Behaviour change

Figure SKILLS offered an excellent overview of the core skills required for health care professionals to offer effective self-management support. Further information on behaviour change is offered in this section. Research evidence suggests that there are a number of important components of behaviour change that are successful and sustained. Much of the literature suggests that getting change is relatively easy but that there is regression back to the mean. Sustained behaviour change requires motivation and readiness for change. Prochaska and DiClemente have demonstrated with smoking that patients can be seen to be ‘pre-contemplators, contemplators; ready for action; in action mode and then in relapse prevention mode’.⁽¹⁾ These stages of motivation are important clinically even though the model has been criticised. Cognitive behaviour therapy has defined some of the ways in which behavioural change can be tackled in a specific problem-focused way and these include:

• Motivation enhancement by motivational interviewing (Miller), public announcement of the decision to change; gathering a support group which offers moral and practical support including measurement (so people don’t cheat) and receive reward for change achieved; contracting in writing; creation of cognitive dissonance 
• Measurement and acknowledgement of change 
• Monitoring objectively 
• Education and provision of information 
• Tackling the problem in a graded way 
• Provision of rewards for changes made and maintained 
• Provision of effective social support. People experience support when they receive communications from others that they are cared for and loved; esteemed and valued; that they belong to a network of mutual obligation.⁽²⁾ Weiss states that these are provided for people through support.⁽³⁾ Support is provided through five categories of relationships: intimacy, social integration, opportunities to exercise nurturing behaviour, reassurance of worth, practical assistance. 

 Models of health behaviour change

• Social Cognitive Theory – This theory was developed by Bandura, based on his theory of social learning. Individuals learn behaviour through observation.⁽⁴⁾ Self-efficacy is a significant predictor of behaviour change, based on an individual’s ability to perform, others’ belief that the individual has the ability to perform, others’ influence and social support and the physical feeling of well-being from successfully performing the task.

• Stages of Change Model – This model is also known as the Transtheoretical Model, developed by Prochaska et al (1992). Individuals will make behaviour changes based on the stage of change that the person is at. To be successful with behaviour change, health strategies need to be targeted at the correct stage of the model. The six stages of change are:
  
  

  pre-contemplation contemplation preparation action maintenance termination.

An individual will make a conscious effort to change behaviour. It is not something that occurs on its own. Individuals will vary between the stages based on their current situation.

• Health Belief Model – This model described by Rosenstock (1974) examines how an individual, who believes that they are at a high risk of acquiring a disease which will affect their physical and psychosocial health, will change behaviour for positive health gains. The individual will take into account the susceptibility of the problem, the perceived severity of the problem and the barriers and benefits to changing behaviours.

• Theory of Adult Learning – This theory, developed by Knowles, suggests that five main concepts should be included within an adult learning program: self-concept, experience, readiness to learn, orientation to learning and being motivated to learn.

• Health Locus of Control – This theory offers three components to the way that individuals behave. Internal locus of control is where the individual takes control of their behaviour, making their own decisions. External locus of control is where the individual searches for answers from outside. The influence of powerful others is where behaviour is influenced by situations such as economic or social.

• Theory of Reasoned Action – This theory was first explained by Azjen and Fishbein and is based around behaviour being predicted by two types of attitudes or beliefs. The first attitude is based around learned experiences and knowing that the behaviour selected will result in a positive outcome. The second is based on the beliefs of a group. If they believe in a certain outcome then the individual could be pressured into acting out that behaviour.

 Motivational interviewing

Motivational interviewing is a process that can be used to support behaviour change. It is a ‘client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence’.⁽⁶⁾ It has been shown to be particularly effective for patients with substance abuse but was also shown to be an effective method for people with psychotic illness.⁽⁷⁾ Motivational interviewing offers a flexible intervention that can be used by many health care professionals. It is highly suited to chronic conditions as it accommodates different levels of readiness and a range of consultation times.⁽⁸⁾ Further information can be found at http://motivationalinterview.org/.

  Collaborative problem definition

Problem definition is working in collaboration to identify the actual problems as defined by the patient. The patient will set goals based on his or her particular individual needs and lifestyle and not the targets that others perceive are the issues. One process for achieving this will be described in module 3, titled 'Problem and goal statement'.

   References

1. DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting & Clinical Psychology. 1991;59(2):295–304.
2. Cobb S. Social support as a moderator of life stress. Presidential Address-1976 Psychosomatic Medicine. 1976 Sep-Oct:38(5):300-14.
3. Weiss RS. The fund of sociability. Society 1969;6(9):36-43.
4. NSW Health. NSW Chronic Care Program Implementing Rehabilitation for Chronic Disease Volume 2, 2006.
5. Holloway A, Watson, HE. Role of self-efficacy and behaviour change. International Journal of Nursing Practice 2002;8(2):106–15.
6. Rollnick S, Miller WR. What is motivational interviewing? Behavioural and Cognitive Psychotherapy 1995;23:325–34.
7. Lawn S, Pols RG, Battersby MW. Myth exploded. Working effectively with patients with comorbid mental illness and substance abuse: a case study using a structured motivational behavioural approach. BMJ Case Reports 2009 [doi:10.1136/bcr.08.2008.0674].
8. From the website http://www.motivationalinterview.org/.