Behaviour Change for Health
Public Health CPD workshop
9th May 2013
What are we aiming for?
• Reflecting systematically on our
Health Behaviour Change work
• Discussing and sharing
with colleagues
Agenda
•
•
•
•
Recap of health behaviour change
Introduction to Behaviour MAP tool
Practicing identifying routes to change
Can this apply to our own work?
Exercise 1
3 min
In your group, list as many different
behaviours which affect health as you
can. The more unusual the better!
Health and behaviour recap
A huge range of factors influence our
health, including:
•
•
•
•
•
Where we live
Where we work
Our age
Our family and friends
Our educational background
Many of these
influence health by
affecting what we
choose to do, or
our behaviours
• Positive health behaviours are associated with
health, longevity and wellbeing
Leading actual causes of death,
USA
Tobacco
Poor diet/lack of physical activity
Alcohol consumption
Microbial agents
Toxic agents
Motor vehicle
Firearms
Sexual behaviour
Illegal drugs
See also Buckland et al.
2011, Moore et al. 2012,
Paffenberger et al. 1986,
Rhee et al. 2012, Rizzuto
et al. 2012, Xu et al. 2010,
Moore et al. 2012, Tada et
al. 2011; Romaguera et al.
2012.
0
100000
200000
300000
400000
500000
Number of deaths
Mokdad et al. 2004
If Grampian’s adult population were
smiley faces…
21% smoke
Costing North of Scotland £68.7 million per year
43% are drinking alcohol above
recommended weekly limits
Costing North of Scotland £85.7 million per year
65% are overweight or obese, linked
to unhealthy diet and inactivity
Costing North of Scotland £48.7 million per year
Behaviour change can..
• prevent disease
• improve disease management
• improve quality of life
 Behaviour (change) is good for your health!
Behaviour change interventions
‘Coordinated sets of activities designed to
change specified behaviour patterns’
Michie, van Stralen & West (2011)
Group smoking
cessation counselling
Buddies/peer support
Smoke free legislature
Alcohol
minimum
pricing
Public Health posters
for cervical screening
Midwife alcohol brief
interventions/advice
Coca Cola billboard
adverts
Pharmacist advising
customer on their
medicines
A family deciding to
change their diet and
exercise to lose weight
The secret to HBC intervention
success?
They are more likely to work when we think carefully about:
-
The behaviour
-
The population group’s thoughts, feelings and
resources, and so the best routes to change for them
E.g. NICE 2007; Michie et al. 2008, 2010; NHS Health Scotland 2011;
Scottish Government 2011 (CEL 10)
Recent work from health
psychology:
1) What we do: Content or ‘active ingredients’ of
interventions
The Behaviour Change Technique Taxonomy
Reduce reward frequency
Social support (practical)
Habit formation
Remove punishment
Social support (emotional)
Behaviour substitution
Material incentive (behaviour)
Social support (unspecified)
Habit reversal
Social incentive
Pharmacological support
Overcorrection
Non-specific incentive
Reduce negative emotions
Incompatible beliefs
Conserving mental resources Generalisation of target behaviour Self-incentive
Graded tasks
Identity associated with changed
Incentive (outcome)
Paradoxical instructions
Restructuring the physical environment
behaviour
Material reward (behaviour)
Feedback on behaviour
Restructuring the social environmentSocial reward
Information about health
Feedback on outcome(s) of behaviour
Avoidance/reducing exposure to cuesNon-specific reward
consequences
Self-monitoring of behaviour
the behaviour
Information about emotional
Self-reward
Self-monitoring of outcome(s) offor
behaviour
Distraction
consequences
Reward (outcome)
Monitoring of behaviour by others
without feedback
Addingwithout
objectsfeedback
to the environment Future punishment
Information about social and
Monitoring of outcome(s) of behaviour
Body changes
environmental consequences
Problem solving
Biofeedback
Instruction on how to perform a
Salience of consequences
Goal setting (behaviour)
Prompts/cues
behaviour
Monitoring of emotional
Goal setting (outcome)
Reduce prompts/cues
Information about antecedents
consequences
Action planning
Cue signalling reward
Anticipated regret
Review behaviour goal(s)
Remove access to the reward Re-attribution
Behavioural experiments
Demonstration of the behaviour
Review outcome goal(s)
Remove aversive stimulus
Verbal persuasion about capability Behavioural contract
Social comparison
Satiation
Mental rehearsal of success
Information about others’
Commitment
Exposure
performance
Discrepancy between current approval
Associative learning
behaviour and goal Imaginary punishment
Behavioural practice/rehearsal Focus on past success
Self-talk
Imaginary reward
Credible source
Punishment
Vicarious consequences
Pros and cons
Behaviour cost
Comparative imagining of future
Remove reward
outcomes
Reward approximation
Identification of self as role model
Rewarding completion
Valued self-identify
Situation-specific reward
Michie et al. 2013
93 techniques!
