Behaviour Change Behaviour Change

Self-management is the active participation of individuals in their own health care. The self-management approach is effective with people who have coronary heart disease (CHD) and other chronic diseases.[#clark-m.-2008,#clark-nm-nothwehr-f.-1997,#clark-nm-rakowski-w-wheeler-jr-et-al.-1988,#coull-aj-taylor-vh-elton-r-et-al.-2004,#lewin-b-robertson-ih-cay-el-et-al.-1992]

Self-management support is integral in all health care interactions.   This approach places demands on both clinicians and patients to learn skills and apply strategies to support self-management.

The patient’s tasks are to: [#gruman-j-von-korff-m.-1996]

  • Engage in activities that protect and promote good health
  • Monitor and manage symptoms and signs of illness
  • Manage the impact of illness on functioning, emotions and interpersonal relationships
  • Adhere to treatment regimes
  • Actively collaborate with their treating clinician

The clinician’s tasks are to:

  • Adopt a patient-centred approach
  • Support behaviour change
  • Empower individuals to gain skills for self-management
  • Foster an environment that supports active collaboration to achieve shared goals

Key components of self-management programs are list below. [#fisher-eb-brownson-ca-otoole-ml-et-al.-2005] Consider how many of the following are integrated into clinical service delivery:

  • Individualised assessment
  • Collaborative goal setting
  • Skills enhancement
  • Follow up and support
  • Access to resources in daily life
  • Continuity of quality clinical care
  • Problem solving
  • Managing emotions
  • Self-monitoring
  • Behavioural support

Sustaining long-term behaviour changes is a challenge for people with cardiac disease. They need to not only understand the importance of lifestyle changes, but also build the confidence to make and sustain such changes.

Motivational interviewing assists people with a chronic disease to improve their lifestyle and self-management and to sustain lifestyle changes. [#clark-m-hampson-se.-2001,#scales-r-miller-jh.-2003,#scales-r-miller-j-burden-r.-2003] The interviewing approach is effective to empower individuals to strengthen motivation and movement towards change (see figure below) by exploring and resolving ambivalence. The task for the clinician is to increase importance and build confidence.

Figure 1: Motivation rationale

Motivation_rationale

Self-reflection task

When I am working with individuals:

  • How much time do I spend on the importance of lifestyle change?
  • How much time do I spend on building confidence that they can change?

It is important that both aspects of motivation (importance and confidence) are addressed to assist individuals with the task of lifestyle change. Motivational interviewing will give you these skills.

Principles of motivational interviewing which are diagrammatically represented below focus on: [#coull-aj-taylor-vh-elton-r-et-al.-2004]

  • Express empathy through respectful communication
  • Develop two minds (raising awareness of ambivalence)
  • Avoid any arguing
  • Don’t push; roll with resistance
  • Increase the individual’s confidence (self-efficacy)

Figure 2: Motivational interviewing relationship 

Motivational_interviewing

Adapted from Rollnick et al. 2008[#rollnick-s-miller-w-butler-c.-2008]

Behavioural goal setting can build a person’s confidence and ability to manage a chronic condition. Behavioural goal setting is a collaborative process of exploration and confidence building. To support self-management, the health professional needs to ensure that the client is an equal partner in the process of goal setting.

Key areas to consider include:

  • Enablers of behaviour change as these will support clients to achieve their goals
  • Clients’ beliefs about the need for change. These are influenced by:
    • Clients perceptions of their health condition – severity, consequences, chronicity, duration, cause, curability
    • Clients perceptions of their health behaviours – confidence to make changes, views of others, importance of change, costs and benefits of change
    • Beliefs about their illness and the need for change need to be explored in a non-judgemental manner
    • Identify areas that may impact  upon a  client’s confidence to reach a specified goal

Barriers to behaviour change

  • Clients’ stage of change or the clients’ readiness to change their health behaviour. It is pointless to set goals in an area where the client is unwilling or unready to make a change. This will only increase resistance to change and will impact on the relationship between client and health professional
  • Clients’ past experience attempts to make changes

Characteristics of goals that support self-management are shown in the table below:

Figure 3: BeSMART Goals

beSMART Goals
Be

Behavioural

This type of goal is focused on a change in behaviour relating to a specific activity pattern, e.g. smoking, physical activity, diet.
S

Specific

Some goals can be vague and difficult to measure.  It is important to set goals that are clear and precise.
M

Measurable

Making the goal specific means that it should be easy to measure progress, whether or not the client has achieved their goal.
A

Achievable

Set goals that are within the client’s reach.  Failing to achieve a goal can have a negative effect on their motivation to work towards their goal.
R

Realistic

Ensure the goal is realistic.  Take into account the amount of time, resources, and support required.
T

Timeframe

Set an end date to accomplish the goal.  Revise and update the goal when you reach the date.


