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Individual approaches to behaviour change

Informing people of their risks for certain
diseases may lead to them engaging in long
term risk protective behaviour
• E.g. showing an overweight man in his 60’s- smoker with high cholesterol- a heart disease calculator which displays high risk of a heart attack
• Some people strive to change behaviour once aware of health risk, HOWEVER many will not, or the changes will not be sustained
• Being aware of risk may not be enough to foster behavioural change
• More targeted interventions have been developed to change behaviours- taking into account people’s differing levels of motivation



1. Motivational interviewing
2. Problem solving approaches & implementation planning
3. Modelling and behavioural practice


1. Motivational interviewing

Is a person-centred method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Miller & Rollnick 2002)
• The intervention generally considered most likely to be effective for people who are reluctant to engage in change
• Motivational interview (MI) is collaborative, non-confrontational, non-authoritative
• Key questions within the interview are:
• ‘What are some of the good things about your present behaviour?’
• ‘What are the not-so-good things about your present behaviour?’


The spirit of motivational interviewing: Collaboration

Collaboration: patient-practitioner
partnership; joint decision making.
Practitioner acknowledges patient’s expertise
about themselves

vs Authoritative Therapeutic Style:
Confrontation: practitioner assumes patient
has an impaired perspective and imposes the
need for ‘insight’. Practitioner tries to persuade
and coerce a patient to change


The spirit of motivational interviewing: Evocation

Evocation: practitioner activates patient’s own
motivation for change by evoking their reasons
for change- connects health behaviour change
to things patient cares about

vs Authoritative Therapeutic Style:
Education: patient is presumed to lack the
insight, knowledge or skills required to change.
Practitioner tells the patient what to do


The spirit of motivational interviewing: Honoring Patient Autonomy

Honouring patient autonomy: Whilst
informing the patient, practitioner
acknowledges the patient’s right and freedom
not to change. ‘It’s up to you’

vs Authoritative Therapeutic Style:
Authority: practitioner instructs the patient to
make changes


1. Motivational interviewing

• Key elements and strategies include:
• Expressing empathy by the use of reflective listening
• Supporting self-efficacy and optimism for change
• ‘Rolling with resistance’ rather than confronting or opposing it
• Developing an awareness of the discrepancies between the client’s current behaviours and their values/goals


1. Is motivational interviewing effective?

Goal of MI is to motivate people to consider change
• Most studies focus on whether it can alter behaviour
• Meta Analysis: Smedslund et al. (2011)
• MI in drug abuse setting more successful (substance use behaviour) than no intervention
• Limited differences with other active treatments
• Schneider, Casey, & Cohen (2000)
• Compared MI with confrontational interviewing in persuading substance users to enter treatment
• At 3 & 9 months- equal % of groups had completed their treatment program and had made similar gains in reduced drug use
• HOWEVER>> MI was more acceptable and less stressful for both counsellors and clients than confrontational approach


2. Problem focused counselling

• “Problem oriented”
• Focused specifically on the issues at hand and in the ‘here and now’, and has three distinct phases (Egan, 2006):
• Problem exploration and clarification: detailed exploration of problems individual is facing; breaking ‘global insolvable problems’
into carefully defined solvable elements
• Goal setting: Identifying how individual would like things to be different; setting clear, behaviourally defined, achievable goals
• Facilitating action: Developing plans and strategies through whichthese goals can be achieved

Role of counsellor NOT to act as expert solving person’s problems –
• Rather to mobilise the individual’s own resources to identify problems and arrive at solutions
• Important to deal with stages sequentially and thoroughly


2. Effectiveness of problem focused counselling

• Despite generally acknowledged effectiveness of problem focused counselling styles- surprisingly little examination of effectiveness
• Gomel et al. (1993) risk factors for heart disease study
• 3 groups: risk education; problem focused counselling; no intervention
• Problem solving intervention had greatest effect >> greater reductions in blood pressure, BMI, smoking than in education only or no intervention groups


2. Problem focused counselling- applied example

Many behaviour change programs have an element of problem identification and resolution
• Most smoking interventions use combination of nicotine replacement therapy and problem solving approaches
• Example: smoking cessation strategies eg. sit with non-smokers during coffee breaks


