Behaviour Change GN PDF

Behaviour Change Jacky Hart Preena Shah Foundation in Clinical Skills and Practice, Year 1 GDC Learning Outcomes 1.1.1 1.1.11 1.7.1 1.10.1 1.10.2 1.10.3 1.11.1 2.3 3.1 3.2 4.1 6.1 6.2 6.3 11.1 3 Intended Learning Outcomes By the end of the sessions students will be able to: Descr...

Behaviour Change Jacky Hart Preena Shah Foundation in Clinical Skills and Practice, Year 1 GDC Learning Outcomes 1.1.1 1.1.11 1.7.1 1.10.1 1.10.2 1.10.3 1.11.1 2.3 3.1 3.2 4.1 6.1 6.2 6.3 11.1 3 Intended Learning Outcomes By the end of the sessions students will be able to: Describe what is meant by behaviour change and its relevance to oral and general health Familiarise with the evidence-based guidelines for oral health-related behaviour change Identify factors that influence behaviour in line with the COM-B model Discuss how patient-centred conversations can support oral health-related behaviour change in dental hygiene and therapy practice 4 Assessment Formative Active engagement throughout today’s sessions and peer feedback Summative E-assessment OSCE Future Effective behaviour change can improve health outcomes for our patients Links to prior learning dental History taking social diet Delivering Evidence Based Better Oral Health Toolkit Guidance for behaviours verbal Communication non-verbal clinical conversations Outline for the session Theory Practical Definitions, context, evidence Case studies discussions – in Oral health-related behaviours teams we have opportunity to change and their evidence Influences on behaviour, psychological theory (COM-B) Behaviour change in action, link to communication 7 Definitions Something we don’t even think about - what we do in Behaviour response to internal or external factors Health what we do that can impact on Behaviour our health, +/- Behaviour doing something that changes the change way a person does something 8 Getting patients to change habits in order to improve oral health Why is this important? Behaviours impact on our health and well-being by increasing our risk of, or protecting us from long-term conditions and illness including oral diseases. Oral health care professionals are strategically placed to support patients to adopt positive health behaviours using patient centered conversations – it is our duty!  Evidence-based guidance Oral Health promotion in general dental practice (NG30) How to adopt a patient centred approach? Behaviour change: Individual approaches (PH49) Chapter 3 Behaviour Change Interventions for the individual targeting general health NHS Long Term Plan Prevention and Treatment of Periodontal Disease in Primary Care Oral health-related behaviours quiz Mentimeter recap and test your knowledge: What behaviours are related to oral health? What is the guidance for these? 11 Oral health in the UK 75% clean 2/day 66% visible plaque 9 in 10 1 in 10 need support excellent oral health ADHS 2009 Toothbrushing advice Powered OR manual toothbrush Clean all tooth Clean the Adapt technique to patient needs. surfaces gumline Benefits: Reduces the risk of dental caries Reduces the risk of periodontal Last thing at One other time night during the day disease 13 Dietary guidance According to the DBOH Toolkit: Reduce frequency and quantity of sugar Eat a balanced diet with lots of vegetables and fruit Daily free sugar recommendations from the NHS: 30g/day of free sugar 11years + 24g/day 6-10yrs 19g/day 4-6yrs OR no more than 5% of total calorie intake This Photo by Unknown Author is licensed under CC BY-SA 14 Dietary intake of free sugars NDNS 2016/17 15 Fluoride Exposure Fluoride toothpaste 1450ppm Spit don’t rinse 76% use fluoride toothpaste (less for under 6yrs) 16 Smoking advice Recommendation is not to smoke Encourage smoking cessation Around 14% population smoke in the UK aged 18yrs+ (ONS 2019). More to come in Smoking Cessation sessions 17 Alcohol advice Not to exceed 14 units/week This Photo by Unknown Author is licensed under CC BY-SA-NC Refer to alcohol lectures in FCSP 18 Attendance Recommendations based on risk: 3-24 months as per NICE guidance – Dental Checks: Intervals between oral health reviews CG19 Most people do attend dental care professional’s regularly ADHS 2009 Part of treatment is to effect and review behaviour change 20 Impact of oral health-related behaviours Oral health Systemic Behaviours health 21 What makes us do what we do? What influences our behaviour? 