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.

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.

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