2. Implementing plans and intentions

Egan’s (2006) last stage of problem focused counselling may be key therapeutic element:
• Facilitating action: Developing plans and strategies through which these goals can be achieved
• Similarly, HAPA (Schwarzer & Renner, 2000) & implementation intentions (Gollwitzer & Schaal, 1998) identified planning as important determinant of behavioural change
• Approaches encourage individuals to plan how they will engage in their behaviour of choice
• Positive results in interventions for: Increased fruit intake (DeNooijer et al., 2006); Cervical screening (Sheeran & Orbell, 2000); Quitting smoking (Armitage, 2007); Weight loss (Luszczynska et al., 2007)


3. Modelling change

Problem focused and planning strategies can help- BUT achieving
change can still be difficult
• Particularly where individual lacks skills and confidence in their ability to cope with demands of change
• Potentially overcome by learning skills or appropriate attitudes from observation of others performing them- vicarious learning
• Optimal learning and increases in self efficacy can generally be achieved through observation of people similar to the learner succeeding in relevant tasks


Modelling Change Experiment

• Sanderson and Yopuk (2007)
• 220 University students assigned to receive either:
• 30 min condom promotion video (positive attitudes about condom
use, modelling appropriate strategies for negotiating their use; male
presenters version; female presenters version)
• Waitlist control
• Intervention (video) participants reported:
• stronger intentions to engage in protected sex
• higher self efficacy in refusing to have unprotected sex
• higher levels of condom use four months after seeing the videos
• Both male and female students benefited more in terms of
condom use behaviour from viewing the female presenters


3. Modelling & Behavioural practice

• Actual practice of a new behaviour
• Solutions to problems and skills needed to achieve change can be worked out and taught in an educational program
• >>Increasing skills and self efficacy
• E.g. Study by Kelly et al. (1994) reducing risky sexual behaviour
• Women at high risk of HIV infection attending an STI clinic
• Program included risk education, training in condom use, practicing sexual assertiveness skills such as negotiating condom use
• More effective than standard education based intervention in improving rates of condom use


CHANGE: Mass Media Campaigns

E.g. Print advertising, television advertising, radio, billboards, online
• Potential to reach hundreds of thousands/millions of people
• Exposure generally passive- resulting from incidental, routine use of media
• May be of short duration or may extend over long periods
• May be stand alone or linked to other organised program components (e.g. clinical outreach, new products/services, policy changes)
• Multiple methods of dissemination may be used in some initiatives


Potential benefits

“The great promise of mass media
campaigns lies in their ability to disseminate
well defined behaviourally focused messages
to large audiences repeatedly, over time, in
an incidental manner, and at a low cost per
(Wakefield et al., 2010)


MM Potential challenges

• Campaign messages can fall short (or even backfire)
• Exposure of target audience may be suboptimal
• Funding may be inadequate/ceased
• Inappropriate or poorly researched format may be used (e.g. age inappropriate content)
• Homogeneous messages might not be persuasive to heterogeneous audiences
• Campaigns might address behaviours that audiences lack the resources to change
Wakefield et al. (2010)


Are mass media campaigns successful?




Wakefield et al. (2010) review- Smoking

More studies done on effectiveness of smoking campaigns than any
other health related issue
• Controlled field experiments/population studies show mass media
campaigns associated with:
• Decline in young people starting smoking
• Increase in number of adults stopping smoking
• Although more effective when integrated with programs/policies (e.g.
tax, smoke-free policies, school programs)
• Hard to determine actual effectiveness because of lack of formal control groups


Wakefield et al. (2010) review- Alcohol use

Mass media campaigns to lessen alcohol intake have had little success
(other than drink driving campaigns)
• Most campaigns target young people-
• overshadowed by widespread unrestricted alcohol marketing strategies and
the view of drinking as a social norm
• Safe drinking campaigns sponsored by alcohol companies have been
ineffective in changing drinking behaviour
• messages are viewed as ambiguous by recipients


Wakefield et al. (2010) review- Conclusions & Recommendations

Likelihood of success increased by:
• application of multiple interventions
• Target behaviour being one off or episodic (e.g. screening, vaccination) rather than habitual or ongoing (e.g. healthy food choices, physical activity)
• Availability of / access to key services and products
• Creation of policies that support opportunities for change
• So, do mass media campaigns work?
• Isolation of independent effects is difficult
• “Whilst in isolation study findings are not strong, aggregate yield of the body of research shows support for the conclusion that mass media campaigns can
change health behaviours”


