Nutrition Education: Facilitating Why and How to Take Action PDF

Nutrition Education: Facilitating Why and How to Take Action GTN322 NUTRITION EDUCATION AND PROMOTION Dr. Soo KL Nutrition program PPSK, USM  1. Understand why theory is Specific important to nutrition...

Nutrition Education: Facilitating Why and How to Take Action GTN322 NUTRITION EDUCATION AND PROMOTION Dr. Soo KL Nutrition program PPSK, USM  1. Understand why theory is Specific important to nutrition education Outcomes: 2. Understand theories of dietary behaviour and behaviour change 3. Describe a conceptual framework for theory-based nutrition education: Facilitating Why-To and How- To knowledge Nutrition education (NE) is more likely to be effective when it include the following: DETERMINANTS OF BEHAVIOURS A FOCUS ON SPECIFIC BEHAVIOURS/ PRACTICES USE THEORY AND RESEARCH ADDRESSING MULTIPLE STRATEGIES TO ADDRESS LEVELS OF INFLUENCES/ DETERMINANTS OF DETERMINANTS AND BEHAVIORS OR POTENTIAL SUFFICIENT DURATION MEDIATORS What is Theory? Theory is a conceptual model or a mental map representing, derived from evidence, to help us understanding how potential mediators influences on food-related behaviour or behaviour change.  SO1: Why Theory is important to Nutrition Educators? Theory provide a mental map of why a behaviour or behaviour change occur. Such a map helps nutrition educators identify the specific set of mediators of behaviour change that should be addressed in a nutrition education intervention Theory specifies the kinds of information that need to be gathered before designing an intervention Theory provides nutrition educators guidance on exactly how to design the various intervention components and educational strategies to reach people more effectively; and provide guidance what to evaluate to measure the impact of intervention. Theories and models help explain behaviour, as well as suggest how to develop more effective ways to influence and change behaviour. 20XX presentation title 5  SO2: Theories of Dietary behaviour and Behaviour Change Theories or models that are often used in interventions program: A. Transtheoretical Model / Stages of Change Model (TTM) B. Health Believe Model (HBM) C. Theory of Planned behaviour D. Social Cognitive Theory (SCT) E. Social Ecological Model 20XX presentation title 6  Behaviour Change Communication (BCC) NE and BCC are the common used terminology to describe interventions to promote healthy eating BCC is more than just education, it aims to change behaviour and practice Interventions that only aim to increase knowledge or raise awareness cannot be called BCC, although increasing awareness or knowledge is a first step in the behaviour change process 20XX presentation title 7  HOW TO GET STARTED WITH CHANGING YOUR BEHAVIOUR? No single solution that works for everyone Understanding the elements of change, the stages of change, and ways to work through each stage can help you achieve your goals 20XX presentation title 8  3 Important Elements of Change 1. Readiness to Do you have the resources and knowledge to make a lasting change change successfully? 2. Barriers to Is there anything preventing you from changing? change 3. Expect relapse What might trigger a return to a former behaviour? 20XX presentation title 9  A. Transtheoretical Model (TTM) One of the best-known approaches to change is known as the Stages of Change or Transtheoretical Model (TTM). It is effective to understand how people go through a change in behaviour  Transtheoretical Model (Stages of Change Model) Introduced in the late 1970s by researchers James Prochaska and Carlo DiClemente who were studying ways to help people quit smoking It is an effective aid to understand how people go through a change in behaviour It states there are 5 stages (or 6 stages) towards behaviour change 1. Precontemplation (not ready) 2. Contemplation (getting ready) 3. Preparation for action (ready) 4. Action (current action) 5. Maintenance (monitoring) 6. [Relapse/ termination] 20XX presentation title 11 20XX presentation title 12 20XX presentation title 13  People are not even aware of the changes that they need to make 20XX presentation title 14  The person is thinking about changing their behaviour, but needs more information and continued support and persuasion 20XX presentation title 15 20XX presentation title 16 20XX presentation title 17 20XX presentation title 18 20XX presentation title 19 20XX presentation title 20  The transtheoretical model (TTM) 1. It emphasizes that individuals are at different stages in terms of their readiness to engage in a health- or food-related behaviour and that, consequently, nutrition education interventions must be designed to meet the needs of individuals at each stage of change 2. A problem faced with the TTM model is that it is very easy for a person to enter the maintenance stage and then fall back into earlier stages 3. Factors that contribute to this decline include external factors such as weather or seasonal changes, and/or personal issues a person is dealing with 20XX presentation title 21  TTM 4. Change in stage are not always linear. The transtheoretical model acknowledges that change is more like a spiral than a straight line, with a great deal of back and forth movement and recycling between the stage 5. This theory proposes two mediators of change: the pros and cons of change and self-efficacy 6. Decisional balance, or weighing the pros and cons of change, is an important construct in the transtheoretical model. Pros are people’s beliefs about the anticipated benefits of changing, and cons are the cost of changing 20XX presentation title 22 Transtheoretical Model  TTM 7. It suggests that self-change in behaviour is a process that occurs through 5/6 stages, with 2 mediators of change (decisional balance based on pros and cons of change, and self-efficacy) and 10 processes of change. 