Facilitating Health Behaviour Change

Helping individuals to help themselves

Dympna Pearson RDBehaviour Change Trainer & Registered Dietitian

Key Points

• Environment

• Individuals

• Influencing health behaviour

The Environment

‘The environment in which somebody lives clearly has a major influence on health. Public health interventions are designed to make healthy choices easier and are likely to have maximum impact if fully implemented’

NICE 2007

Individuals

What influences change?

‘If you are told what to do, there is a good chance that you will do the opposite!’

(Miller & Rollnick 2002)

For example:Well intentioned, advice-

giving‘Why don’t you…….’

• Use a smaller plate• Take one bite at a time• Chew slowly• Use stairs instead of the

lift

Advice Giving

Research has demonstrated that this approach can render the client a passive recipient to expert knowledge and combined with persuasion can reduce client autonomy and generate resistance.

Providing Information

Has a place but….evidence clearly shows that giving knowledge alone does not necessarily lead to a change in behaviour

Glanz 1985, Contento 1995, Roe 1997, Thorogood 2001

Healthcare Professionals

Many HCPs express frustration with:

Non-compliant patientsPatients who are less than truthfulPatients who are not motivatedPatients who expect a magic wandThose who won’t take responsibilityLack of time, the system…

People change if they come to believe it is both of value and achievableEnhancing motivation and encouraging change is a complex task that demands skilful consultingPractitioners need to consider their style in consultations about behaviour change

What works?

Rollnick et al. BMJ 2005

Why a Behavioural Approach?

There is overwhelming evidence that changing people’s health-related behaviour can have a major impact on some of the largest causes of mortality and morbidity.

NICE (2007)

What is a behavioural approach?

The main principles of this approach include the modification of current behaviour patterns, new adaptive learning, problem solving and a collaborative relationship between client and therapist

(HDA 2003)

Changing Habits

“Bad habits are like a comfortable bed, easy to get into, but hard to get out of”

Anon

A Behavioural Approach

A behavioural approach is based on the patient- centred method

A patient-centred approach

1. Explores the disease and the experience

2. Understands the whole person3. Finds common ground4. Incorporates prevention and health

promotion5. Enhances the patient-practitioner

relationship6. Is realistic

(Stewart el 1995)

A Behavioural Model

Strategies

Skills

Theory & Principles

Client Expectations

To be heard and understood

The opportunity to tell their story

To gain information

To feel able to cope (Gable 2007)

Failure to meet expectations leads to

frustration

Empathy

“The ability to empathise is key. Those with empathy have the ability to put themselves in others shoes, to see things from others perspectives and to gauge the likely impact of their behaviour.”

“Empathy is not just nice to have – it’s a crucial and sophisticated skill. Without it we diminish our ability to influence; we create needless conflict and resistance”

Empathy

Key Skills

Active Listening SkillsActive Listening Skills Greeting/opening the interviewGreeting/opening the interview Non-verbal communicationNon-verbal communication Reflection (min. encouragers, Reflection (min. encouragers,

paraphrasing, reflecting feelings, paraphrasing, reflecting feelings, summarising)summarising)

Ending the interviewEnding the interview

The Evidence

The single most important factor The single most important factor for an effective helping for an effective helping relationship is the practitioners relationship is the practitioners possession of strong interpersonal possession of strong interpersonal skillsskills

(Najavitis and Weiss (Najavitis and Weiss 19941994))

Evidence

There is good evidence that a client centred approach:

• Improves clinical outcomes• Increases client satisfaction• Improves compliance• Reduces patients concerns

(Moira Stewart 1995)

The Evidence

‘Good Communication is Good Evidence-Based Medicine’

Stewart (1995)

‘The therapists style can and does influence motivation and change’

Miller & Rollnick (2002)

But I have no time….

The use of good listening skills can be very effective – even in a short space of time.

Motivation

• Motivation is not something you can do to people

• It has to come from within• It is not an ‘all or nothing’ state• It is influenced by the helping style of

the health practitioner

(Miller & Rollnick (2002)

Motivational Interviewing

A patient-centred, directive method for enhancing intrinsic motivation to

change.

Miller & Rollnick (2002)

Motivating Change

The goal of motivational The goal of motivational interviewing is that the patient, not interviewing is that the patient, not the practitioner, expresses the practitioner, expresses concerns about the current concerns about the current behaviour and presents arguments behaviour and presents arguments for change.for change.

(Miller & Rollnick 2002)(Miller & Rollnick 2002)

Enhancing Motivation

Increasing Talk About Change

Listen/reflect, listen/reflect, listen/reflect…..

(Miller & Rollnick 2002)

Enhancing Motivation

Reducing Resistance to Change

Listen/reflect, listen/reflect, listen/reflect…..

(Miller & Rollnick 2002)

Specific Motivational Strategies

• Exchanging information• Explore current behaviours• Explore Ambivalence

• Explore motivation/readiness

(Miller & Rollnick 2002)

Assessing Readiness to Change

Ready or Not?

Scaling Questions?

Exploring Motivation/Readiness

• Importance– Reasons

• Confidence– Obstacles

Behavioural strategies

• Problem solving• Self-monitoring• Goal setting (Plan: what, how, when)• Social support• Self-rewards (reinforcement)

• Cognitive restructuring (CBT)(Foreyt J & Paschali 2001)

Summary

Working in a behavioural way is not just about using a set of techniques

It is relies heavily on the use of good interpersonal skills and a strong collaborative relationship between the patient & the practitioner

At the very least, we should be sure that we are doing no harm with our well intentioned interventions