Summarised into Three Routes to
Change
The content of interventions can aim to:
Unhealthy
behaviour
Healthy
behaviour
Prompt people into acting without them thinking hard
Or a combination
From Strack and Deutsch, 2004
Dixon and Johnston 2010
Recent work from health psychology:
2) ‘How’ we do it: skills or competencies in
health behaviour change
The Health Behaviour Change
Competency Framework (Dixon + Johnston 2010)
Behaviour MAP tool
Approach and communication skills
Motivation
33.3333%
Action
33.3333%
Behaviour
MAP
Prompts
33.3333%
Approach and communication skills
1: What is the behaviour we aim to
empower people to do?
Behaviour
2. What do we aim to do in the
intervention?
Motivation
33.3333%
Action
33.3333%
Help people to do
it differently, by
strengthening their
skills to take
action after they
have decided to
do it?
Support people to
decide to do
something
differently?
Behaviour
MAP
Prompts
33.3333%
Make use of less
conscious routes
to change, like
habits, prompts
and cues?
Knowing which route guides us in
which kinds of techniques to use
33.3333%
Motivation
e.g. Incentives
e.g. Giving information about
health consequences
Motivation
3. ‘How’ will we make it work?
Approach and communication skills
Motivation
33.3333%
Determines whether
we do the
33.3333%
techniques really
well or totally mess
them up!
33.3333%
Approach and communication skills
munication
munication
Things like….
Tailoring what you do to the
person’s stage of change
Size of printed materials
Using foundation competencies
Being empathic
Listening properly
Tailoring what you do to
the person’s beliefs,
age etc
Body language
Approach and communication skills
Motivation
33.3333%
Action
33.3333%
Behaviour
MAP
Prompts
33.3333%
Approach and communication skills
How does this work in real life?
• Over to Emma Bell, Ian Milne and Caroline
Comerford to explain their services
(see end of slides)
Exercise 2 – Name that route!
You’ll see a series of posters, videos, or
scenarios which aim to change a
behaviour relevant to health.
In your groups, decide each time which
route to change is being used.
Euro RSCG
Australia, 2009
Healthy eating advert
• Change 4 Life
Advertisement on a health website
A typical supermarket checkout
Chlamydia Screening
• You are designing a campaign
to encourage teenage girls in
Grampian to get tested for chlamydia
• Initial interviews with the target
group suggest the majority think the
testing process is straightforward
(return a urine sample by post)
but is not an important priority
• Would you design your
campaign to focus on M, A, or P?
Checking breasts
• Advert for Scottish Government's Detect
Cancer Early campaign
NHS anti smoking advert
NHS staff use of hand gel
• Imagine you are working in Scottish Government
on a hand hygiene programme
• You know that most clinical staff see the need for
using hand gel and they know when and how to
use it. However, they have trouble remembering
• What would you suggest the
programme should focus mainly
on, M, A, or P ?