20XX presentation title 24 10 processes of change to help people make and maintain change i. Consciousness-raising (Get the facts) — increasing awareness via information, education, and personal feedback about the healthy behaviour. ii. Dramatic relief (Pay attention to feelings) — feeling fear, anxiety, or worry because of the unhealthy behaviour, or feeling inspiration and hope when they hear about how people are able to change to healthy behaviours. iii. Self-reevaluation (Create a new self-image) — realizing that the healthy behaviour is an important part of who they are and want to be. 20XX presentation title 25 10 processes of change to help people make and maintain change iv. Environmental reevaluation (Notice your effect on others) — realizing how their unhealthy behaviour affects others and how they could have more positive effects by changing. v. Social liberation (Notice public support) — realizing that society is more supportive of the healthy behaviour. vi. Self-liberation (Make a commitment) — believing in one's ability to change and making commitments and recommitments to act on that belief. 20XX presentation title 26 10 processes of change to help people make and maintain change vii. Helping relationships (Get support) — finding people who are supportive of their change. viii. Counterconditioning (Use substitutes) — substituting healthy ways of acting and thinking for unhealthy ways. ix. Reinforcement management (Use rewards) — increasing the rewards that come from positive behaviour and reducing those that come from negative behaviour. x. Stimulus control (Manage your environment) — using reminders and cues that encourage healthy behaviour as substitutes for those that encourage the unhealthy behaviour 20XX presentation title 27  1. It ignores the social context in which change occurs, such as SES and income 2. The lines between the stages can be arbitrary with no set criteria of how to determine a Limitation of person's stage of change. The questionnaires Transtheoretical that have been developed to assign a person to Model a stage of change are not always standardized or validated 3. There is no clear sense for how much time is needed for each stage, or how long a person can remain in a stage 4. It assumes that individuals make coherent and logical plans in their decision-making process when this is not always true  CASE STUDY You meet with a potential new client who was told by his doctor that he has prehypertension, borderline high cholesterol and had gained some weight in the last year. The physician highly recommended he start adopting a more physically lifestyle to help manage and hopefully prevent going on medications for these conditions. He explains that he doesn’t enjoy exercise and has a job that involves a lot of travel, so he is often eating on the go where healthy food options aren’t always available. In fact, the only reason why he agreed to meet with you today is because he promised his spouse he would. What stage of change do you think this person is in?  The 5 stages of behaviour change (Example: exclusive breastfeeding behaviour) Stage 1. Precontemplation Pre-awareness: People are not even aware of the changes that they need to make. In order to help them become a person who has awareness, you need to give them information. Nutrition education would stop at this stage without making sure that the person being educated has changed their action, practice or behaviour. Before this stage the mother does not know about the importance of exclusive breastfeeding during the first six months. Awareness: The person has heard about the need to change their behaviour, but needs extra help and persuasion to start to actually bring about the changes. At this stage the mother is aware about the need for exclusive breastfeeding during the first six months, but has not thought of doing it for her baby. Stage 2. Contemplation Contemplation (thinking): The person is thinking about changing their behaviour, but needs more information and continued support and persuasion about the advantages and disadvantages of changing their behaviour. At this stage more information about the benefits of exclusive breastfeeding compared to other forms of feeding is needed, as well as support that shows you understand the mother’s situation. Intention: The person has understood the advantages and disadvantages of changing their behaviour but is not sure how they can bring about the new behaviour for themselves. The person needs encouragement to overcome obstacles of how to do the new behaviour. For example, the mother may be worried about not being able to maintain exclusive breastfeeding when she is away for work, or for other individual or personal reasons. In this situation you could show her how she can express breastmilk so the baby can be fed when she is away. Stage 3. Preparation (Trial) The person has tried the behaviour or action required, but has faced difficulties. For instance, the mother tried to exclusively breastfeed her baby, but she faced some difficulties. She now needs support in the form of praise and reinforcement of the benefits. Reinforcing the ways of preventing the problem she faced during exclusive breastfeeding