CHANGING HEALTH BEHAVIOUR · • A persons attitude to the behaviour • The perceived social...
Transcript of CHANGING HEALTH BEHAVIOUR · • A persons attitude to the behaviour • The perceived social...
Learning objectives
1. Identify different types of heath behaviour
2. Identify the importance of understanding
health behaviours
3. Define ‘unrealistic optimism’ as it relates to
health behaviour
4. Identify factors to consider in promoting
behaviour change
What are health behaviours?
Behaviours related to health
• There are 3 main categories:
Health Behaviour
Illness Behaviour
Sick role Behaviour
What are health behaviours?
• Health Behaviour: a behaviour aimed to
prevent disease (e.g. eating healthily)
• Illness Behaviour: a behaviour aimed to
seek remedy (e.g. going to the doctor)
• Sick role Behaviour: any activity aimed
at getting well (e.g. taking prescribed
medications; resting)
Health Behaviours
Health Damaging/Impairing
e.g. smoking , alcohol & substance abuse, risky sexual behaviour,
sun exposure, driving without a seatbelt
Health Promoting
e.g. Taking exercise, healthy eating , attending health checks,
medication compliance, vaccinations
Why do you need to know about health behaviours?
Economics:
• Estimates suggest overall alcohol-related harm
costs the NHS in England £3.5bn/ year (Public Health
England 2012-13)
• Estimates of the direct and indirect costs to the
NHS of treating overweight and obesity range
between £2.6bn and £15.8bn/ year (National audit
office 2001, Butland et al. 2007)
www.bis.gov.uk/assets/bispartners/foresight/docs/obesity/17.pdf
http://www.bbc.co.uk/news/health-29253071
www.bbc.org.uk/news
www.NHS.co.uk
Disease prevention
Sufficient sleep duration contributes to lower cardiovascular disease risk in addition to
four traditional lifestyle factors: the MORGEN study
• Prospective cohort study including 8128 men and 9759
women aged 20–65 years, free of CVD at baseline
• Follow-up for 10 – 14y
• Sufficient sleep and adherence to all four traditional
healthy lifestyle factors was associated with lower CVD
risk.
Hoevenaar-Blom et al. 2013, Eur J Prev Cardiol
Leading causes of death - England & Wales, 2013
http://www.ons.gov.uk/ons/rel/vsob1/death-reg-sum-tables/2013/info-deaths-2013.html
Combined impact of lifestyle factors on mortality
• Relative risk of mortality over 24 yrs in relation
to five lifestyle factors
• Smoking
• Being overweight
• Taking little physical activity
• Excess alcohol
• Poor diet
• Each lifestyle factor independently and
significantly predicted mortality.Van Dam R et al., Combined impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ 2008; 337 doi:
10.1136/bmj.a1440 (Published 16 September 2008)
Why is this important?
• Important from both an individual and population
perspective
• Overwhelming evidence that changing people’s health
behaviour can have an impact on some of the largest
causes of mortality and morbidity
• Interventions to change behaviour may offer a relatively
simple solution to reducing disease
• A genetic predisposition to disease is difficult to alter
• Socio-economic circumstances associated with disease are
difficult to change
• Interventions to treat/manage disease are often very expensive,
with significant side effects
• By comparison, people’s behaviour – as individuals and
collectively – may be easier to change.
NICE Guidelines: Behaviour change at population, community and individual level. NICE 2007
Health behaviour & Medicine
Health impairing behaviours & mortality
are related
Morbidity also an issue - Diabetes, CHD,
mental health issues
Quality of life, working days lost to
sickness
What is the solution?...
Health behaviour & Medicine
Intervention - Population level
Health promotion
The process of enabling people to exert control over
the determinants of health, thereby improving health
(Health Promotion Agency)
Intervention – Individual level
Patient centred approach
Care responsive to individual needs
Health Promotion
• Health promotion campaigns
• ‘Everyone enjoys a drink, no one enjoys a
drunk.’
• Change 4 Life Campaign
• Stoptober, Movember
• Promoting screening and immunisations
• Cervical smear screening
• MMR vaccinehttp://www.nhs.uk/change4life/Pages/brand-assets.aspx?filter=BrandGuidelines
http://uk.movember.com/
https://stoptober.smokefree.nhs.uk/registration-c
Effects of intervention are rarely restricted to one level
E.g. a brief primary care intervention aimed at reducing
alcohol consumption among individuals could have an
impact:
• Individual's behaviour (level of alcohol consumption,
individual health outcomes, or incidence of domestic
violence)
• Local community (local alcohol sales, alcohol-related crime
or accident and emergency [A&E] events)
• Population level (for example, national alcohol sales and
consumption, national statistics on alcohol-related crime
and A&E events, or demographic patterns of liver cirrhosis)
Why do we
engage in
damaging
health
behaviours?
Or to put it another way – why
take risks with your health?
news.bbc.co.uk/1/hi/health/4443497.stm
Unrealistic OptimismIndividuals continue to practice health damaging behaviour
due to inaccurate perceptions of risk and susceptibility
(Weinstein, 1983)
Perceptions of risk influenced by:
1. Lack of personal experience with problem
2. Belief that preventable by personal action
3. Belief that if not happened by now, its not likely to
4. Belief that problem infrequent
Other reasons
• Health beliefs
• Situational rationality
• Culture variability
• Socioeconomic factors
• Stress
• Age
• Etc…
As health professionals, should we:
1. Focus on the social determinants of health and
not try to change individuals’ behaviour?
