Behaviour Change Behaviour Change

An individual’s behaviour (Eg., smoking, physical inactivity, poor diet) can considerably influence their health outcomes.  Changing these behaviours can significantly impact upon the individual’s mortality and morbidity. Behaviour change describes the various approaches that clinicians can use to influence an individual’s health-related behaviour and evoke sustainable change. See Supporting Behaviour Change for a summary of suggested tips for assisting individuals to make meaningful change.

The barriers to patients decreasing their cardiac risk may be categorised into four groups, using the acronym BEST:[#gale-j.-2012]

  1. Behaviours — Ingrained habits, lifestyle behaviours and lack of planning
  2. Emotions — Moods and our emotional reactions to situations, e.g., getting angry or depressed about a diagnosis, or anxious about not achieving our planned goals
  3. Situations — Finances, medical conditions, cognitive and physical abilities, social supports, work and childcare commitments, access to services
  4. Thinking — Beliefs, attitudes, expectations, habitual thinking patterns, motivation and knowledge

Clinicians should explore all four categories to help patients identify barriers to adhering to clinical advice. This helps uncover subtle factors that might otherwise undermine attempts to change.

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

Motivational interviewing (MI) is a means of assisting people with a chronic disease to improve their lifestyle and self-management and to sustain the changes that they make. [#fisher-eb-brownson-ca-otoole-ml-et-al.-2005,#clark-m-hampson-se.-2001,#scales-r-miller-jh.-2003] Using a collaborative and respectful approach, the individual is assisted to explore their personal values and motivators of change.  They are then empowered to strengthen their motivation and move towards change by exploring and resolving ambivalence. Motivational interviewing now has a strong evidence base for assisting people to change a variety of health behaviours such as smoking, exercise, diet and drinking. 

Self-reflection task
 

Are you finding some patients are reluctant to change their behaviour? How much time you spend discussing with the patient how important change is to them?
 

How much time do you spend building confidence that they can change?

Key to motivational interviewing is creating a relationship with the patient as demonstrated in the figure below. The motivational interviewing spirit focuses on: [#coull-aj-taylor-vh-elton-r-et-al.-2004,#miller-wr-rollnick-s]

  • Expressing empathy through respectful communication
  • Developing two minds (raising awareness of ambivalence)
  • Avoiding any arguing (ask, not tell)
  • Not pushing; rolling with resistance
  • Increasing the individual’s confidence (self-efficacy)

Figure 1: Motivational interviewing relationship 

Motivational_interviewing

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

Change talk

Through motivational interviewing, clinicians are able to assist individuals to identify their goals and values and how these factors may influence their lifestyle choices. This process is achieved by helping patients to verbalise personal arguments or motivators for change that are specific for them. Key components of this “change talk” are listed in the table below. Clinicians should listen out for these in order to structure the interview effectively. 

Table 1: Listening for change talk

Desire for change

Relates to things the individual would like to change.

Eg. “ I would really like to exercise more”
Ability to change

Relates to how the individual might act on the plan to change and strategies that might be used. The clinician may evoke the individual’s thoughts and ideas to help formulate an action plan.

Eg “ I think if I could find somewhere flat to walk, I would exercise more often”
Reasons for change

Relates to the individual’s reasons and motivation for changing.

Eg “ I think if I exercised more I might find it easier to lose weight”
Need for change

Relates to why the change is important or why it matters? This often reflects the individual’s personal values.

Eg “ I need to improve my health so I can have more energy to play with my kids. Maybe then I would be a better father”
Commitment to change

Relates to how strong the commitment to change is. Commitment language often predicts the likelihood of action.

Eg “ This is really important to me. I am going to start this afternoon by driving to the park down the road and walking for 15 minutes”

Core skills that clinicians should integrate into consultations for effective motivational interviewing include the following:

  • Ask open questions
  • Use affirmations
  • Use reflections
  • Summarise

The table below provides examples of how clinicians may use the core skills listed above to evoke “change talk” during the interview.

