4. Health behaviour change_slides - Tagged.pdf

Genes, Behaviour and Environment 4MBBS103 Neuroscience, Behaviour and Social Science Health Behaviour Change Learning objectives 1. Recognise the theory and evidence base underpinning behaviour change techniques (BCTs) 2. Describe the role of motivation and its effects on app...

Genes, Behaviour and Environment 4MBBS103 Neuroscience, Behaviour and Social Science Health Behaviour Change Learning objectives 1. Recognise the theory and evidence base underpinning behaviour change techniques (BCTs) 2. Describe the role of motivation and its effects on applying behaviour change techniques 3. Other evidence based techniques Objective 1 Recognise the theory and evidence base underpinning behaviour change techniques (BCTs) Evidence Based Medicine Evidence based medicine (EBM) is based on the principle of ‘integrating individual clinical experience with the best available clinical evidence from systematic research’ (Sackett et al., 1996) Find up to date research Systematic reviews and meta-analysis can provide a good over-view Critically evaluate the evidence “As long as I explain clearly…..” Performance of health behaviours Knowledge = necessary but not sufficient for behaviour change. Knowledge and attitude towards behaviour explains 10% of variance in whether behaviour is performed (McEachan et al., 2011; meta-analysis 209 studies). Education is just one type of behaviour change technique. What other factors account for the remaining 90%? Drivers of health behaviours/ change Health belief model Theory of planned behaviour PERCEIVED SUSCEPTIBILITY Attitude towards PERCEIVED the behaviour THREAT PERCEIVED BEHAVIOUR CUE TO SEVERITY CHANGE Subjective Behavioural Behaviour ACTION norm intention PERCEIVED COSTS/BARRIERS COST BENEFIT PERCEIVED ASSESSMENT Perceived BENEFITS Behavioural control  Drivers of health behaviours/ change COM-B PERCEIVED Attitude towards SUSCEPTIBILITY the behaviour PERCEIVED THREAT PERCEIVED CUE TO SEVERITY BEHAVIOUR Subjective Behavioural Behaviour ACTIO CHNAGE norm intention N PERCEIVED COSTS/BARRIERS COST BENEFIT Perceived ASSESSMENT PERCEIVED Behavioural BENEFITS control Behaviour Change Techniques Behaviour change techniques are the building blocks of behaviour change interventions “Active ingredients” used when intervening to change a person’s behaviour (Michie et al., 2015) 93 different BCTs in total that apply across a range of behaviours (Michie et al., 2013) Identified from analysing the content of behaviour change interventions and expert consensus (N= 42).  BCTs: A psychological period table BCTs are: Observable Replicable Irreducible components Used alone or in combination Examples: Information provision Goal setting Feedback Action plans  Evidence for BCTs: an example Comparing effects of self-monitoring vs no self-monitroing Meta-analysis of 122 studies (Michie) on lifestlye behaviour change 0.45 Most effective BCT 0.4 Self-monitoring of behaviour 0.35 46 used self-monitoring of behaviour vs 0.3 76 did not use self-monitoring 0.25 Effect size 0.2 Those studies that used self-monitoring of behaviour in combination with 1+ BCTs 0.15 demonstrated even greater efficacy. 0.1 0.05 0 Self-monitoring No self-monitoring What do I do then? Which one do I use? The individual patient and their COM characteristics (e.g. their capacity, opportunity, and level of motivation) The behaviour being targeted, for example the techniques you would use to promote adherence may be different to those you would use if you were trying to encourage an individual to exercise. Objective 2 Describe the role of motivation and its effects on applying behaviour change techniques Communication strategies are key  Describe the role of motivation Motivation explains initiation (intention), direction, persistence, and termination of behaviour (Jensen et al., 2003) State that can be influenced by: Conscious deliberative processes Unconscious automatic processes  Patient-centred consultation BCTs selected to target one or more of the components of the COM-B framework At an individual level target capability and opportunity Explore with the patient the effect of this on motivation What information do I need to elicit from patients? COM-B Framework (Michie et al., 2011) Drivers of health behaviours/ change b Health belief model Theory of planned behaviour PERCEIVED SUSCEPTIBILITY Attitude towards PERCEIVED the behaviour THREAT PERCEIVED BEHAAIOUR CUE TO SEVERITY CHANGE Subjective Behavioural Behaviour ACTION norm intention PERCEIVED COSTS/BARRIERS COST BENEFIT PERCEIVED ASSESSMENT Perceived BENEFITS Behavioural control Patient-centred consultation b Patient-centred care allows level of motivation to be established and its drivers The patient is most knowledgeable about their: Capability Motivation Habits Physical and cognitive function Role of health care professional is to: Proactively engage the patient in health behaviour change Evoke arguments for changing their behaviour Bolster the patient’s confidence by supporting patient autonomy, reinforcing their commitment to behaviour change Provide information tailored to individual need  Motivational Interviewing Engagement Focussing Evoking Planning Collaborative relationship Raising with the patient Eliciting arguments for Developing a Generating an accepting the target behaviour and change from the patient