Reproduced with permission from Higgins et al. 2010[#higgins-r-elliott-p-furber-g-et-al.-2010]

Goal setting should:

  • Be collaborative
  • Build self-efficacy
  • MOST IMPORTANTLY, avoid setting individuals up for failure

Check the importance of the goal – Ask the individual to rate the importance of achieving the goal, on a scale of 1 to 10. If the importance is below 7, either explore strategies to increase importance or consider selecting a different goal.

Check the level of confidence to achieve the goal – Ask the individual to rate their confidence in achieving the goal on a scale of 1 to 10. If the confidence is below 7, consider selecting a different goal with the client.

  • Ideally, change the goal rather than trying to change the person
  • Set the client person up for success rather than failure
  • Reward any progress toward the goal (providing attention is a reward in itself)
  • Be prepared to renegotiate the goal

Behaviour change support can be integrated into the following areas of group education sessions.

For tips on delivering the health education component of group education see Tips for delivery of education topics in a group.

Practical ways to increase participation

  • Advise participants not to attempt too many changes at once – as this can decrease confidence and lead to inaction and non-adherence
  • Create ‘menus of options’, i.e., a smorgasbord of ideas for action in each treatment and lifestyle area
  • Whiteboard the things that the participants think would be beneficial to work on and what they are already doing. A different set of tasks or actions may be relevant to each participant
  • Incorporate education about health behaviour change into education content. Highlight the principles of successful health behaviour change that participants can apply to their own lifestyle
  • Before leaving the end of the meeting, ask participants to write down the things they intend to do before the next session. Consider formally setting goals and creating action plans or perhaps simply have a group discussion about the types of things participants intend to do as a consequence of attending
  • At the next education session, discuss as a group or in pairs how participants went got on with their task lists and action plans
  • When providing patients with exercise plans, check that each person is willing to do the required exercises (importance) and believes they will be able to do them regularly (confidence)
  • Before the end of the program, discuss strategies to maintain the skills and behaviours learned throughout the program

Recruitment to groups (see columns 1 and 2 in the table below)

Sometimes, situational barriers prevent people from attending programs, such as prior commitments or lack of transport. However, often there are avoidable factors that result in a patient choosing not to attend because of low motivation. Common patterns of thinking, which become barriers, include:

  • Denial of a seriousness or cardiac disease – ‘My heart isn’t that bad; I don’t need to come’
  • Do not see how the program will benefit them –‘I wouldn’t enjoy talking to/exercising with a bunch of other patients’, ‘Turning up to that program won’t help me’
  • A negative expectation of the program – ‘They will make me do some really hard exercise’

Retention of participants (see column 3 in the table below)

If participants are not staying in the program, it could mean they do not perceive any benefits of attending, or that the program itself is not enjoyable. Clinicians can gain feedback about the participants’ experience to identify any factors affecting the drop off rate. It may be useful to contact participants who drop out of programs to find out why they have done so.

Evaluation and sustainability of outcomes (see column 4 in the table below)

Clinicians commonly find that participants do not continue to engage in the relevant behaviours or skills once the program has finished. This could reflect a lack of emphasis on supporting self-regulation and maintenance after completion of the program. Clinicians should ensure that participants have the skills to continue with what they have learned after the program. Some clinicians invite participants in the final session to create a ‘survival kit’ containing individualised tips for them to get back on track if their new lifestyle and treatment habits taper off at any stage.