is also important. So she needs counselling to find the best ways of overcoming her problems. At this stage the mother may have inadequate breast milk output and think that her breast milk is not enough for the baby to feed on until six months old. Here, she needs to be assisted on proper positioning and attachment and be reassured about the capacity of the breastmilk to feed the baby for the first six months. Your skills in negotiating the different options the mother can use will be important at this stage. Stage 4. Action (adoption) At this stage, the person is demonstrating the new behaviour. They now need discussion to reinforce their behaviour and sustain the change they have made. For example, the mother has now sustained exclusive breastfeeding. What she needs at this stage is further discussion on the benefits of exclusive feeding to reinforce the behaviour and make sure that she continues exclusive breastfeeding for a few weeks. You can help her with this, by encouraging and praising her and emphasising the importance of exclusive breastfeeding for her baby’s health. Stage 5. Maintenance Maintenance: The person’s behaviour by this stage has changed and they understand the benefits of the change. Now they just need support if they face any difficulties. For example, the mother has changed her behaviour and is now used to exclusive breastfeeding and has understood its benefits. It has become part of her behaviour and she thinks that she will exclusively breastfeed when she has another baby. What she needs at this stage is support in overcoming any further difficulties. Telling others: The person has done the behaviour for a considerable length of time, it has become routine behaviour and now leads to the person convincing others about the benefits of their health related behaviour. For example, the mother is encouraging other mothers to exclusively breastfeed their babies and describing the benefits to the baby and mother. What the mother needs at this stage is praise. Nutrition behaviour change communication strategies: examples 20XX presentation title 37 20XX presentation title 38 20XX presentation title 39  Case Study A woman has heard the new Questions breastfeeding information, and 1. What stage in the behaviour her husband and mother-in- change model do you think the law are also talking about it. women has reached? She is thinking about trying 2. What could the health worker exclusive breastfeeding do to help the women? because she thinks it will be 3. Using exclusive breastfeeding best for her child behaviour as an example, illustrate the key points of goal and intervention/ communication strategies based on the five stages of behaviour change. B. Health Belief Model (HBM) HBM People’s beliefs influence their health related actions or behaviours People’s beliefs about whether or not they are at risk for a disease or health problem, and their perceptions of the benefits of taking action to avoid it, influence their readiness to take action. A framework for understanding individuals’ psychological readiness or intention to take a given health action 20XX presentation title 42 HBM: the 6 key constructs/ concepts This model proposes that people’s likelihood of taking specific health related action is primarily motivated by the 6 concepts/ beliefs 20XX presentation title 43  Constructs of the Model 1. Perceived susceptibility: Perceived susceptibility is our belief about the possibility or likelihood of personally contracting this illness or healthrelated condition. The health belief model predicts that individuals who perceive that they are susceptible (high risk) to a particular health problem will engage in behaviours (or more motivated to behave in healthy ways) to reduce their risk of developing the health problem. Individuals who believe they are at low risk of developing an illness are more likely to engage in unhealthy, or risky, behaviours. 20XX presentation title 44  Constructs of the Model 2. Perceived severity: ▪ The construct of perceived severity refers to our beliefs about the seriousness of contracting an illness or other health related condition. It may include an evaluation of the personal medical consequences (such as pain, disability, or death) or social consequences (impact on work, family life, and so forth) of the health condition. ▪ Research showed that a high perceived severity of disease causes proactive health-protection behaviours.  For example, people actively followed the pandemic-control instructions (such as washing hands frequently, wearing masks, not gathering and going out) when the perceived severity of COVID-19 increased 20XX presentation title 45  Constructs of the Model 3. Perceived threat or risk. ▪ The combination of perceived severity and perceived susceptibility is referred to as perceived threat. These perceptions together result in our psychological state of readiness to take action. ▪ Perceived severity and perceived susceptibility to a given health condition depend on knowledge about the condition. ▪ The HBM predicts that higher perceived threat leads to higher likelihood of engagement in health-promoting behaviours. 20XX presentation title 46  Constructs of the Model 4. Perceived benefits: ▪ Perceived benefits are our opinions of whether a particular action or behaviour is useful or effective in reducing the risk or threat of getting the condition. The behaviours may be eating fruits and vegetables to reduce cancer risk or safe food handling practices to reduce foodborne illness. ▪ If an individual believes that a particular action will reduce susceptibility to a health problem or decrease its seriousness, then he or she is likely to engage in that behaviour. For example, people with diabetes take medication believing it will work to control blood sugar. People quit smoking because they believe it will improve their health. 