22 Own experiences of influences on behaviour… Mental health Education Up bringing Family and peers Authoritative/professionals figures Knowledge Skills Environment Mood/stress 23 The wider determinants of health – influences on behaviour This is NOT exhaustive…can you think of any others? ↑ What factors can we/individuals controls? Lower socio-economic - higher rates of decay  (Motivate and inspire patients to improve their oral health and periodontal disease) Motivation ↑Inspire What motivates you to do things? Intrinsic (internal) and extrinsic S S (external) Within yourself External factor Habits Aim for behaviours to become habits It takes 66 days to build a habit on average I Imbed until it becomes something we do without thinking about What does this mean for our patients? 26 Advocated by DBOH COM-B Model Evidence based framework For effective behaviour change Patients need to have capability, motivation and opportunity to change behaviour to take place, interventions should be underpinned by an evidence-based theory. There are several theories relevant to behaviours and changing them. The COM-B model is well- (Michie et al 2011) recognised in health as key. 27 COM-B Model Physical Weather they want to do it Psychological Intrinsic behaviour - what we do without thinking Automatic processes Due to education and Reflective processes inspired to make a change Socio-economic factors Social environment Do they have opportunities to make changes? Physical environment (Michie et al 2011) 28 Understand the barriers in place to understand COM-B Model – example application Physical: Physically able to eat chocolate. Psychological: Knows how to eat chocolate. Eating chocolate Automatic: Likes the taste of chocolate makes you feel good. Reflective: deciding on and Justifying the need to eat chocolate Social environment: Able to buy chocolate, Socially acceptable, affordable Physical environment: available in the cupboard, staff room (Michie et al 2011) 29 COM-B Model applied to oral health Age/medical history S Physical skill/dexterity Psychological capacity to do &Mental health Toothbrushing Habitual Believes it is beneficial Social norm/culturally accepted Able to afford/source a tb (Adapted from Michie et al 2011) 30 Psychology of clinical practice - Case scenario 1 - Bella Bella attends the dental clinic for a routine visit. When asked how often she cleans her teeth, she responds that she is brushing every day but does not floss anymore. She mentions that since she tried flossing, her gums had started bleeding so she stopped flossing them and the bleeding stopped. The clinician responds that daily flossing is recommended to prevent gum disease and decay so she should start doing it again. Apply the COM-B model to this scenario. Behaviour - Bella’s flossing 31 COM-B Model applied to Case Scenario 1 - Bella Not really an issue - can floss, has access to and physical ability 1. Which are should we target? - Why? Able to floss but is technique damaging? 2. How will you do this? Examples? Knowledge of how to floss No motivation to floss teeth - as she thinks causes bleeding SEmotional reaction to bleeding Main barrier for Bella Bella’s Flossing ↑ prevents flossing Beliefs about consequences Not a social norm Able to afford/source floss She told us (Adapted from Michie et al 2011) 32 COM – B + Bella case study Bella’s main concern - bleeding when flossing Get Bella to understand why her gums bleed when flossing and educate Ask Bella what she understands first Build on knowledge base or correct How can we explore Bella’s motivation around flossing? Start to educate Bella why her gums bleed Hopefully be able to motivate her to change behaviour What questions could you ask? Not as effective -- Give advice Instruct Modify Motivation - different approaches Explore in Educate conversation 33 Consider… The benefits and consequences of a behaviour should reflect those valued by the patient. WHY?... 34 What can we do as dental professionals? Behaviour change in-action 35 Show empathy to patient if not wanting to make the change - support patient Cycle to address behaviour change: Raise the issue, build motivation & inspire the patient Patients needs to want to make changes Assess Support patient readiness for on next steps change 36 Raise the issue and build motivation Draw a reaction or answer from patient ↑ Elicit…provide…elicit…provide - Elicit: ask patient if they are aware/can you inform them about it/what do you already know? Provide: give information specific to patient Specific behaviour, its link to oral and general health in the short, medium and long term, relate it