Session 2 - Theories of Behaviour Change PDF

Session 2 Theories of Behaviour Change (Part 2) r credit: Prof Melinda Transtheoretical Model The transtheoretical model suggests that health behavior change involves progressing through six stages of behavior change: precontemplation, contemplation, preparation, action, maintenance, and terminat...

Session 2 Theories of Behaviour Change (Part 2) r credit: Prof Melinda Transtheoretical Model The transtheoretical model suggests that health behavior change involves progressing through six stages of behavior change: precontemplation, contemplation, preparation, action, maintenance, and termination. 2 Transtheoretical Model This is a common theme that is highlighted in exercise physiology and many independent practitioners are taught early on to identify a client’s readiness to change based on where they are at within this model. 3 Transtheoretical Model •Precontemplation ("not ready") – People are not intending to take action in the foreseeable future, and can be unaware that their behaviour is problematic •Contemplation ("getting ready") – People are beginning to recognize that their behaviour is problematic, and start to look at the pros and cons of their continued actions •Preparation ("ready") – People are intending to take action in the immediate future, and may begin taking small steps toward behaviour change •Action – People have made specific overt modifications in modifying their problem behaviour or in acquiring new healthy behaviours •Maintenance – People have been able to sustain action for at least six months and are working to prevent relapse 4 Transtheoretical Model- Limitations The theory ignores the social context in which change occurs, such as social economic status, income, culture, ethnicity, etc. The lines between the stages can be arbitrary with no set criteria of how to determine a person's stage of change. 5 Nudge Theory • Definition: “Nudge Theory is based upon the idea that by shaping the environment, also known as the choice architecture, one can influence the likelihood that one option is chosen over another by individuals. A key factor of Nudge Theory is the ability for an individual to maintain freedom of choice and to feel in control of the decisions they make. ” https://www.imperial.ac.uk/nudgeomics/about/what-is-nudge-theory/ 6 Nudge Theory • How much of what we do in a day is automatic? How much do we think about and do deliberately? • In psychology, this is known as Dual Process Theory (DPT) • Our brain has two systems, and they operate differently. Often, the two processes consist of an implicit (automatic), unconscious process and an explicit (controlled), conscious process. • Knowing this, how can we consider this system to impact behaviour? 7 Dual Process Theory 8 Reflective and Automatic thinking Explicit --- Implicit Conscious --- Sub/non-conscious Reflective --- Impulsive Thinking --- Intuitive 9 Automatic and Reflective Processes Automatic Processes: Based on associations in memory, patterned responses, innate needs/ desires. Evoked without the conscious intention of the individual to drive cognitive and behavioural responses. Reflective Processes: Conscious decisions, attitudes, motivations and behaviours based on knowledge, values. These processes are structured by logic, social rules and deliberation. (Bargh, 1984; Smith & DeCoster, 2000; Strack & Deutsch, 2004) 10 Automaticity • Typical features of automatic process • Continuum of automaticity (Bargh, 1984; 1994) 11 Dual Process Theory 12 Dual Process Theory 13 Dual Process Theory 14 Incongruous Reflective and Automatic Self‐control/ effort/ cognitive load required to put the behaviour back on track. Easier to drive behaviour if Automatic and Reflective responses are similar. <Presentation Title> 15 Changing Unhealthy Automatic Processes • Strong • Resistant to change • Difficult to measure 16 How Can We Influence Automatic Processes? How Can We Use Automatic Processes to Increase PA? 17 Nudge theory examples • https://medium.com/swlh/the-7-most-creative-examples-of-habit-changing-nudges-7873ca1fff4a 18 Nudging and Stealth Strategies “Any aspect of choice architecture that alters people’s behaviour is a predictable way without for bidding any options or significantly changing their economic incentives” Thaler & Sunstein, 2008. Acknowledges the role that the physical and social environment shape our behaviour. 