changing health behaviour · • a persons attitude to the behaviour • the perceived social...

CHANGING HEALTH BEHAVIOUR

Dr Sam Caton

ScHARR

s.caton@sheffield.ac.uk

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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