patients’ values Find out what’s important for the patient/their values 37 Have to accept some patients will resist no matter what inspiration you give them - due to patients values Assess readiness to change Discuss advantages and disadvantages of making changes Listen to cues from patient regarding their desires, ability and reasons for change or not Where multiple behaviours requiring changing, select one to start with – which one patient feels most ready to tackle Roll with resistance Timing – life events, all takes time Review readiness at each visit 38 Support patients to take the next step… Demonstrations or techniques Plan, SMART goals Identify barriers and how can overcome Coping mechanisms for relapse Encouragement and praise Support capability, motivation and/or Rewards for progress opportunity (COM-B model) Signpost or refer to services and resources 39 Behaviour change techniques (BCT’s) At least 93 BCT’s!! Think about how you carry out behaviours – there is probably a name for it! Lots of research happening in this area Essentially, behaviour change is an approach that draws on key communication skills founded in your patient-professional relationship. 40 Essentially.. Communication skills Patient- professional Psychology relationship Behaviour change approach History taking Behaviour skills Management 41 Communication Skills Patient- Trust Ask centred The power is Active Acknowledge Respect in the listening efforts conversation No Non-verbal Rapport judgement cues Open Empathetic Relevant... questions 42 OARS Framework Not yes or no answer O Open questions Reflect and summarise patients answer A Affirmations R Reflections S Summaries 43 Question Style Well… Yes? A. Are you B. How are you using your getting on with interdental A or B? the interdental brushes? brushes? 44 Question Style Well… Um… A. Why are B. What you here brings you today? A or B? here today? 45 Affirmations 46 Reflective Listening Paraphrase – sounds like you are saying… 47 Summaries Use reflections to summarise information ‘Can I summarise for you?’ Check whether summary is correct: ‘Is there anything I missed?’ 48 SCDEP OH TIPPS video https://www.periodontalcare.sdcep.org.uk/supporting-tools/oral-hygiene-tipps/oral-hygiene-tipps-video/ 49 SCDEP OH Video BINGO + examples Benefits of toothbrushing Support for patients next Action plan detailed reinforced steps Reflective listening Summarises Specific demonstration Affirmations Patient confidence Open questions enhanced Emotions addressed Asks if can demonstrate Explains bleeding (elicits) Raises the issue Builds motivation Assesses readiness for change 50 COM-B Model & SCDEP OH video Specific demonstration Confidence built Benefits of toothbrushing Emotions addressed Action plan detailed Replace brush (Adapted from Michie et al 2011) 51 Determining the need and desire for change Review continually at every appointment Patient histories and preferences Oral health Continually education revisit and on review behaviours and change Clinical findings 52 Summary so far What is behaviour change and the evidence? Evidence-based oral health-related behaviours Influences on behaviour Positive and negative influences on health COM-B model and application Behaviour change in-action Raise the issue and build motivation Assess readiness to change Support patients next steps OARS model Application: Case scenarios to develop communication skills, offer peer feedback and reflect on experiences 53 References Adult Dental Health Survey 2009 https://digital.nhs.uk/data-and-information/publications/statistical/adult-dental-health-survey/adult-dental-health-survey-2009- summary-report-and-thematic-series COM-B model Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science : IS, 6, 42. https://doi.org/10.1186/1748-5908-6-42 National Diet and Nutrition Survey 2016/17 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/772434/NDNS_UK_Y1- 9_report.pdf NHS statistics on obesity, physical activity and diet England 2020 https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet/england- 2020/part-6-diet-copy 54 Learning resources and evidence base NICE Guidelines: Oral health promotion in General Dental Practice https://www.nice.org.uk/guidance/ng30 NICE Guideline: Behaviour change: Individual approaches https://www.nice.org.uk/guidance/ph49 Delivering better oral health: an evidence-based toolkit for prevention 4th Edition https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based- toolkit-for-prevention/chapter-3-behaviour-change Scottish Dental