Table 1: Questions to consider asking to help improve participant involvement

Engaging Referring Clinicians Recruitment of Participants Retention of Participants Evaluation & Sustainability of Outcomes
Who are your referral sources? What do you want to enrol in your program and are they registering? Are participants staying until the end of the program? Does the program have a component on maintaining skills?
What knowledge do they need to have about the program?  Are they ‘selling’ it to patients? What’s in it for them?  Do they understand the benefits? What is the percentage that completes the program? Are patients continuing with behaviour changes after the program?
How can you communicate the benefits of your program to referring clinicians and services so that they refer effectively? What is affecting the enrolment rate? What can be done about this? What is affecting the drop off rate?  What can be done about this? Are you collecting follow-up data on participant outcomes?  If so, what type (motivational, psychosocial, behavioural, physiological) and over what timeframe?
Have you asked referral sources why they have/haven’t referred patients to your program?  Are you providing feedback on patients that have enrolled/attended? Have you asked patients why they did/didn’t enrol in the program? Have you collected participant feedback on the program? What other resources can participants access to aid self-regulation after your program?

©2012 HCA. Reproduced with permission from Health Change Australia (from training materials)

Further information on behaviour change training in Australia is available from the following websites.

Flinders Program™

The Flinders Program™ provides a set of person-centred tools and steps for undertaking comprehensive care planning with people who have existing chronic conditions. The program provides health workers with a structured process for understanding and supporting their clients’ motivation for behaviour change, to enable clients to better self-management their health in collaboration with health workers and other support providers. Through the assessment process, areas where the person is managing well are identified, as well as areas for further support, and barriers to change which can then be addressed according to the person’s priorities and needs. Overall, the Flinders Program™ provides generic and holistic chronic condition management, case management, self-management support, systemic and organisational change, and Health professional change.

Health Change Australia

Health Change Australia (HCA) uses the HCA Model of Health Change, a clinical practice framework for integrating client-centred communication and behaviour change principles and processes into clinical consultations and programs. It provides practitioners with a health behaviour change clinical pathway using evidence-based principles and techniques to complement usual clinical pathways for prevention and treatment of health conditions. The purpose of the HCA approach is to increase the likelihood that clients will act in accordance with lifestyle and treatment recommendations appropriate to their health condition/s.

Heart Research Centre

The Heart Research Centre offers face-to-face and online training in supporting chronic disease self-management (CDSM) and in motivational interviewing.

The training covers:

  • Understanding CDSM
  • Effective communication
  • Behavioural goal setting
  • Motivational interviewing
  • Cognitive strategies to support self-management
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  • Clark NM, Rakowski W, Wheeler JR, et al. Development of self-management education for elderly heart patients. Gerontologist 1988;28:491-494.

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  • Coull AJ, Taylor VH, Elton R, et al. A randomised controlled trial of senior lay health mentoring in older people with ischaemic heart disease: The Braveheart Project. Age Ageing 2004;33:348-354.

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  • Lewin B, Robertson IH, Cay EL, et al. Effects of self-help post-myocardial-infarction rehabilitation on psychological adjustment and use of health services. Lancet 1992;339:1036-1040.

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  • Gruman J, Von Korff M. Indexed bibliography on self-management for people with chronic disease. Washington DC: Centre for Advancement in Health. 1996.

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  • Fisher EB, Brownson CA, O'Toole ML, et al. Ecological approaches to self-management: the case of diabetes. Am J Public Health 2005;95:1523-1535.

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  • Clark M, Hampson SE. Implementing a psychological intervention to improve lifestyle self-management in patients with type 2 diabetes. Patient Educ Couns 2001;42:247-256.

    clark-m-hampson-se.-2001
  • Scales R, Miller JH. Motivational techniques for improving compliance with an exercise program: skills for primary care clinicians. Curr Sports Med Rep 2003;2:166-172.

    scales-r-miller-jh.-2003
  • Scales R, Miller J, Burden R. Why wrestle when you can dance? Optimizing outcomes with motivational interviewing. J Am Pharm Assoc 2003;43(5 Suppl 1):S46-47.

    scales-r-miller-j-burden-r.-2003
  • Rollnick S, Miller W, Butler C. Motivational interviewing in health care: helping patients change behaviour. New York: Guilford Press. 2008.

    rollnick-s-miller-w-butler-c.-2008
  • Higgins R, Elliott P, Furber G et al. Online training program in supporting chronic disease self-management. 2010.

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