Evaluation of health behaviour change interventions

House of Lords Science and Technology Committee 2011 (UK)
• Report identified range of issues related to the way health behaviour change interventions are evaluated:
• Evaluation should be considered throughout the intervention design process
• Interventions should be evaluated against relevant outcome measures
• The evaluation should consider whether the intervention has resulted in long term
behaviour change
• Sufficient funds should be allocated for evaluation



1. Appropriate use of fear messages
2. Information framing
3. Specific targeting of interventions


Maximising the effectiveness of mass media campaigns

• Despite the (potentially) limited effect of single media campaigns--
remain an attractive and frequently used means of influence
• >> reach large numbers of people with relative ease
• There are a number of potential methods to maximise effectiveness
• Appropriate use of fear messages
• Information framing
• Specific targeting of interventions


Appropriate use of fear

Popular approach
• High levels of threat proven relatively ineffective in engendering behavioural change
• e.g. fear arousal campaign for HIV/AIDS
• >> increased HIV/AIDS anxiety but did not increase knowledge or trigger behavioural change


Appropriate use of fear
• Witte (1992) proposed threatened individuals can take two courses of action:

• Danger control: reducing the threat- actively focusing on solutions
• Fear control: reducing the perception of risk, often by avoiding thinking about the threat
• For danger control to be selected:
• person needs to consider that an effective response is available (response efficacy)
• they are capable of engaging in the response (self efficacy)
• >>> Otherwise fear control will become dominant coping strategy


Witte argued that the most persuasive messages are therefore those that:

• arouse fear
– e.g. unsafe sex increases your risk of getting HIV.
• increase the sense of severity if no change is made
– e.g. HIV is a serious condition.
• emphasise the ability of the individual to prevent the feared outcome (efficacy)
–e.g. here’s how you engage in safer sex practices.
• If the ability of the individual to prevent the feared outcome is not emphasised, any fear messages may actually inhibit behavioural change:
• Such messages may increase resistance to the message
• Lead to denial that it applies to the individual
• Increase engagement in the targeted risk behaviour
Despite these results, health messages frequently emphasise vulnerability and severity and neglect efficacy


Information framing

Health messages can be framed in either positive (stressing positive outcomes associated with action) or negative terms (emphasising negative outcomes associated with failure to act)
• Negative frames may be more memorable, but positive frames may enhance information processing
• Conflicting results of studies
• Some suggest positive framing is better (e.g. Detweiler et al., 1999 sunscreen study)
• Others suggest negative framing is preferable (e.g. Gerend & Shepherd, 2007 HPV vaccine study)
Cannot make a priori judgement about effect of +/- information framing, should aim to test intervention as a pilot before public launch


Targeting the audience

Mass media campaigns may ‘dilute’ the message
• It is more effective to target your audience
• Media campaigns can be targeted on several factors:
• behaviour
• age
• gender
• socio-economic status
• sexuality
• psychological factors such as their motivation to consider change
eg. little black dress ads


Environmental influences on healthy behaviour

• Behaviour and behaviour change do not occur in isolation from the environment in which they occur.
• The environment may contribute directly to risk for disease.
• It can also indirectly influence health by influencing the ease with which health promoting or health damaging behaviours can be conducted.
• An environment that encourages healthy behaviours should:
• provide cues to action – or remove cues to unhealthy behaviours
• enable health behaviours by minimising the costs and barriers associated with them
• increase the costs of engaging in health damaging behaviours


Success of cigarette interventions

Research into what is more effective on cigarette packets:
• Larger and clearer health warnings on cigarette packets more effective (Borland, 1997)
• Graphic imagery rather than text about risks may also be more effective (Thrasher et al., 2007)
• Coping information in addition to risk information (Kessels et al., 2010)

Australia’s introduction of plain packaging in 2012
• Tobacco consumption in 2014 lowest ever recorded in Australia (ABS data)
• Rates of smoking have fallen since 2012 (15.9% in 2010 to 13.3% in 2013) (AIHW data)
• Rates of attempts to quit have increased (20% per month to 27% per month)
• Wakefield et al.’s evaluation study (2015, BMJ) found that since introduction of plain packaging, more smokers:
• Dislike their packs
• Are less satisfied by smoking
• Notice the graphic health warnings
• Attribute motivation to quit to graphic health warnings