20XX presentation title 47  Constructs of the Model 5. Perceived barriers: ▪ Perceived barriers are our perceptions of the difficulties of performing the behaviour, which can be psychological as well as physical. These may include perceptions of the cost and inconvenience of eating fruits and vegetables or the perception that some fruits and vegetables may not be agreeable. ▪ The barriers or obstacles may also be environmental, such as perceptions of the lack of availability and accessibility of healthful foods or options for physical activity. We tend to weigh costs of action against the benefits of action before taking action, even if we are not always conscious of doing so. ▪ The perceived benefits must outweigh the perceived barriers in order for behaviour change to occur. Changing these beliefs through nutrition education, such as by increasing the perceived benefits and decreasing perceived barriers, should increase our likelihood of taking a given health action. 20XX presentation title 48  Constructs of the Model 6. Self-efficacy: ▪ Self-efficacy refers to an individual’s perception of his or her competence/confidence to successfully perform the behaviour (such as selecting, storing, or preparing fruits and vegetables). 7. Cues to action: ▪ The HBM posits that a cue, or trigger, is necessary for prompting engagement in health-promoting behaviours. ▪ Cues to action can be internal or external. External events, such as the illness of a friend or family member or news stories on a scientific study about the issue, or internal events, such as personal symptoms and pains, are cues that remind us to act. These cues may influence our perceived threat for the condition and increase the likelihood that we will take action. 20XX presentation title 49  Summary of the model 20XX presentation title 50  Health Belief Model (HBM) ▪ The model also postulates that demographic variables (such as age, sex, and ethnicity) indirectly influence behaviour through their impact on perceived threat or perceived benefits and barriers. ▪ Sociopsychological variables (such as personality, socioeconomic status, and peer and reference group pressure) also influence behaviour indirectly through their impact on perceived threat or perceived benefits and barriers. 20XX presentation title 51  Message about HBM When people experience a personal threat about a health condition they will likely to take action, but only if the benefits of taking action outweigh the barriers and costs Useful for designing nutrition education activities to enhance awareness and motivation to take action to reduce risk of health related condition Can be used in developing educational materials Useful for adults who are at risk for health conditions or who are beginning to think about their health. It may be less useful for children, for whom health is not a motivator Most-often applied for health concerns that are prevention-related and asymptomatic, such as early cancer detection and hypertension screening. The HBM is also clearly relevant to interventions to reduce risk factors for cardiovascular disease. 20XX presentation title 52  Considerations for Implementation The HBM can be used to design short- and long-term interventions. The five key action-related components that determine the ability of the HBM to identify key decision-making points that influence health behaviours are: i. Gathering information by conducting a health needs assessments and other efforts to determine who is at risk and the population(s) that should be targeted. ii. Conveying the consequences of the health issues associated with risk behaviours in a clear and unambiguous fashion to understand perceived severity. iii. Communicating to the target population the steps that are involved in taking the recommended action and highlighting the benefits to action. iv. Providing assistance in identifying and reducing barriers to action. v. Demonstrating actions through skill development activities and providing support that enhances self-efficacy and the likelihood of successful behaviour changes. 20XX presentation title 53  HBM in practice Examples 20XX presentation title 54 20XX presentation title 55 20XX presentation title 56 20XX presentation title 57 20XX presentation title 58 20XX presentation title 59 20XX presentation title 60  Limitations of Health Belief Model 1. It does not account for a person's attitudes, beliefs, or other individual determinants that dictate a person's acceptance of a health behaviour. 2. It does not take into account behaviours that are habitual and thus may inform the decision-making process to accept a recommended action (e.g., smoking). 3. It does not account for environmental or economic factors that may prohibit or promote the recommended action. 4. It assumes that everyone has access to equal amounts of information on the illness or disease. 5. It assumes that cues to action are widely prevalent in encouraging people to act and that "health" actions are the main goal in the decision-making process. 