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Behaviour change: theories & techniques
Lucie Byrne-Davis Jo Hart
Hart & Byrne-Davis 2015
Objectives
At the end of this session you will:
• Understand more about behaviours related to health and why people find it hard to change • Understand the components of the COM-B framework • Have knowledge of some strategies that have been shown to be effective and ineffective to support behaviour change • Start to think about how a behavioural approach might influence your own individual practice.
Hart & Byrne-Davis 2015
Why behaviour change?
• Five ways to wellbeing: they involve ACTIONS i.e., behaviours
• Health threatening behaviours cause disease
• Health protective behaviours prevent disease
• Physical health and mental health are inextricably linked
Smoking causes 1 in 10 deaths worldwide
Smoking causes 1 in 10 deaths worldwide
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60-72% UK adults don’t meet exercise recommendations
2012 US Food and Health Survey found: • More people found it hard to work out how to eat healthily (52%) than found it hard to complete their taxes (48%) • Over ½ of US adults had tried or were trying to lose weight
Hart & Byrne-Davis 2015
“Let’s just tell everyone to change!”
• Why do people engage in health threatening behaviours?
• What psychological changes are needed?
• What techniques can health professionals use?
• How can we help health professionals use these techniques?
Hart & Byrne-Davis 2015
How behavioural science can help
• Why do people engage in health threatening behaviours?
• What psychological changes are needed?
• What techniques can health professionals use?
• How can we help health professionals use these techniques?
Hart & Byrne-Davis 2015
How behavioural science can help
Hart & Byrne-Davis 2015
Are people rational?
Why do people engage in health threatening behaviours?
So does that mean we have no control?
People are not rational in all behaviours – we know that some behaviours are conditioned and learned in other ways
No, we do make up our minds about what we are going to do but these intentions interact with our conditioned and learned behaviours (habits) to result in behaviour.
Models with rational decision making (social cognition models) explain around 50% of behavioural intention and less of actual behaviour
KEY POINT: There is a difference between intention and behaviour that can best be understood in a dual process model
PRIME theory (West, 2006): http://www.primetheory.com
Plans (intentions) Evaluations
(beliefs)
Motives Wants etc.
Impulses (urges)
Responses
Internal environment (percepts, drives, emotional states, arousal ideas, frame of mind)
External environment (stimuli, information)
Hart & Byrne-Davis 2015
PRIME theory of motivation: Dual processes
Hart & Byrne-Davis 2015
PRIME theory of motivation
“Three central ideas in the theory are: • It is wants and needs at each moment that drive our behaviour. • Our intentions and beliefs about what is good or bad only influence our actions if they create sufficiently strong wants and needs at the relevant moment. • Our image of ourselves and how we feel about that (our identity) is a potentially very strong source of wants and needs which can be enough to overcome ones arising from biological drives such as hunger.”
– From http://www.primetheory.com
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Hart & Byrne-Davis 2015
PRIME theory of motivation
Identity: a closer look “Identity is a potentially important source of motives, it is the ultimate source of self-regulation and it is a major source of stability of behaviour. Major elements of identity are Labels (e.g. non-smoker), Attributes (e.g. health-conscious) and Rules (e.g. I do not smoke). Implementing behaviour change in the face of conflicting wants, needs and urges can be effortful and use up mental resources but ‘deep’ identity change and rules with clear boundaries reduce conflict and effort required.”
– From http://www.primetheory.com
What behaviours have you encountered?
?
Natasha is 21 years old. She has been at university for over a year and when she started University for the first time she began buying and cooking her own food. She has put on 3 stone in this year.
She spends a lot of money on take away food and eating out with friends. She doesn’t eat much in the day time but drinks a lot of so-called ‘energy drinks’ and snacks from a campus vending machine.
Hart & Byrne-Davis 2015
Using PRIME theory to understand risky behaviour
What is the behaviour?
?
Plans: Has Natasha ever thought about eating differently? (previous intention) or does she plan to change her eating habits in the future (intention) and if so, when? (timeline)
Evaluations: What does she think about the healthy food guidelines (beliefs) and would following the guidelines be good or bad and why (evaluation of behaviour)
Motives: Does she want to follow the healthy eating guidelines? How much? What motivates her to eat healthily? How important is that motivation to Natasha?
Impulses: Are there times when Natasha has a strong impulse to eat healthily (positive impulse) What triggers (precedes) this impulse (trigger). How could Natasha use this impulse to help her eat healthily (harnessing impulse). Are there times when Natasha has a strong impulse NOT to eat healthily (negative impulse) What triggers (precedes) this impulse (trigger). How could Natasha avoid this impulse or change it to help her eat healthily (harnessing impulse).
Responses: How does she respond to the positive impulses and negative impulses?