Table 2: Motivational interviewing core clinician skills

Clinical skills Change talk Example questions or comments
Ask open questions Desire “What would you like to change about your diet?”
  Ability “If you did decide to change your diet, how would you go about it?”
  Reason “What are your 3 biggest reasons for making this change?”
 

Need

Scaling questions helps to determine importance and confidence

“On a scale of 1-100, how important is it for you to make this change?” “What makes it important to you?”

“What makes you give yourself a “(insert number given as answer above)” and not 0?”
  Commitment “What will you do next about changing your diet?”
 

Goals and values

These questions enable discrepancies to be identified

“What is important to you as a parent/ teacher/ daughter?”

“How does your current diet fit in with that?”
Affirmations

Affirmations can be aligned with goals and values to assist the patient to argue for change

“It sounds like you know a lot about the benefits of eating a healthy diet?”

“Last Saturday when you had no alcoholic drinks for the day, that was you being a responsible father.”
Reflections Reflections involve restating things that the patient may have just said and can be simple or complex.  Complex reflections usually involve the clinician offering a suggestion of how the patient may feel as in the example given. In this way the clinician expresses empathy and assists the individual to continue talking.

Patient: “I’m really worried about exercising because I might have another heart attack.”

Clinician: “It must be frightening when you remember back to how you felt when you had your heart attack”

Patient: “Yes, it makes me want to avoid exercising, even though I know it is probably good for me.”

Clinician: “By going to the shopping centre last week, that was you starting to do more activity in a very safe way.”

 

 

Giving advice

Giving advice is important for clinicians but it can also be challenging. Despite good intentions, clinicians often instruct patients about what to do, thus creating a hierarchical relationship.  This approach unfortunately often evokes resistance. Giving advice in a manner that works collaboratively with the patient and is therefore less likely to evoke resistance, is often more successful. One example of this is an “ask tell ask” approach such as listed below.

  • Ask what the patient knows already – “What do you know about smoking and heart disease?”
  • Ask permission – “Is it OK if I tell you a few things about what I know (about smoking and heart disease)?”
  • After giving advice, check in by asking“how does that information (about smoking) sit with you?”

Summary

Underpinning motivational interviewing, is that the patient, rather than the clinician needs to make the argument for change. The clinician’s role, in the context of a safe therapeutic relationship is to help the patient to navigate between their own arguments for change and arguments against change.  Using careful listening skills the clinician validates and accepts the patient’s arguments against change (sustain talk) and then gently guides them towards considering their arguments towards change (change talk), thereby helping them to elaborate and build this case for change.

Next time you are with a patient, consider these 3 simple tips:

 

Tips for successful motivational interviewing
 

  1. Try to do more listening than speaking. Try speaking for  <50% of the total talk time of the interview.
     
  2. Try to use more reflections than questions. Avoid the interview feeling like an interrogation for the patient by using twice as many reflections or every question.
     
  3. Try to ask mainly open questions. A few closed questions are OK  but aim for open questions being >70% of all questions

 

For further information about motivational interviewing, refer to: www.MIoceania.org or Motivational interviewing.org

A limited supply of Motivational Interviewing kits (including practical CDs) is available from the National Heart Foundation of Australia.

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:

Table 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
  • Gale J. A practical guide to health behaviour change using the HCA approach. Sydney, Australia: Health Change Australia. 2012.

    gale-j.-2012
  • 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.

    coull-aj-taylor-vh-elton-r-et-al.-2004
  • Miller WR, Rollnick S. Motivational interviewing: Helping people change. Third edition. New York Guilford Press. 2013.

    miller-wr-rollnick-s
  • 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.

    fisher-eb-brownson-ca-otoole-ml-et-al.-2005
  • 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
  • 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.

    higgins-r-elliott-p-furber-g-et-al.-2010