PSK409-Health Psychology

Transcription

1 PSK409-Health Psychology An Introduction to Health Psychology Val Morrison and Paul Bennett Chapter 6 Changing behaviour: Mechanisms and Approaches Assoc. Prof. Okan Cem Çırakoğlu okanc@baskent.edu.tr

2 Learning Outcomes By the end of this chapter, you should have an understanding of: the process of working with communities to determine the targets of public health programmes strategies used to increase motivation to change strategies used to change behaviour when and how best to use these interventions

3 Developing Public Health Interventions The best known framework to develop public health interventions is known as the PRECEDE-PROCEED model (Green and Kreuter 2005). The PRECEDE element identifies a range of psychosocial variables that could be the target of any intervention: Predisposing factors: e.g. knowledge, attitudes, beliefs, personal preferences and self-efficacy in relation to desired behaviour change Enabling factors: environmental factors such as the availability and accessibility of resources or services (e.g. exercise facilities, cookery classes) to facilitate behavioural change Reinforcing factors: factors that reward or reinforce desired behaviour change, e.g. social support, economic rewards, and social norms

4 The PRECEDE Model (Green and Kreuter 2005) The PRECEDE model also takes into account any political, social, and environmental influences that may facilitate behaviour change: Phase 1: social diagnosis Planners gain an understanding of the health problems that affect community QoL; involve local people in focus groups etc. Phase 2: epidemiological, behaviour, and environmental diagnosis Identifying and assessing health issue(s) specific to the community, and their related behavioural and environmental influences; involves analysis of social and physical environmental factors that could be linked to target behaviours. Phase 3: educational and ecological diagnosis Prioritising and determining factors identified in phase 2, and identifying predisposing factors, enabling factors and reinforcing factors of relevance. Considers the likelihood and potential impact of any behavioural change. Phase 4: administrative and policy diagnosis Ensures the programme is consistent with organisation policies and addresses aim. Phase 5: programme implementation

5 The PRECEDE Model (Green and Kreuter 2005) The PROCEED phase is just that: the implementation of the planned intervention with three elements of evaluation: Process: did the programme do what was intended? Impact: what impact did the intervention have on the target behaviours/outcomes? Outcome: what long-term effects on health were achieved.

6 Strategies for Changing Risk Behaviour But how do we increase motivation, change beliefs and attitudes, encourage people to work towards desired goals, and so on? Consider the psychological state of the target individuals. One helpful model for this is the stages of change model of change. This identified a series of five stages through which an individual may pass when considering change: Pre-contemplation: not considering change; Contemplation: considering change but without thought about its exact nature or how it can be achieved; Preparation: planning how to achieve change; Change: actively engaged in change; Maintenance or Relapse: maintaining change (for longer than 6 months) or relapsing.

7 Motivating Change: Information Provision NICE guidelines (2014) on behaviour change identified ways of presenting information to increase motivation to quit smoking. Key messages should influence: Outcome expectancies: Smoking causes people to die on average 8 years earlier than the average. Personal relevance: If you were to stop smoking, you could add 6 years to your life, and be fitter over that time. Positive attitude: Life is good and worth living. Self-efficacy: You have managed to quit before. Descriptive norms: Around 30% of people your age have successfully given up smoking. Subjective norms: Your wife and kids will appreciate it. Personal and moral norms: Smoking is anti-social and you do not want your kids to start smoking.

8 Motivating Change: The Elaboration Likelihood Approach Only those with a pre-existing interest in the issue are likely to attend to mass media campaigns and, perhaps, act on it. Individuals are more likely to centrally process messages if they are motivated to receive an argument when it is congruent with their pre-existing beliefs; it has personal relevance to them; recipients have the intellectual capacity to understand the message. However, peripheral processing can occur when individuals: are not motivated to receive an argument; have low issue involvement; hold incongruent beliefs.

9 Motivating Change: The Use of Fear Popular approach (Biener et al. 2000) yet relatively ineffective in engendering behavioural change; e.g. UK and Australian government early attempts of a fear arousal campaign for HIV/AIDS. Rogers (1983) argued that the most persuasive messages are those that: arouse fear unsafe sex increases your risk of getting HIV ; increase the sense of severity if no change is made HIV is a serious condition ; emphasise the ability of the individual to prevent the feared outcome (efficacy) here s how you engage in safer sex practices.

10 Motivating Change: Information Framing Health messages can be framed positively (stressing positive outcomes associated with action) or negatively (emphasis on negative outcomes with failure to act). Health Behaviour Positive Framing Negative Framing Smoking cessation gain of being more able to exercise, looking and smelling better not dying of cancer or other lung diseases Use of sunscreen maintain a healthy skin reduce the risk of skin cancer Note: Inconsistent evidence of both positive and negative framing being effective, and the optimal approach will depend on the behaviour and target population.

11 Motivating Change: Motivational Interviewing Generally considered most likely to be effective for people who are reluctant to engage in change Motivational interview (MI) is deliberately non-confrontational the key questions within the interview are as follows: What are some of the good things about your present behaviour? What are the not-so-good things about your present behaviour? Additional strategies, which make it a more explicit process of persuasion include: consideration of the disadvantages of the status quo; consideration of the advantages of change; evoking the intention to change; evoking optimism about change.

12 Problem Solving Approaches Problem-focused counselling approach was developed by Egan (2013). It focuses on the issues at hand and in the here and now, and has three distinct phases: Problem exploration and clarification: detailed and thorough exploration of problems; Goal setting: identifying how the individual would like things to be different; Facilitating action: developing plans and strategies through which these goals can be achieved. However, its effectiveness in primary health promotion has been studied less than expected

13 Problem Solving: Smoking Cessation Smoking is driven by two processes: A conditioned response to a variety of cues within the environment picking up the telephone, having a cup of coffee and so on the socalled habit cigarette. A physiological need for nicotine to top up levels of nicotine and prevent the onset of withdrawal symptoms. When an individual stops smoking, they may have to deal with the loss of a powerful means of altering mood and level of attention; withdrawal symptoms as a consequence of a biological dependence on nicotine; the urge to smoke, triggered by environmental cues.

