Introduction. A New Approach to Stimulate Positive Behavioural Change CURRENT BURDEN OF ORAL DISEASE. Goals and Objectives

Transcription

1 A New Approach to Stimulate Positive Behavioural Change Joanna Asadoorian RDH, PhD September 24 th, 2016 Goals and Objectives By the end of the session, you will be able to 1. Describe client need for oral health behaviour change 2. Express a basic understanding of human behaviour 3. Outline key steps in behaviour change techniques 4. Apply health behaviour counseling techniques to stimulate behavioural change in clients Introduction CURRENT BURDEN OF ORAL DISEASE 1

2 Current State of Disease % North American population has gingivitis periodontitis affects more than 90% of sub-populations Most individuals do not perform adequate plaque control Eke et al. J Dent Res 91(10)2012 Rode et al. BrazOral Res 26(S)2012 Oliver, RC et al. J Periodont 69(2)1998 Research increasingly implicates gingival/periodontal disease with systemic disease and conditions Linden, G. & Herzberg J. Periodontol, 84(4S)2013 Challenges Achieving Optimal Oral Hygiene Homecare primarily consists of mechanical methods Haas et al, Braz J Periodontol 22:40-46, 2012 Periodontal disease mostly initiated and severe interproximally 39% mean plaque reduction post tooth brushing Weijden et al, J Clin Periodontol 25: , 1998 Van der After brushing and flossing, 65-75% of oral surfaces remain colonized by pathogenic microorganisms Collins and Dawes, J Dent Res 66: , 1987 Challenges Achieving Optimal Oral Hygiene Limitations of mechanical methods: Lack of motivation Lack of dexterity Lack of time Teles and Teles, Braz Oral Res 23:S39-S48, 2009 Lack of effectiveness 2

3 The Nature of the Oral Biofilm Biofilm bacteria distinct from planktonic form X more resistant to antimicrobial agents Biofilm bacteria communicate and cooperate with each other -> regulate community ~ quorum sensing Creates pathogenic synergism Pan et al, J Dent 38:S16-S20, 2010; Marsh, J Dent 38: S11-S15, 2010 Microflora at diseased sites is different Effective Approaches to Control Oral Biofilm Mechanical hygiene fundamental to prevent plaque accumulation/gingival inflammation, optimal control not achieved by most individuals Rode et al, Braz Oral Res 26: , 2012 Adjunctive use of chemotherapeutic agents essential for disruption of oral biofilm Boyle et al., Oral Disease Jan:20 Suppl 1:1-68, 2014 Rode et al, Braz Oral Res 26: , 2012 Translating Research to Practice Knowledge Translation Knowledge generation Knowledge dissemination Knowledge acquisition Deliberation & decision making Appropriate knowledge application/ (in)action 3

4 Human Health Behaviour and the brain Human Behaviour Behaviour: Anything a person does in response to internal or external events. Michie & Johnston, 2012 A response controlled by the brain Several key theories viewing intention as the variable most proximal to behaviour 2 phases: Motivational: develop an intention Volitional: transformation of intention into behaviour Geidl, W., Semrau, J., & Pfeifer, K., 2014; McDermott et al; 2016 Human Behaviour & the Brain Brain: Main organ of CNS kg ( lb) ~ about 2% of total body weight Brain cells present at birth and last a lifetime High metabolic rate ± 100 billion cells forming complex interconnected networks 4

5 The Brain and Habit Formation Basal ganglia, especially striatum, modulates motor behaviour and activity related to learning Dopaminergic pathways provide input via striatal receptors Striatum is a learning machine dedicated to achieving success from behaviours; hub for neuroplasticity Graybiel & Grafton, 2015 What is Human Behaviour? Behavioural Psychology ~ 5 Main Perspectives: Biological: inherited, evolutionary; defines behaviour in neurological terms Psychodynamic (Freud): behaviour is unconscious and stems from childhood Behaviourism: behaviour is learned based on experience; controlled from environmental stimuli; no free will Classical (Pavlov): neutral stimuli becomes conditioned Operant (Skinner): modify behavior through the use of positive and negative reinforcement Humanism (Rogers, Maslow): behaviour is based on inner feelings and selfimage; free will; ability for self-actualization Cognitive: concerned with mental functions: memory, perception, attention, etc.; human brain is a processor Health Behaviour Counselling Techniques to Stimulate Positive Change 5

6 A New Approach to Changing Behaviour Old Approach Using a prescriptive approach Power structures with clients Being judgmental Using coercion Relying on education and compliance Motivational Approach Generated intrinsically Independent Sustainable Neutral power structures with clients Motivating vs. inspiring Based on self-efficacy Behaviour Change System 3 Necessary Factors for Behaviour: Capability: psychological and physical ability to engage Motivation: brain processes that energize and direct behaviour Opportunity: factors outside of the client favouring or prompting the behaviour Michie, S., 2011 Facilitating Behaviour Change Healthy behaviours are abnormal! Unhealthy behaviour: Easier More pleasant More short term benefits Where client desire to be healthier exists our aim is to help client access inner motivation and transcend pleasure associated with unhealthy behaviours 6