Hart & Byrne-Davis 2015
Using PRIME theory to understand risky behaviour
• Why do people engage in health threatening behaviours?
• What psychological changes are needed?
• What techniques can health professionals use?
• How can we help health professionals use these techniques?
Hart & Byrne-Davis 2015
How behavioural science can help
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Plans: Implementation intentions, coping planning
Evaluations: beliefs and thoughts about the behaviour(s)
Motives: needs and wants
Impulses: Positive impulses, triggers, negative impulses, harnessing impulses
Responses: to the positive impulses and negative impulses?
Hart & Byrne-Davis 2015
What psychological changes are needed? What other things influence health
behaviour?
?
Susan Michie, Maartje M van Stralen and Robert West (2011) The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science 6: http://www.implementationscience.com/content/6/1/42
Educa-on Increasing knowledge or
understanding
Providing informa-on to promote healthy
ea-ng
Interven-on Defini-on Example
Persuasion Using communica-on to
induce posi-ve or nega-ve feelings or s-mulate ac-on
Using imagery to mo-vate increases in physical ac-vity
Incen-visa-on Crea-ng expecta-on of
reward
Using prize draws to induce aBempts to stop smoking
Coercion Crea-ng expecta-on of punishment or cost
Raising the financial cost to reduce excessive alcohol consump-on
Interven-on Defini-on Example
Training Impar-ng skills Advanced driver
training to increase safe driving
Restric-on
Using rules to reduce the opportunity to engage in the
target behaviour (or to increase the target behaviour by reducing the opportunity to engage in compe-ng
behaviours)
Prohibi-ng sales of solvents to people under 18 to reduce
use for intoxica-on
Environmental restructuring
Changing the physical or social context
Providing on-‐screen prompts for GPs to ask
about smoking behaviour
Interven-on Defini-on Example
Modelling Providing an example for people to aspire to
or imitate
Using TV drama scenes involving safe-‐sex prac-ces to increase
condom use
Enablement
Increasing means/reducing barriers to increase capability or
opportunity1
Behavioural support for smoking cessa-on, medica-on for
cogni-ve deficits, surgery to reduce
obesity, prostheses to promote physical ac-vity
1Capability beyond educa-on and training; opportunity beyond environmental restructuring
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Communica-on / marke-ng
Using print, electronic, telephonic or broadcast
media
Conduc-ng mass media campaigns
Policies Defini-on Example
Guidelines
Crea-ng documents that recommend or mandate
prac-ce. This includes all changes to service
provision
Producing and dissemina-ng
treatment protocols
Fiscal Using the tax system to reduce or increase the
financial cost
Increasing duty or increasing an--‐
smuggling ac-vi-es
Regula-on Establishing rules or
principles of behaviour or prac-ce
Establishing voluntary
agreements on adver-sing
Policies Defini-on Example
Legisla-on Making or changing laws Prohibi-ng sale or
use
Environmental/ social planning
Designing and/or controlling the physical or social
environment
Using town planning
Service provision
Delivering a service
Establishing support services in
workplaces, communi-es etc.
COM-B – The Centre of the BCW
• Individual’s psychological and physical capacity to engage in the activity concerned.
• It includes having the necessary knowledge and skills.
• Physical and psychological capability • Psychological capability being the capacity to
engage in the necessary thought processes - comprehension, reasoning et al.
Hart & Byrne-Davis 2015
Capability
• Factors that lie outside the individual that make the behaviour possible or prompt it.
• Physical and Social • Physical opportunity afforded by the environment • Social opportunity afforded by the cultural milieu
that dictates the way that we think about things e.g., the words and concepts that make up our language
Hart & Byrne-Davis 2015
Opportunity
• Brain processes that energize and direct behaviour, not just goals and conscious decision-making.
• Includes habitual processes, emotional responding, as well as analytical decision-making.
• Reflective and automatic • Reflective processes - involving evaluations and
plans • Automatic processes - involving emotions and
impulses that arise from associative learning and/or innate dispositions
Hart & Byrne-Davis 2015
Motivation
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What explanations are common?
? • Policies and interventions influence behaviour.
• However, behaviour is mediated through people and therefore through psychology.
• As health care professionals you typically intervene at the level of the psychology of the person
Hart & Byrne-Davis 2015
What influences behaviour
• Why do people engage in health threatening behaviours?
• What psychological changes are needed?
• What techniques can health professionals use?
• How can we help health professionals use these techniques?
Hart & Byrne-Davis 2015
How behavioural science can help
• Why do people engage in health threatening behaviours?
• What psychological changes are needed?
• What techniques can health professionals use?
• How can we help health professionals use these techniques?
Hart & Byrne-Davis 2015
How behavioural science can help
What techniques have you seen or used?