Clinical Effectiveness Programme: Periodontal Care Guidance https://www.sdcep.org.uk/published-guidance/periodontal-management/ 55 Further Learning Sign up at Health Education England e-learning to access to a number of learning resources including a module on Behaviour Change https://www.e-lfh.org.uk/ Article on behaviour change in oral health Asimakopoulou, K, Newton, JT. The contributions of behaviour change science towards dental public health practice: a new paradigm. Community Dent Oral Epidemiol 2015; 43: 2– 8. https://doi.org/10.1111/cdoe.12131 56 Time for application CASE SCENARIOS 57 Case scenario 1 - Bella Bella attends the dental clinic for a routine visit. When asked how often she cleans her teeth, she responds that she is brushing every day but does not floss anymore. She mentions that since she tried flossing, her gums had started bleeding so she stopped flossing them and the bleeding stopped. The clinician responds that daily flossing is recommended to prevent gum disease and decay so she should start doing it again. Describe Bella’s belief about flossing? Causes flossing No, doesn’t address her initial concern regarding bleeding. Based on the clinician’s advice, do you think Bella will start flossing again? Why? Not relevant to her Not motivational How would you describe the patient-clinician relationship? Impersonal What would you do differently? Relevant and motivational advice, give empathy What assumptions can you make about Bella’s oral health? Inflammation Case Scenario 2&3: Smoking Cessation Advice Watch the 2 videos: Points for discussion: How NOT to do Motivational - Discuss the positive of each Interviewing in Dental Practice approach Addressing tobacco use with - Discuss the negatives of each David - YouTube approach Motivational Interviewing in - Which approach is better and Dental Practice Addressing why? tobacco use with David - YouTube - When would it be appropriate to use each approach? 59 Guidelines - guide you to treat a patient - use guidelines to be patient specific - sometimes have to step outside of guidelines with justification for patients best interest Case Scenario 4: Bob’s Story ‘The following narrative, although not based in the dental surgery, involved a patient who sadly was in the end stages of oral cancer. His name has been altered to protect his identity. Many years ago, I had recourse to visit this man – let’s call him Bob – in hospital, he was dying from the ravaging effects of oral cancer. He was being fed through a peg tube and his breathing eased by a tracheostomy. This gentleman had been a rough sleeper for most of his life and had enjoyed solace from a homeless centre where I worked. On visiting him in his hospital room I brought him shower gel and soap to which he promptly replied: “What the hell are you bringing me these for? I need Guinness and fags!” On exiting the room I put this request to the nursing sister; she looked at the patient and then myself and said to bring him some Guinness and some fags. On my next visit, I watched Bob syringe the Guinness into his peg tube and smoke his cigarette through his tracheostomy. That nurse had treated Bob as a human being, she had given him dignity and respect. This man had lived on the streets where alcohol and cigarettes, for whatever reason, had been his only consolation. At this end stage of his life the nurse had looked on him with empathy and unconditional positive regard and bestowed upon him the dignity of being permitted to die with the tools that had enabled him to live. She, within the limits of her environment, had not allowed rigid protocols to undermine the humanity of the other.’ 60 Case Scenario 4 - Bob’s Story Questions Think about the benefits and harms for each statement: So should we advocate cigarettes and alcohol? And ignore guidelines and evidence-based practice if that is what a patient wants? Can we assume all oral cancer patients have a history of alcohol and cigarette use? How can we balance our duty of care with patient-centered care? 61 Discussion in groups In your groups discuss the statement, the arguments for and against it and decide on a conclusion. 1. Information given to increase knowledge about interdental brushing is sufficient to change patients’ behaviour. 2. Demonstrations of toothbrushing on a model is sufficient to change patients’ behaviour. 3. It is pointless tackling smoking cessation with a patient who is not ready to give up. 4. Where a patient is a regular attender there is no need to address fluoride use.