7 Behaviour Change Interventions Defined as: coordinated sets of activities designed to change specified behaviour patterns. Michie, S., 2011 Designed to best promote adoption and use Aim to bring about change by operating on behaviour change system Define a specific behaviour as end-point to the intervention goals are the outcome or desired end state of the behaviour Only beginning to be theoretically based; Behaviour Change Techniques (BCT) Active ingredients of behaviour change interventions Observable and replicable components of behaviour change interventions; smallest component mechanism Can be grouped together into an intervention Number of BCT does not predict overall efficacy but having a theoretical underpinning improves outcomes Behaviour Change Technique Studies SR with studies on healthy eating and exercise, the BCTs most commonly used were: action planning (n = 18); goal setting (behaviour) (n = 17); prompt self monitoring of behaviour (n = 15); and barrier identification/problem solving (n = 15) (McDermott 2016) Showed a medium to large effect on intention Showed a small to medium effect on behaviour No evidence the overall number of BCTs in each intervention moderated the impact of interventions on intentions or behaviour 7

8 Dual-Processing Theory of Cognition Explains the different levels of information processing in individuals 2 pathways: System 1: slow, deliberate, and voluntary; conscious and aware; working memory is used; information is explicit and more detailed System 2: very fast, automatic, involuntary, unconscious process Behaviour: Learning Skills and Habits Skill: Changes in physical repertoire; new combinations of movements lead to new capacities for goal-directed action i.e. capacity to tie shoe laces properly Habit: consistent behaviors triggered by appropriate stimuli occurring within particular contexts i.e. tying shoes after putting them on Both leverage reward-based learning Graybiel, A.M., & Grafton, S.T. Habit Formation: Making Behaviour Automatic Habit defined: behaviour is prompted automatically by cues as a result of learned associations Gardiner, 2014 Make up major part of behavioral and cognitive lives Requires motivation to prompt behaviour repetition > repetition with associated cues strengthens habit Forms through repetition of behaviour in stable context Mental Context Association Behavioural control gives way to external cues 8

9 Habit Formation: Developing Automaticity Intentional action requires conscious effort and thought; habitual responses occur automatically when relevant cue encountered ~ automaticity is defining characteristic of habits Automaticity depends on behaviour complexity Simpler behaviours easier to habitualize When cue is associated with specific behaviour, alternate response less available Habits self-sustained beyond honey-moon period of change; resistant to motivation lapses Optimizing Habit Formation Behaviour targets should be SMART Not doing a behaviour believed to be less conducive to habit formation Single versus multiple behaviour targets at a time Behaviour targets should have specified frequency Types of target behaviours: Adding a desired behaviour Substituting an undesired behaviour with a desired behaviour Stopping an undesired behaviour (not ideal) The Brain and Habit Formation Striatum learns by evaluative circuits gradually selecting most ideal behaviour minimize cost, optimize reward Brain circuitry is affected Circuits favour habit formation: as activity declines in associative striatum, increases in sensorimotor striatum: Ventral striatum, medial dorsal striatum: goal motivated learning Lateral dorsal striatum: habit learning Graybiel & Grafton,

10 The Brain and Habit Formation Dopaminergic input Striatum Dorsal Ventral Putamen (lateral dorsal striatum) Caudate (medial dorsal striatum) Optimizing Habit Formation As habits become engrained, activity at the beginning and end (Brackets) of behaviour becomes more prominent The opposite pattern occurs with goal directed learning Bracketing: behaviour becomes patterns of behavioural sequences autonomous except being triggered by start cue Dependent on feedback about how successful a behavioural sequence has been in gaining the desired outcome Interstriatal neural networks undergo profound reorganization Beginning and ends of activity are built and changed together Chunking : set of behaviours reliably combined and expressed as a habit; framed by the neuronal bracketing activity in the striatum and observed in striatal activity Graybiel & Grafton, 2015 Optimizing Habit Formation Context behaviour associations for habit formation requires careful planning: specific action in the presence of relevant cue within existing routines Need to examine current routines and where new behaviour will fit Can involve motor behaviours or cognitive habits of thought Types of Cues: Time-based Place-based Activity-based/situation specific Visual-based 10