? Where do they fit on the wheel?
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Health professionals say it is common and an important part of being a health care professional
BUT they report feeling untrained in this
Opportunities to discuss lifestyle
change with patients are often missed
It can be a frustrating experience
This stops illnesses being prevented or
properly managed
Hart & Byrne-Davis 2015
Discussing lifestyle with patients What obstacles might occur for the health
professionals?
?
What doesn’t work?
? Fear influences human behaviour so it seems plausible that ‘fear inducing’ messages would encourage behaviour change
We might expect that telling someone ‘smoking kills’ would result in cessation (health professionals often try this)
BUT we know this doesn’t work…Why?
People tend to try to reduce the sensation of fear and this doesn’t always mean removing the true risk
Thus someone may disengage with fear-inducing conversations about smoking risks or may not attend cessation clinics to reduce the fear they feel, rather than stopping smoking
Hart & Byrne-Davis 2015
Why scare tactics don’t work
A patient may be experiencing internal conflict as an argument they are having with themselves. If we take the side of change, the patient is likely to respond with the other side of the argument (i.e. ‘yes but…’) to redress the balance. People can easily end up talking themselves into not changing or digging their heels in against change.
If you continue being so inactive, your weight is going to keep going up and your risk of a heart attack is really quite high. I know you would feel much better in yourself if you did more
and were fitter.
But I’m far too busy to waste time going to the gyms or running in circles round the park. I don’t think exercise has anything to do with my weight anyway. We’ve always been
big in my family.
Taking the side of change
Defending the status quo
Hart & Byrne-Davis 2015
What to avoid – ‘Taking the side of change’
• Why do people engage in health threatening behaviours?
• What psychological changes are needed?
• What techniques can health professionals use?
• How can we help health professionals use these techniques?
Hart & Byrne-Davis 2015
How behavioural science can help
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• Why do people engage in health threatening behaviours?
• What psychological changes are needed?
• What techniques can health professionals use?
• How can we help health professionals use these techniques?
Hart & Byrne-Davis 2015
How behavioural science can help
Hart & Byrne-Davis 2015
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Hart & Byrne-Davis 2015
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Objectives
At the end of this session you will be able to:
• Understand more about behaviours related to health and why people find it hard to change • Understand the components of the COM-B framework • Have knowledge of some strategies that have been shown to be effective and ineffective to support behaviour change • Start to think about how a behavioural approach might influence your own individual practice.
Hart & Byrne-Davis 2015
Thank you
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Hart J, Peters S. (2011) Healing talk: Health psychology’s contribution to clinical communication. Psychologist. Chisholm A, Hart J, Lam V, Peters S. (2012) Current challenges of behaviour change talk for medical professionals and trainees. Patient Education & Counseling. 87, 389-394. Chisholm A, Hart J, Mann K, Peters S. (2013) Development of a behaviour change communication tool for medical students: The 'Tent Pegs' booklet. Patient Education and Counseling. Chisholm A, Peters S, Mann K, Hart J. (2015). Investigating the feasibility and acceptability of health psychology informed obesity training for medical students. Psychology, Health & Medicine (in press) Keyworth C, Peters S, Chisholm A, Hart J. (2013) Nursing students’ perceptions of obesity and behaviour change: implications for undergraduate nurse education. Nurse Education Today. 33(5) 481-485. Hart J, Yelland S, Mallinson A, Peters S. (2015). When is it ok to tell patients they are overweight? General public’s views of the role of doctors in weight management Journal of Health Psychology, in press Peters S, Bird L, Ashraf H, Ahmed S, McNamee P, Ng C, Hart J. (2013) Medical undergraduates’ use of behaviour change talk: the example of facilitating weight management. BMC Medical education 16(7) Chisholm A, Hart J, Mann K, Harkness E, Peters S. (2012) Preparing medical students to facilitate lifestyle changes with obese patients: a systematic review of the literature. Academic Medicine. 87(7)1-12. Fillingham A, Chisholm A, Hart J, Peters S. (2013) Early training in tackling patient obesity: a systematic review of nurse education. Nurse Education Today. Chisholm A, Peters S, Mann K, Hart J. (2013) Are medical educators following General Medical Council guidelines on obesity education: if not why not? BMC Medical Education 13(53). Michie, S., et al. (2011). A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: The CALO-RE taxonomy. Psychology & Health 26, 1-20. Dixon, D., & Johnston, M. (2010). Health behaviour change competency framework: Competences to deliver interventions to change lifestyle behaviours that affect health. Retrieved from http://www.healthscotland.com/documents/4877.aspx Susan Michie, Maartje M van Stralen and Robert West (2011) The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science 6: http://www.implementationscience.com/content/6/1/42 Hart & Byrne-Davis 2015
Reference list
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