through program development, implementation and evaluation. They can reinforce health messages, act as advocates and become involved in research.
• Political support and funding—without ongoing political support and funding, health promotion programs and organisations have a tenuous future. It is important for the success of health promotion initiatives that the political and financial support for them does not become politicised.

RESOURCES

Australian Federation of AIDS Organisations. http://www.afao.org.au.

Australian Health Promotion Association. http://www.healthpromotion.org.au.

Cancer Council of Victoria. http://www.accv.org.au.

International Union for Health Promotion and Education. http://www.iuhpe.org.

Public Health Association of Australia. http://www.phaa.net.au.

Quit Program. http://www.quit.org.au.

Transport Accident Commission. http://www.tac.vic.gov.au.

VicHealth. http://www.vichealth.vic.gov.au.

REFERENCES

1 Syme SL. Psychosocial interventions to improve successful aging. Ann Intern Med. 2003;139(5/2):400-402.

2 Kivimaki M, Leino-Arjas P, Luukkonen R, et al. Work stress and risk of cardiovascular mortality: prospective cohort study of industrial employees. BMJ. 2002;325(7369):857.

3 This section draws upon principles outlined in the Monash University Health Promotion course in 2007 by Dr Rob Moodie, the then CEO of VicHealth.

4 State Government, Victoria. Quit Victoria. Smoking rates in Victoria. Online. Available: http://www.quit.org.au/article.asp?ContentID=7241.

5 State Government, Victoria. Quit Victoria. Smoking rates in Australia. Online. Available: http://www.quit.org.au/article.asp?ContentID=7240.

6 State Government, Victoria. Transport Accident Commission. Online. Available: http://www.tacsafety.com.au/jsp/content/NavigationController.do?areaID=12.

7 Davis KJ, Cokkinides VE, Weinstock MA, et al. Summer sunburn and sun exposure among US youths ages 11 to 18: national prevalence and associated factors. Pediatrics. 2002;110(1):27-35.

8 VicHealth (Victorian Health Promotion Foundation). Online. Available: www.vichealth.vic.gov.au.

9 Moodie R, Hulme A. Hands on health promotion. Melbourne: IP Communications, 2004.

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