11 Integrating New Habits into Existing Routines Event Segmentation Theory (EST) Certain points within existing routines offer ideal opportunities for the initiation of new behaviours Use of implementation intentions: When I encounter situation X, I will do Y Example: When I finish flossing, I will rinse Behaviour is arranged in a hierarchy Complex behaviour is broken down into simpler sequences of more and less detail Facilitating Client Behaviour Change: A 3-Step Process Change Relationship Shared decision making Motivational interviewing Change talk Get to Behaviour Readiness assessment Explore beliefs about readiness Change Behaviour Set smart goals Behaviour modification Sustain Behaviour Adapted from: Vallis, M. Behaviour Change Councelling: How do I know if I m doing it well? Can J Diabetes, 2013,37:18-26; Vallis, M. Surrendering to Succeed: Accepting the Challenges, Presentation to UM Psychology Society, Winnipeg MB, 2013 Facilitating Client Behaviour Change Step 1: Change-based Relationship Developing a relationship based on client empowerment Problem sharing and ownership Shared-Decision Making Motivational Interviewing (MI) relationship builder for changing behaviour asking permission using open-ended questions express empathy normalizing Change talk reflective listening detecting discrepancies rolling with resistance Ramseier and Suvan, Wiley-Blackwell, 2010; Vallis, University of Manitoba,

12 Motivational Interviewing (MI) Dental setting provides a privileged situation for discussing client health behaviour change MI is a communication style and techniques designed to empower clients and foster collaboration Skilled communication is key to creating an environment supporting change conversations key to giving professional advice and supporting behaviour change MI is directed at finding discrepancies between a value and behaviours and exploring ambivalence MI recognizes ambivalence as a normal part of the change process and one s autonomy in making choices Facilitating Client Behaviour Change The most important thing about MI is accepting ambivalence: An uncertainty caused by the simultaneous desire to do two opposite or conflicting things The coexistence of positive and negative feelings toward the same object or action, simultaneously drawing him or her in opposite directions Facilitating Client Behaviour Change Step 2: Getting to the Behaviour Assessing client readiness to change Small % ready to change 1. Is having an unclean mouth/teeth a problem for you? 2. Is having an unclean mouth/teeth causing you distress? 3. Are you interested in more thoroughly cleaning your mouth/teeth? 4. Are you ready to do something to more thoroughly clean your mouth/teeth now? From: Vallis M. Behaviour Change Councelling: How do I know if I'm doing it well? Canadian Journal of Diabetes. 2013;37:

13 Step 2: Getting to the Behaviour Assessing Readiness From: Vallis M. Behaviour Change Councelling: How do I know if I'm doing it well? Canadian Journal of Diabetes. 2013;37: Getting to the Behaviour Yes, but. means? Ambivalence is normal; examine it closely Explore values and goals Gaps between goals and behaviours Explore beliefs and readiness to make the change Costs to doing behaviour, consequences of not doing behaviour Benefits to doing behaviour, benefits to not doing behaviour Patient feels dissonance between desire and current behaviours => fuels motivation Compelled to commit to change Facilitating Client Behaviour Change Step 3: Changing (and sustaining) the Behaviour Behaviour Modification: Client goal setting (SMART) Small and achievable steps Realistically aligned with behaviour change From: Vallis M. Behaviour Change Councelling: How do I know if I'm doing it well? Canadian Journal of Diabetes. 2013;37:

14 Facilitating Client Behaviour Change Step 3: Changing (and sustaining) the Behaviour Make a plan: Determine how the behaviour will fit into existing routines; optimize habit formation Anticipate obstacles and have a plan; lapses are a part of habit formation Reinforce behaviour and self-efficacy, manage emotions, provide ongoing education and support From: Vallis M. Behaviour Change Councelling: How do I know if I'm doing it well? Canadian Journal of Diabetes. 2013;37: Summary: 3-steps to change! Relationship PARTNERSHIP DH: create relationship > rapport, empathy, client empowerment and engagement Client: recognizes role in their own health care; takes responsibility for own health Outcome: client and DH work together to improve health Motivation DH: Assess readiness to change; explore client ambivalence and values; bring about internal motivation Client: feels discomfort of dissonance > fuels motivation to change Outcome: client is compelled to change Change CAPACITY DH: Facilitates client goals and plan for change; supports self efficacy (when, where, how) and what if plans; optimizes habit formation Client: develops capacity for change; self-efficacy Outcome: change made; cues developed and habits being formed Summary: The Dental Hygienist s Role Apply evidence based practice approach to making client recommendations Have an understanding of key elements of behaviour change and habit theory Apply psychological theory based approach in client counseling for the adoption of new healthy behaviours Develop a change based relationship, get to the behaviour, modify the behaviour Understand and implement habit formation strategies with clients; make plans for habit development 14

15 How d we do? Presentation Goals and Objectives By the end of the session, you will be able to 1. Describe client need for oral health behaviour change 2. Express a basic understanding of human behaviour 3. Outline key steps in behaviour change techniques 4. Apply health behaviour counseling techniques to stimulate behavioural change in clients 15