commitment for change and trusting environment maintaining direction Use health psychology A detailed plan for action towards it models to identify capacity, motivation, and opportunity Miller and Rollnick (2012)  “I can see how challenging you find “Are there other this alongside being a mum and activities you enjoy fulltime working.” outside the house or that you see your Motivational friends doing?” interviewing Expressing empathy Supporting self-efficacy - 4 guiding principles Develop discrepancy Rolling with resistance “It seems like losing weight is “Ok so it seems from important for you to look good, but what you are telling me it is challenging with kids?” we need to think of some alternatives. Shall we look at these together?” OARS Open questions – allows you to elicit patient perspective fully and identify their capability and motivation “You mentioned you don’t know where to start with dieting. To help me get a better understanding, what is a typical day like for you?” Affirm – Recognise the positive attributes of the patient – helps to avoid defensive behaviours. “It’s really good that you’re finding out information about diabetes.” Reflect – Use short statements to confirm you’re listening. “It must be hard for you not seeing your friends anymore now you’re making these changes” Summarise – Allows you to check-in with the patient that you have a O A R S correct understanding of their situation. Open questions Closed non-collaborative Open collaborative How do you feel about that? Are you happy with that? What would be the benefits of changing your Do you want to change your eating eating habits? habits? How does smoking affect your life at the moment? Do you think smoking is good for you? What do you think about your diet? Is your diet unhealthy? How are you getting on with your medicines? Are you taking your medicines correctly? Affirm Affirmation sustains collaboration “It’s great you have decided to make some healthy lifestyle changes, and you already have some things in place some Praising the strengths of the patient things to help you do that.” i) Patient recognition of need to change Prompts for providing ii) Patient reflections on previous attempts that went well affirmation include: iii) Elements of behaviour change that the patient has achieved (even if not all) Reflective listening “So it seems as if now is not the right time for you to think Paraphrasing what the patient has said about quitting smoking” Reflecting back the feelings underlying what they have said Reflect with statements rather than questions Can also reflect feelings the patients is expressing in their body language Encourages the patient to elaborate further Indicates that you are listening Summarisi ng “So you have said you are ready to make some changes to your lifestyle, in particular diet changes and exercise but perhaps it’s not a good time to give up smoking.” Try not to ask a long series of questions Instead summarise and reflect instead Confirms your understanding Demonstrates listening Structures the patient’s thoughts and concerns Structures the consultation to move from engagement to focussing At the end of summary collaboratively decided on a behaviour you would like to focus on  Motivational Interviewing- a recap MI provides a 4 stages 4 principles 4 skills communication skills framework for Engagement implementing BCTs Expressing Supporting (Hardcastle 2015). Focussing empathy self-efficacy It includes: Evoking Develop Rolling with discrepancy resistance Planning O A R S  Motivational Interviewing- in practice The more a person defends their behaviour (e.g. smoking) the Sustain Change more committed they become to talk talk sustaining it – sustain talk The more a person reinstates a commitment for change (e.g. During evoking stage need to try and elicit stopping smoking) the more likely and reinforce change talk: the change will occur – change Recognise change talk talk Elicit change talk Affirm change talk Reflect change talk Using MI the practitioner guides a Summarise change talk person from a state of ambivalence to a state of change Motivational Interviewing- toolkit IMPORTANCE RULER CONFIDENCE RULER On a scale from 0-10 (where 0 is not On a scale from 0-10 (where 0 is not at all confident), how confident do all important) how important do you feel that you will achieve your you feel it is to walk regularly? goal? For example, if a score of 4 is given: For example, if a score of 6 is given: “Why did you not put down 3?” - “Why did you not put down 5?” - supporting self-efficacy identification of necessity beliefs “What would help you move to a 7 or 8?” “What would help you move to a 7 or 8?” - identification of how to increase necessity -> identification of problem-solving beliefs strategies Objective 3 Other evidence-based techniques  BCTs recommended by NICE The BCTs recommended by NICE include: NICE (2014) set out to identify: “which behaviour change techniques Goal setting and planning work most effectively together?” Feedback and monitoring Social Support And noted: “theories of behaviour change may help determine which techniques Techniques effective for following behaviours: should work synergistically.” Alcohol Diet Physical Activity Sexual Behaviour Smoking Consult also behaviour specific guidance (e.g. smoking, obesity) in conjunction with general NICE behaviour change