Sleepless in Healthpoint
• You are working in Healthpoint and a 42 year old mother
comes in telling you they are exhausted and don’t know
what to do about it
• On asking them more about this, you learn that she is
very keen to get more sleep, but not confident she
knows how much sleep is enough or what strategies can
help promote restful sleep (sleep hygiene)
• Would your work with her focus on
M, A, or P ?
The piano staircase
NHS Grampian breastfeeding
• Breastfeeding video
Exercise 3: Can this apply to
your work?
10 min
•Does your own work apply to any of the three
‘layers’ in the tool?
•Use the post-its to stick ideas onto the model,
and/or the reminder sheet provided to have a
think and chat in your groups
Exercise 4: Sharing your work
15 min
•Finally, in rotating partners we’ll discuss
and share our work with others
•We’ll end with a whole group discussion
Wrap-up
• Thoughts, comments, questions on
today’s workshop?
• Many thanks for participating!
Health Coaching Service
Free, one-to-one support to help
you improve your health and
wellbeing.
Health Coaching Service
•Linked in with GP practices - nurses and GPs refer Keep Well patients
or other patients that they think could benefit from the service.
•Trained Health Coaches meet with clients for up to four, 45 minute
sessions to talk about a lifestyle factor the client would like to
change and to support them in setting achievable goals.
•Focus on: diet, physical activity, smoking or alcohol.
Behaviour
•Many people have benefited from Health Coaching and have offered
very positive feedback, such as: ‘This definitely helped me change
my habits,’ and that described it as a, ‘No preaching, common
sense approach’.
•Signposting is also offered to a range of useful health and nonhealth related services including: Healthpoint, Healthy Helpings, Cash
in Your Pocket Partnership, and the Smoking Advice Service.
Communication Techniques
in Health Coaching
• Open questions
Approach and communication skills
Motivation
33.3333%
• Affirmations
• Reflections
• Summarising
33.3333%
33.3333%
Approach and communication skills
• ‘Elicit-Provide-Elicit’ - E-P-E Framework for providing
information
(Motivational Interviewing: Preparing people for change - Miller and Rollnick, 2002; and
Motivational Interviewing in Health Care: Helping patients change behaviour Rollnick, Miller and Butler, 2008.)
Behaviour Change Techniques
Specific skills and techniques for changing behaviour outlined
in Health Behaviour Change Competency Framework
(Dixon and Johnston, 2010):
Three key routes to change - effective Health Behaviour
Change techniques use this MAP:
• Some increase a person’s Motivation to change
• Some help a person to Act on their motivation
• Some work to Prompt or cue behaviour in a particular
environment
(Dixon and Johnston, 2010)
Behaviour Change Techniques
in Health Coaching
Health Coaching teaches and encourages the use of techniques
which reflect all three MAP routes to behaviour change:
• Decisional balance/pros and cons – Motivation
• Antecedents and consequences – Motivation or Action
• SMART goal setting – Action
Motivation
33.3333%
• Barriers and facilitators – Action
• Self-monitoring – Action
Action
33.3333%
Behaviour
MAP
Prompts
33.3333%
• Use of rewards - Prompting
Healthy Helpings
• Healthy Helpings is an eight-week weight
management programme supporting individuals
with a BMI over 25 to achieve and maintain a
healthier weight.
• The programme aims to increase knowledge
around healthy eating and physical activity with
an emphasis on active learning.
• The behaviours HH addresses are healthy
eating and physical activity.
Behaviour Change Techniques
•
•
•
•
•
•
Provision of information
Persuasion
Prompt monitoring
Prompting practice
Specific Goal Setting
Social Support
Routes to change
HH motivates people to change through persuasion:
• 2 digestive biscuits = 150 kcal/ day; 1 month = 4 500
kcals; gain of 1lb or ½ kg in one month.
HH helps people take action to use / develop skills:
• Provides instructions on specific goal setting,
coping planning and self-monitoring.
Routes to change
HH prompts healthy habits by suggesting ways in
which the environment can work for people:
• For example suggesting people stick reminders
on their fridge, or give them praise specifically
when they have stuck to their eating plan.