14 Problem Solving: Smoking Cessation Some strategies that smokers may use to help them cope in the period immediately following cessation

15 Implementing Plans and Intentions According to Gollwitzer (1999), we often fail to translate goal intentions into goal attainment. This may occur by: Failing to start: e.g. forgetting to start, not seizing the opportunity to act, or having second thoughts at the critical moment. Becoming derailed from goal striving: e.g. derailed by enticing stimuli, difficult to suppress habitual behavioural responses, or adversely affected by negative mood by implementing change. To overcome this, implementation intentions may be utilised. These involve an if-then approach for example: Sheeran and Orbell (2000) to increase cervical screening uptake If it is [time and place], then I will [make an appointment, e.g., by phone]!

16 Implementing Plans and Intentions Here are some typical implementation intentions, linked to potential problems they are trying to combat: Failing to get started: If it is 8 am on Friday, I will ride my bike to work. Missing opportunities: As soon as I hear from the doctor, I will book my health check up. Initial reluctance: If it is Saturday 10 am, I will prepare five healthy meals to eat during the week. Unwanted attention to distractors: If I start to think about snacking, I will focus on alternative things to do. Stopping old habits: If I see the stairs, I will tell myself how good I will feel if I walk up the stairs and do it.

17 Modelling Change Problem-focused interventions can help individuals to develop strategies of change. Bandura (2001): social cognitive theory both skills and self-efficacy can be increased through a number of simple procedures, including: observation of others performing relevant tasks; practice of tasks in a graded programme of skills development; active persuasion. Bandura identified three basic models of observational learning: a live model, which involves an actual individual demonstrating or acting out a behaviour; a verbal instructional model, which involves descriptions and explanations of a behaviour; a symbolic model, which involves real or fictional characters displaying behaviours in books, films, television programs or online media.

18 Cognitive Interventions The central principle of cognitive therapy is that our thoughts are central to the regulation of behaviour. They influence our feelings, motivations and actions. The role of cognitive therapy is to teach the individual to treat their beliefs as hypotheses and not facts, to try out alternative ways of looking at the situation and to have different responses to it based on these new ways of thinking.

19 Cognitive Interventions Within therapy, the therapist may engage the person in what Beck (1976) termed a Socratic dialogue or guided discovery, in this case, about drinking: Therapist: You feel quite strongly that you need to be relaxed by alcohol when you go to a party. What is your concern about being sober? John: I wouldn't enjoy myself and I wouldn't be much fun to be with. Therapist: What would be the implications of that? John: Well, people wouldn t talk to me. Therapist: And what would be the consequence of that? John: I need to have people like me. My job depends on it. If I can't entertain people at a party, then I'm no good at my job... Therapist: So, what happens if that is the case? John: Well, I guess I lose my job! Therapist: So, you lose your job because you didn't get drunk at a party? John: Well, put like that, perhaps I was exaggerating things in my head...

20 Cognitive Interventions Homework to directly challenge inappropriate cognitive beliefs: For example if a person believes that they cannot go to a party without drinking, they may be setting the homework task of trying to do so. Such challenges should be realistic. Failure may maintain or even strengthen the pre-existing beliefs. Should be mutually agreed to by both the individual concerned and the therapist. Success in these tasks can bring about long-term cognitive and behavioural changes.

21 Changing the Environment The Health Belief Model (Becker et al. 1977) provides a simple guide to key environmental factors that can be influenced in order to encourage behaviour change. In particular, an environment that encourages healthy behaviours should: provide cues to action or remove cues to unhealthy behaviours; minimise the costs and barriers associated with healthy behaviour; increase the costs of engaging in health damaging behaviours. A number of projects, under the Healthy Cities movement (World Health Organisation 1988) have attempted to design city environments to promote the mental and physical health of their inhabitants.

22 Spreading the Word Rogers (1983) proposed the diffusion of innovations by segmenting the population in terms of their responsiveness and social influence: Innovators: small group, high status; seek out and test new ideas from a wide range of sources and bring innovations to early adopters. Early adopters: larger group, wider influence than innovators; described as opinion leaders and role models for the wider population. Early majority: adopts ideas reasonably early, but does not have the power to influence the wider population. Late majority: cautious group who adopt the innovation only after the early majority have tested it. Laggards: this group of people are the last to adopt, or may never adopt, an innovation.

23 Spreading the Word Rogers also noted a number of characteristics of any innovation that may influence its likely uptake by each group: Its advantage over other behaviours: the bigger the advantage the more likely it is to be adopted. Its compatibility with the values and norms of the target social system: If the innovation is too radical it will be rejected. Ease of uptake: if the innovation is easy to adopt, it is more likely to be adopted than if it is difficult to understand or engage in. Evidence of effectiveness: the more any effectiveness can be seen, the more likely it is to be adopted.

24 Getting It Right (Michie et al., 2012) Information provision should include information about: Consequences of the behaviour in general Consequence of behaviour to the individual Others approval of behavioural change Normative information about others behaviour

25 Getting It Right (Michie et al., 2012) Problem-focused approaches include: Goal setting Action planning Barrier planning/problem solving Set graded tasks Prompt review of behavioural goals Prompt review of outcome goals Prompt rewards contingent on effort or progress towards beh. Prompt rewards contingent on successful behaviour