19 Nudge Theory and Public Health • Video‐ Nudge and Public Health: What can we learn from the British experience (35 minutes – if you’ve not yet done so, please watch on your own) • What are some arguments to support the use of nudging in public health? • What are some arguments against the use of nudging strategies? • Do you think that nudging is a worthwhile strategy for governments to use to improve physical activity or reduce sedentary behaviour 20 Influencing behaviour: MINDSPACE a helpful mnemonic for thinking about the effects on our behaviour that result from contextual (rather than cognitive) influences. (Dolan et al., 2012) 21 Messenger • Who is communicating the information? • Similarity between audience and messenger increase adherence • Sociodemographic and behavioural similarity • Affective response to the messenger • Do we like them? • Is the messenger credible? 22 Incentives 1. Losses are perceived as more important than gains in the short term. (We strongly avoiding losses) 2. We do not treat increases in probability in a linear/ rationale manner (we don’t think of an increase from 510% in the same way as 45-50% • We place disproportionately high weightings on small chances • Focus random/unlikely events (winning the lottery or being audited) 3. We instinctively go for the immediate incentive as opposed to the long‐term win. 23 Norms • We follow trends and behaviour of people around us • If a norm is desirable, let people know. • Relate the norm to the target population as much as possible • Consider social networks (relationships) • Norms might need reinforcing • Be careful with undesirable norms • Healthy people might reduce their commitment to healthy behaviours. 24 Default • We ‘go with the flow’ more often than not. • Opt‐out campaigns more successful than opt‐in. • Make the healthy choice the easy choice • Reduces the amount of self‐control required 25 Salience • Salience: something that is noticeable or prominent • Time • Importance • Novelty 26 Priming • An external stimulus activates thoughts/ideas, which in turn prompt behaviour • The automatic activation of a psychological construct by exposing an individual to a stimulus that is symbolic of the construct being primed (Bargh, 1984). • For example, if you have people read certain words (fit, athletic, etc) you influence their walking pace • If you ask someone how often they intend to floss that week, they floss more • If you serve a meal in a larger bowl, people will eat more • Reflective‐impulsive model (Strack & Deutschman, 1994) • Automotive model (Bargh, 1990) • Concrete goals: Being helpful (Nelson and Norton, 2005) • Abstract constructs: Motivational orientations (Hodgins et al., 2006; Banting et al., 2009). 27 Real world Priming • Advertising and product placement • Language/ behaviour of staff • Language/ behaviour of other trainers • Signage and documents associated with physical activity • Teaching • Staff meetings 28 Affect • How much we like or enjoy a stimuli can automatically shape our actions. • Emotional responses to words, colours, sounds • Irrational • Prone to automatic influence and prejudices 29 Commitment • We seek to be consistent with our promises and publicly acknowledged commitments. • Deviating from commitments creates cognitive dissonance • Consistent actions and goals increase wellbeing • Commitment comes in many forms‐ financial, verbal, unspoken, contracts. 30 Ego • We act in ways that make us feel better about ourselves or in a way that we feel makes us look better to important others. • • • • • • Intelligent Attractive Powerful Healthy Rational Consistent 31 Using MINDSPACE • The MINDSPACE framework can be used whenever behaviour change is being considered, a framework for nudges • The insights from MINDSPACE offer a to way of reassessing whether and how policy/interventions are shaping behaviour • MINDSPACE can support consideration of the ‘behavioural dimension’ of all actions • MINDSPACE is linked to nudges 32 APPLYING THE THEORIES TO POPULATIONS • How can theory relate to different populations? • • • • Adults Inactive Very active Children • Older adults • • • • • How can theory be applied in different settings? Group vs individual Workplace Clinic Club 33 Activity: Applying the TBP to an online health promotion initiative • Case Study: https://thisgirlcan.com.au/ • In small groups, work in your break out room to conceptualise how the “this girl can” website/initiative is aiming to promote behavior change in its target population. Consider the following: • Who is the target population, what aspects of the initiative address the three key components of TPB (attitude, subjective norm, perceived behavior control) 34 Applying Theory of Planned Behaviour to This Girl Can • Population Specifics • • • • Females Ages 18+ years PA: Inactive Particular focus on diverse groups (i.e. LGBTQI, culturally diverse) 35 Applying Theory of Planned Behaviour to This Girl Can Initiatives to improve attitudes Value of exercise Likelihood of positive outcomes Beliefs about gender stereotypes Initiatives to improve subjective norms Supportive and similar group environment Diverse representation Initiatives to improve perceived behavioural control Highlighting activity opportunities Barrier identification 36 How can theories of behaviour drive policies and urban planning? We will watch the VU collaborate videos together • Bike Friendly Cities: Copenhagen • Cycling in the Snow: Copenhagen Do you think Melbourne has been designed un such a way to promote active behaviours? Why or why not? 37 Urban Design and SDT 38 Theories covered so far: • Theory of planned behaviour • Social cognitive theory • Self-determination theory • Social ecological model • Transtheoretical model • Dual processing theory/nudge model <Presentation Title> 39 Group Activity Go to VU collaborate “Group Activity Park 3: Theory Mapping.” In pairs, you will work through the this interactive module. You will be given examples of theory mapping and then you will have the chance to try it yourself. 40 Case Study: ENGAGE Trial: A physical activity intervention for prostate cancer survivors PCa Statistics: Cancer Australia Benefits of Exercise for People with Cancer Exercise Programs for People with Cancer The benefits of exercise have been endorsed by peak exercise and cancer associations in Australia and internationally Evidence-based recommendations for PA have been developed • recommends that cancer survivors should engage in at least 150 minutes per week of moderate intensity or 75 minutes per week of vigorous intensity aerobic PA, or an equivalent combination; and two sessions of resistance training Less than a third of cancer survivors engage in recommended levels of exercise (Galvão et al, 2015) No widespread implementation of these recommendations in to clinical care I became interested in improving participation in physical activity for men with prostate cancer So… Long-term adherence So that they can achieve the positive physical and psychological outcomes Initial Studies: Factors that Influence Participation Interviews with PC survivors Main Findings • Clinician endorsement of exercise important • Lack of confidence in ability to exercise following treatment • Few recalled receiving advice about exercise from their clinician or referrals to exercise practitioners Initial Studies: The Role of Clinicians Survey of clinicians who treat men with prostate cancer Main findings: • Clinicians recognized the benefits of exercise for their patients • Few gave advice about physical activity • Few prescribe physical activity to their patients or refer them to exercise specialists ARC Linkage Grant: ENGAGE Study • Funding: ARC Linkage and Prostate Cancer Foundation of Australia. • Investigators: Livingston, PM., Salmon, J., Courneya, K., Gaskin, C., Botti, M., Broadbent, S., Kent, B • Project Manager: Craike, M • 3-year project ENGAGE Study Primary aim: To compare the efficacy of a clinician referral to a 12week exercise physiologist-led exercise program with usual care, in improving the physical activity levels over a 12month period Intervention 1. Clinicians randomised into intervention condition refer sequential patients to an Exercise Program, using referral slip Intervention 2. Participants undertake oneon-one session with an exercise physiologist (fitness testing) 3. Participants undertake 12week program, includes supervised exercise sessions (2 x per week) and individual homebased physical activity (1 x per week) needs, beliefs, preferences, expectations, goals, beliefs revisited throughout program Strategies to enhance adherence Feature Rationale 1. During sessions, EPs discussed physical activity preferences, outcome expectations, goals, and strategies for overcoming barriers to performing PA Topics based on the constructs of social cognitive theory 2. The exercise program was tailored to suit the ability of each participant To encourage task self-efficacy, through mastery of behaviour 3. Supervised exercise sessions facilitated persuasion, encouragement and social support Based on social cognitive theory- to increase selfefficacy 4. Home-based sessions- take-home instructions and recording of activity Self-monitoring of exercise goals, encouraging long term adherence 5. Convenient gym locations Lower barriers (eg., travel) to exercise 6. Clinician referral Social support, confidence to perform the activity (Self-efficacy) ENGAGE Outcomes Main findings: • Men who received the exercise