Throughout, HH facilitators use communication
skills:
• Facilitators are trained to use skills like open
questions, empathic / reflective listening,
summarising thoughts and plans.
Healthy Helpings Participant Booklet
NHS Grampian Smoking Advice Service
How to Help Individuals to Stop Smoking
Changing Behaviour
Ian Milne
Tobacco Training &
Development Co-ordinator
Ian.milne3@nhs.net
Smoking Advice Service
•
Secondary Care
•
Intensive support
•
Community Pharmacy Scheme
•
Workplace
Helping individuals change
health risk behaviour (smoking)
•
Assessments
•
Behaviour change techniques
Helping individuals change
health risk behaviour (smoking)
Assessments
•
Smoking history
•
Nicotine dependence
•
Self efficacy
•
Readiness to change
•
Identifying smoking cues
Smoking History
• Listen to the individual
• Find out why they started smoking, social
influences, previous quit attempts
Assessing Strength of Addiction
Fagerstrom Test for Nicotine Dependence
How soon after you wake up do you have
your first cigarette
 Within 5 min
6 to 30 min
31 to 60 min
After 60 min
Do you find it difficult to refrain from
smoking in places where it is
forbidden such as churches, libraries
or cinemas?
Yes
 No
Which cigarette would you most hate to
give up? (Tick one box)
First in the morning
All others
How many cigarettes do you smoke in a
typical day? (Tick one box)
10 or less
11 to 20
21 to 30
31 or more
Do you smoke more frequently during the
first hours after waking than the rest
of the day?
Yes
No
Do you smoke if you are so ill that you are
in bed most of the day?
Yes
No
Assess Self efficacy
• On a scale of 1 to 10 how confident are
you that you will be able to change….
Assess readiness to change
On a scale of 1 to 10 how strong is your
desire to change…..
Identify smoking cues
• Smoking diary
Behaviour Change Techniques
• Providing information
• Positive reinforcement/encouragement
• Setting goals – individual’s decision
• Action & Coping Planning
• Relapse Prevention
• Preparing for quit day
• Medication
Behaviour Change Techniques
• Providing information
• Positive reinforcement/encouragement
• Setting goals – individual’s decision
• Action & Coping Planning
• Relapse Prevention
• Preparing for quit day
• Medication
Behaviour Change Techniques
Providing information
• Information on health risks of smoking
and benefits of stopping smoking.
Health Behaviour Change
Competency Framework
MOTIVATION - ACTION – PROMPT
Providing information about health
consequences = Motivation
Behaviour Change Techniques
• Providing information
• Positive reinforcement/encouragement
• Setting goals – individual’s decision
• Action & Coping Planning
• Relapse Prevention
• Preparing for quit day
• Medication
Positive: Promoting the benefits of stopping
smoking.
20 minutes
BP & pulse rate return to normal, circulation improves in
hands & feet, making them feel warmer.
8 hours
Nicotine & carbon monoxide levels in the blood will reduce
by half and oxygen levels will return to normal.
24 hours
Carbon monoxide will be cleared from your body & your
lungs will start to clear out mucus & other smoking debris.
48 hours
Your body is now free of nicotine & your sense of taste &
smell will improve.
72 hours
You should be breathing more easily, Airway passages in
the lungs begin to relax, Energy levels increase.
2 – 12 weeks
Your circulation improves and you’ll feel fitter.
3 – 9 months
Lung function is better & coughs & wheezing reduce.
1 year
The risk of heart attack falls to half that of a smoker.
10 years
The risk of lung cancer falls to half that of a smoker.
15 years
The risk of heart attack falls to the same as someone who
has never smoked.