20XX presentation title 61 C. Theory of Planned behaviour (TPB) Theory of Planned behaviour (TPB) TPB states that people’s behaviour are determined by their intention, which in turn are influenced by attitudes, social norms, and perception of control over the behaviour People are likely to take action: if they expect the action will lead to outcomes they desire (positive attitudes toward the behaviour) if other people they value think it is good idea if they feel they have some control over taking action TPB is useful to enhance motivation for healthful eating and active living.  TPB Behaviours should be stated specifically The more specifically the behaviour is stated, the more predictive the theory is of the behaviour E.g., question regarding very specific behaviours are: “How many time do you eat fruit as part of your noon day meal each month? “How often do you eat vegetables each week?” Nutrition educators can help individuals set specific plans to implement their intention to take action. 20XX presentation title 64 D. Social Cognitive Theory (SCT)  Social Cognitive Theory (SCT) SCT explains human behaviour in terms of a three-way, dynamic, reciprocal model in which personal factors, environmental influences, and behaviour continually interact 20XX presentation title 66  SCT A basic concept of SCT is that people learn not only through their own experiences, but also by observing the actions of others and the results of those actions. Key constructs of social cognitive theory that are relevant to health behaviour change interventions include: Observational learning Reinforcement Self-control Self-efficacy 20XX presentation title 67 E. Social Ecological Model (SEM)  Social Ecological Model This model helps to understand factors affecting behaviour and also provides guidance for developing successful programs through social environments. Social ecological models emphasize multiple levels of influence (such as individual, interpersonal, organizational, community and public policy) and the idea that behaviours shape and are shaped by the social environment. The principles of social ecological models are consistent with social cognitive theory concepts which suggest that creating an environment conducive to change is important to making it easier to adopt healthy behaviour 20XX presentation title 69  Social Ecological Model 20XX presentation title 70  Example of social ecological model: 20XX presentation title 71  Element contribute to Effective NE: Strategies NE develops strategies to address the identified determinants of behaviours or potential mediators of change and their environmental contexts 20XX presentation title 72 Nutrition education (NE) is more likely to be effective when it include the following: DETERMINANTS OF BEHAVIOURS A FOCUS ON SPECIFIC BEHAVIOURS/ PRACTICES USE THEORY AND RESEARCH ADDRESSING MULTIPLE STRATEGIES TO ADDRESS LEVELS OF INFLUENCES/ DETERMINANTS OF DETERMINANTS AND BEHAVIORS OR POTENTIAL SUFFICIENT DURATION MEDIATORS DESIGNING STRATEGIES FOR NUTRITION EDUCATION Components or phases of nutrition education 1. Motivational phase - a focus on why to take action 2. Action phase – a focus on how to take action 3. Environmental phase - an emphasis on changes in environment Each component needs to be based on appropriate theory and research  Design strategies: 3 Components or phases of nutrition education 20XX presentation title 75  Design strategies: 3 Components or phases of nutrition education 1. The motivational phase (pre-action or thinking phase) This stage aims to increase awareness, promote contemplation, enhance motivation to act, and facilitate the intention to take action. Focus on: why to make changes / to take action? E.g. role of calcium in bond health, role of antioxidants in reducing cancer risk. Point out the risks of not taking action, explore the barriers to taking action and suggest ways to overcome the barriers. 20XX presentation title 76  Design strategies: 3 Components or phases of nutrition education 2. The action phase (or doing phase) This stage aims to facilitate the ability of the intended audience to take action. Focus on: how to make changes? To provide skill E.g. knowing the key feature of Food Pyramid, knowing what is meant by balance diets, being able to read food labels, identifying food sources of nutrients, being able to practice safe food preparation methods, etc. Research has shown that when people make specific action plans, they are more likely to take action. This process is referred to as goal-setting to make goals or action plans that are very specific, such as: - “I will add to my diet a fruit for a snack three days this coming week” or - “I will bring a fruit to work to eat at my morning break” or - “I will replace my sweet dessert at dinner with fruit 3 times this week”. 20XX presentation title 77  Design strategies: 3 Components or phases of nutrition education 3. An environmental component The nutrition education program objective is i. to educate decision makers / policy makers to make changes in the environments about the importance of nutrition and health concerns ii. to work in collaboration with policymakers and others to promote environmental supports for action, with an emphasis on changes in environment. For example, nutrition educators work with relevant decisionmakers at the community, regional and national level to increase the availability of healthful foods at affordable prices and accessibility at places where food is selected or eaten and improve social structures, food policy in institutions and communities (and even in the agricultural sector) in order to improve people’s opportunities to take healthful actions 20XX presentation title 78 20XX presentation title 79 Thank you