2. Respect individuals’ autonomy and simply
inform them of their risks?
3. Intervene in people’s lives by trying to persuade
them to change their behaviour –whether they
want to or not?
If we want to help people change their health behaviour we need
• An overview of the theories and
models of behaviour change
• An understanding of what works in
practice
Some models and theories of behaviour change
1. Health belief model (HBM)
2. Theory of Planned Behaviour
3. Stages of change (transtheoretical) model
4. Motivational interviewing (MI)
5. Social marketing
6. Nudging (choice architecture)
7. Financial incentives
8. Social norms theory
Health Belief Model(Becker 1974)
Individuals will change if they:
• Believe they are susceptible to the condition in
question (e.g. heart disease)
• Believe that it has serious consequences
• Believe that taking action reduces susceptibility
• Believe that the benefits of taking action
outweigh the costs
Theory of planned behaviour (Ajzen, 1988)
• Proposes the best predictor of behaviour is
‘intention’ e.g. I intend to give up smoking
• Intention determined by:
• A persons attitude to the behaviour
• The perceived social pressure to undertake the
behaviour, or subjective norms
• A persons appraisal of their ability to perform
the behaviour, or their perceived behavioural
control
Ajzen, I (1988) The theory of planned behaviour, Organisational Behaviour and Human Decision Processes,
50:179-211
Theory of planned behaviour
Attitudes
Perceived
behavioural
control
IntentionsSubjective
normBehaviour
Perceived
behavioural
control
IntentionsSubjective
normBehaviour
Attitudes
Theory of planned behaviour
• Attitude – I do not think
smoking is a good thing
• Subjective Norm – most
people who are important to
me want me to give up
smoking
• Perceived Behavioural
Control – I believe I have the
ability to give up smoking
• Behavioural Intention – I
intend to give up smoking
Stage Models of health behaviour
• Stage theories see individuals located at discrete
ordered stages, rather than on a continuum.
• Each stage denotes a greater inclination to change
outcome, typically behaviour, than the previous one.
• Transtheoretical model, or Stages of change model
(Prochaska & DiClemente, 1984)
• Proposes 5 stages of change: precontemplation,
contemplation, preparation, action, maintenance
Not ready
yet
Thinking about it
Getting ready
Doing itSticking with it
Pre-contemplation (Not ready yet)
Contemplation (Thinking about it)
Preparation (Getting ready)
30 days
Action (Doing it)
3 – 6months
Maintenance (Sticking with
it)
> 6 months
Progress
Relapse
Transtheoretical model
Transtheoretical Model
• Precontemplation – no intention of giving up
smoking
• Contemplation – beginning to consider giving up,
probably at some ill-defined time in the future
• Preparation – getting ready to quit in the near
future
• Action – engaged in giving up smoking now
• Maintenance – steady non-smoker,
i.e. state of change reached
Other factors to consider
• Over recent years - growing interest in the development
of interventions to change health behaviour. However
mixed patterns of results reported.
• Single unifying theory yet to be developed
• Other factors to consider:
• Impact of personality traits on health behaviour
• Assessment of risk perception
• Impact of past behaviour/habit
• Automatic influences on health behaviour
• Predictors of maintenance of health behaviours
• Social norms
So what can you do?
Being a doctor helps!
Public’s trust in sources of health information (max score 4)
• GP 3.51
• Radio documentary 2.43
• TV documentary 2.39
• Magazine article 1.8
• TV advert 1.72
• Newspaper advert 1.69
• Friend/neighbour 1.68(692 adults, Budd & McCron in Tones and Tilford 2001)
NICE guidance on behaviour change
1. Planning interventions
2. Assessing the social context
3. Education and training
4. Individual-level interventions
5. Community-level interventions
6. Population-level interventions
7. Evaluating effectiveness
8. Assessing cost-effectiveness
Individual-level interventions
Health professionals should help people to:
• Understand the short, medium and longer-term
consequences of their health-related behaviours, for
themselves and others
• Feel positive about the benefits of health-enhancing
behaviours and changing their behaviour
• Plan their changes in terms of easy steps over time
• Recognise how their social contexts and relationships may
affect their behaviour
In summary, as doctors helping individuals to change their health behaviours.... (NICE 2007)
• Work with your patient’s priorities
• Aim for easy changes over time
• Set and record goals
• Plan explicit coping strategies
• Review progress regularly (this really matters)
• Remember the public health impact of lots of you
making small differences to individuals
To conclude...
• Addressing health behaviour is an important
aspect of medical care
• Attending to modifiable risk factors can improve
health
• Interventions at a population / local level affect
individuals and vice versa
• Numerous theories and models of behaviour
change exist, however, a single unifying theory
needs to be developed
Recommended reading
• Ogden J. (2007) Health Psychology: A Textbook, 4th Ed. Open
University Press. Berkshire, UK.
• Marks, D.F., Murray, M., Evans, B., Willig, C., Woodall, C. & Sykes,
C.M. (2005). Health psychology: Theory, research and practice (2nd
Edition). London: SAGE.
• NICE 2007. Behaviour change at population, community and
individual level. NICE, London.
• PH006 Quick Reference guide available as pdf.
http://www.gserve.nice.org.uk/nicemedia/live/11868/37925/37925.pd
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