recommendation and participated in the exercise program were four times more likely to meet recommended levels of exercise than those in the control group • Exercise program improved cognitive functioning and reduced depressive symptoms • 80% reported that the clinician’s referral influenced their decision to participate In the program ENGAGE Findings Main findings: • Adherence to supervised program was 80.3% • Role functioning and hormonal symptoms independently predicted adherence ENGAGE Findings Main findings: • Community-based exercise program improved strength and flexibility, resting heart rate • ADT did not modify responses to exercise training Engage Findings SCT AS MEDIATORS PAPER IN PRESS References • Bennie JA, Pedisic Z, van Uffelen JG, et al.: The descriptive epidemiology of total physical activity, muscle-strengthening exercises and sedentary behaviour among Australian adults - results from the National Nutrition and Physical Activity Survey. BMC Public Health. 2016, 16:73. • Gidlow C, Johnston LH, Crone D, James D: Attendance of exercise referral schemes in the UK: A systematic review. Health Education Journal. 2005, 64:168-186. • Active Canada. Social Ecological Model. http://www.activecanada2020.ca/sections-of-ac-2020/appendix-a/appendix-b/appendix-c-1/appendix-d • Ajzen I, Kuhl J, Beckman J: From intentions to actions: A theory of Planned Behaviour. Action-control: From cognition to behaviour. New York: Springer, 1985, 11-39. • Hochbaum GF: Public Participation in Medical Screening Programs: A Socio-Psychological Study. In Department of Health Education and Welfare (ed) (Vol. PHS Publ no 572). Washington, DC: US Government Printing Office, 1958. • Bandura A: Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall, 1986. • Young MD, Plotnikoff RC, Collins CE, Callister R, Morgan PJ: Social cognitive theory and physical activity: a systematic review and meta-analysis. Obesity Reviews. 2014, 15:983-995. • Williams SL, French DP: What are the most effective intervention techniques for changing physical activity self-efficacy and physical activity behaviour--and are they the same? Health Educ Res. 2011, 26:308-322. • Dolansky MA, Stepanczuk B, Charvat JM, Moore SM. Women's and men's exercise adherence after a cardiac event. Research in gerontological nursing. 2010;3(1):30-38. References • Australian Institute of Health and Welfare: Key indicators of progress for chronic disease and associated determinants: Data report In., vol. Cat. no. PHE 142 • Canberra: AIHW; 2011. • Olney SJ, Nymark J, Brouwer B, Culham E, Day A, Heard J, Henderson M, Parvataneni K: A randomized controlled trial of supervised versus unsupervised exercise programs for ambulatory stroke survivors. Stroke 2006, 37(2):476-481. • Australian Institute of Health and Welfare: Cardiovascular disease, diabetes and chronic kidney disease—Australian facts: Risk factors. In: Cardiovascular, diabetes and chronic kidney disease series no 4 Cat no CDK 4. Canberra: AIHW; 2015. • Thursfield V, Giles G, Farrugia H: Cancer in Victoria: Statistics & Trends 2013. Melbourne: Cancer Council Victoria, 2014. • Shi Q, Smith TG, Michonski JD, et al.: Symptom burden in cancer survivors 1 year after diagnosis: a report from the American Cancer Society's Studies of Cancer Survivors. Cancer. 2011, 117:2779-2790 • Speck RM, Courneya KS, Mâsse LC, Duval S, Schmitz KH: An update of controlled physical activity trials in cancer survivors: A systematic review and meta-analysis. Journal of Cancer Survivorship. 2010, 4:87-100. • Bonn SE, Sjölander A, Lagerros YT, et al.: Physical activity and survival among men diagnosed with prostate cancer. Cancer Epidemiol Biomarkers Prev. 2015, 24:57-64. • Galvão DA, Newton RU, Gardiner RA, et al.: Compliance to exercise-oncology guidelines in prostate cancer survivors and associations with psychological distress, unmet supportive care needs, and quality of life. Psycho-Oncology. 2015. References • Bargh, J.A. (1984). Automatic and controlled processing of social information. In R. S. Wyer, Jr., & T. K. Srull (Eds.), Handbook of social cognition (Vol. 1, pp. 1‐41). Hillsdale, NJ: Erlbaum. • Smith, E. R., & DeCoster, J. (2000). Dual‐Process Models in Social and Cognitive Psychology: Conceptual Integration and Links to Underlying Memory Systems. Personality and Social Psychology Review, 4(2), 108‐131. • Strack, F., & Deutsch, R. (2004). Reflective and impulsive determinants of social behavior. Personality and Social Psychology Review, 8(3), 220‐247. • Thaler, R.H., & Sunstein, C. (2008). Nudge: improving decisions about health, wealth and, happiness. New Haven, CT: Yale University Press. 60