Positive Reinforcement
Carbon monoxide measurement
Verification
of cessation
& an
excellent
motivator
Xmas bus advertisement
Health Behaviour Change
Competency Framework
MOTIVATION - ACTION - PROMPT
Positive reinforcement = Prompt/Motivation
Behaviour Change Techniques
• Providing information
• Positive reinforcement
• Setting goals – individual’s decision
• Action & Coping Planning
• Relapse Prevention
• Preparing for quit day
• Medication
Goal Setting
Goals should be set by the individual with
guidance: not forced upon them
Health Behaviour Change
Competency Framework
MOTIVATION - ACTION - PROMPT
Goal Setting = (making a plan) Action
Behaviour Change Techniques
• Providing information
• Positive reinforcement
• Setting goals – individual’s decision
• Action & Coping Planning
• Relapse Prevention
• Preparing for quit day
• Medication
Action Planning
• Action planning is the practice of linking goaldirected behaviours to certain environmental
cues by specifying WHEN, WHERE and HOW to
act.
• Action planning helps individuals to implement
their intentions to change.
• e.g. Goal: to create a new non-smoking
behaviour.
• Plan: ‘I am going to leave a pencil and pad
beside my telephone and draw a picture when
I’m speaking on the phone’.
Coping Planning
• Coping planning is a barrier focused self
regulation strategy.
• Represents a mental link between anticipated risk
situations and coping responses.
• e.g. Barrier: ‘I need to smoke to cope with life’s
stresses’.
• Plan: ‘When I feel stressed. I will do progressive
relaxation exercises’.
Health Behaviour Change
Competency Framework
MOTIVATION - ACTION - PROMPT
Action Planning = Prompt/Action
Coping Planning = Action
Behaviour Change Techniques
• Providing information
• Positive reinforcement
• Setting goals – individual’s decision
• Action & Coping Planning
• Relapse Prevention
• Preparing for quit day
• Medication
Relapse Prevention
• After time (estimate 4 weeks)
everyday cues become extinct.
• However, cues from occasional
smoking situations may not.
• E.g. holidays, weddings, funerals,
stressful situations, IWOANO.
Relapse Prevention
Avoid relapse by planning ahead.
• Identify alternative activities/behaviours.
• Practice ‘no thank you, I don’t smoke’.
Health Behaviour Change
Competency Framework
MOTIVATION - ACTION - PROMPT
Relapse Prevention = Prompt/Action
Behaviour Change Techniques
• Providing information
• Positive reinforcement
• Setting goals – individual’s decision
• Action & Coping Planning
• Relapse Prevention
• Preparing for quit day
• Medication
Preparing for quit day
PLANNING FOR THE QUIT DATE.
On the day you stop smoking you need to be prepared to make changes in the way you think and act. It helps if you plan
ahead to prepare for the day.
To remove temptations:
Choose a quit date that is as stress-free as possible.
Do not keep any cigarettes near you; nor buy any.
Put away all reminders such as ashtrays, matches, lighters etc.
Get support from people around you:
Talk to a friend/relative about your plans and why stopping is important to you.
Talk to an ex-smoker. Find out how they stopped. If they can, you know you can too!
Team up with someone else who wants to stop – arrange mutual support.
Change the way you think about smoking:
‘Just one’ cigarette may undo all your hard work, don’t allow yourself to be tempted.
Remind yourself why YOU want to stop and the benefits YOU will gain from stopping.
Coping with urges to smoke:
Remember that the cravings always pass in a few minutes.
Sit down and take three long, slow, deep breaths.
Drink a glass of water very slowly.
Change your routine for the first smoke-free week:
Try out different routes to work, school, college etc.
Keep busy; begin a project, hobby or DIY project you’ve been putting off.
Go outside; for some air and if possible for a walk each day.
Etc etc
Health Behaviour Change
Competency Framework
MOTIVATION - ACTION - PROMPT
Preparing for the quit date = Action
Behaviour Change Techniques
• Providing information
• Positive reinforcement
• Setting goals – individual’s decision
• Action & Coping Planning
• Relapse Prevention
• Preparing for quit day
• Medication
Cessation Pharmacological Treatments
Nicotine Replacement Therapy
• Zyban (Bupropion)
• Champix (Varenicline)
Health Behaviour Change
Competency Framework
MOTIVATION - ACTION - PROMPT
Medication = Prompt/Action