guidance. https://www.nice.org.uk/guidance/ph49  Goal setting & action planning Specific Agree goals for behaviour and the resulting outcome. Define precisely what/where/when/how the Develop action plans and prioritise actions goal will be achieved. Develop coping plans to prevent and manage relapses Measurable Consider achievement of outcomes and further goals and plans. Define parameters to allow recognition of when the goal is complete (e.g. able to prepare 4 new healthy meals). NB: Motivational Interviewing needed to bring a person to goal setting and planning stage Achievable Make sure goals are realistic for the patients level of confidence/skill. Useful worksheets for setting SMART goals and action plans: Relevant Ensure the goal meets the patient’s needs otherwise motivation is low. Improving Health: Changing Behaviour NHS Health Trainer Handbook Timely http://eprints.uwe.ac.uk/12057/1/dh_085778.pdf Set a time limit for completion of the goal.  Implementation intentions: “If-then” planning Plans to manage habitual behaviours and prevent relapse. Identifies cues where behaviour change may be challenging: “If situation x happens” And subsequently generate plans to manage challenge “Then I will do y” IMPORTANT: Plans need to be generated by the patient not by practitioner Some examples: - “If friend persuades me to have a drink, then I will tell them I am saving money for a holiday” - “If I feel stressed after work, then I will talk to my friend instead of snacking.”  Feedback and Monitoring Encourage and support self-monitoring of behaviour and its outcomes Provide feedback on behaviour and its outcomes. Monitoring allows patient and practitioner to identify links between cues and behaviour. Put in place new “If-then” strategies. Allows you to identify when target behaviour is achieved. Supports self-efficacy Longer-term feedback up to 1 year to support maintaining behaviour Social support If appropriate advise on, and arrange for, friends, relatives, colleagues or 'buddies' to provide practical help, emotional support, praise or reward. Provides practical, emotional and motivational support (e.g. gym buddy) Recognise potential negative social contexts Cues for increasing/proactively engaging patients: Becoming a parent Self or family member becoming ill Summary Information provision alone does not change behaviour. BCTs are tools that can be implemented to support patients in changing behaviour. Motivational Interviewing provides a communication skills framework that supports the delivery of BCTs. BCTs currently recommended by NICE include: Goal setting and planning Feedback and monitoring Social Support “If-then” planning  Definition of EBP Evidence- based practice includes which of the following: A: Best available evidence Quick B: Individual clinical experience quiz 1Q C: Patient values D: All of the above  Definition of EBP Evidence- based practice includes which of the following: A: Best available evidence Quick B: Individual clinical experience quiz 1A C: Patient values D: All of the above  Which of the following best describes the acronym OARS used in Motivational Interviewing? A: Open questions, affirming, Quick reflecting summarizing, summarise decision quiz 2Q B: Open posture, affirm, reflective listening, summarise C: Open posture, affirm decision, reflect plan, summarise D: Open questions, affirm, reflective listening, summarise  Which of the following best describes the acronym OARS used in Motivational Interviewing? A: Open questions, affirming, Quick reflecting summarizing, summarise decision quiz 2A B: Open posture, affirm, reflective listening, summarise C: Open posture, affirm decision, reflect plan, summarise D: Open questions, affirm, reflective listening, summarise Reading Ayers, S., & De Visser, R. (2017). Psychology for medicine and healthcare. Sage. Ogden, J. (2012). Health psychology: A textbook: A textbook. McGraw-Hill Education (UK).  Useful references Hardcastle, S. (2015). Identification of the motivational techniques within Motivational Interviewing and relations with behaviour change techniques from the BCTTv1. European Health Psychologist, 17(3), 115-121. McEachan, RRC, Conner, M, Taylor, NJ, & Lawton, RJ. (2011). Prospective prediction of health-related behaviours with the theory of planned behaviour: A meta-analysis. Health Psychology Review, 5(2), 97-144. Michie, S, Wood, CE, Johnston, M, Abraham, C, Francis, JJ, & Hardeman, W. (2015). Behaviour change techniques: the development and evaluation of a taxonomic method for reporting and describing behaviour change interventions (a suite of five studies involving consensus methods, randomised controlled trials and analysis of qualitative data). Health Technology Assessment. Michie, S., et al. (2013). "The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions." Annals of Behavioral Medicine 46(1): 81-95. Michie, S, van Stralen, MM, & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science, 6(1), 42. Michie, S., et al. (2009). "Effective techniques in healthy eating and physical activity interventions: a meta-regression." Health Psychology 28(6): 690. Miller, W. R. and S. Rollnick (2012). Motivational interviewing: Helping people change, Guilford press. National Institute for Health and Care Excellence (2014). Behaviour change: individual approaches (PH49). London, National Clinical Guideline Centre.