Self empowerment

Module 4.3

Promoting Behaviour Change
For individuals and populations

Produced by The Alfred Workforce Development Team
on behalf of DHS Public Health Diabetes Prevention and Management Initiative
June 2005

Presentation purpose
Target audience


Service providers and project workers on DPMI projects

Aim


To explore the concepts of behaviour change and self management

Objectives






Provide an overview of behaviour change and self management
Explore best practice models of behaviour change
Discuss the key concepts of self management and empowerment
Explore self management models and evidence
Discuss and workshop problem solving and goal setting
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

Communicating risk
 Factors

influencing thinking on risk

People underestimate risk related to chronic
disease overestimate communicable disease
 Trust


 Who



is telling me are they trustworthy?

Risk less acceptable if:
 Imposed
 Distributed

unevenly
 Resulting from man made
 Hidden/irreversible

Behavior change cycle
Trigger
Action &
maintenance

Awareness raising

Assessment
Goal
setting/action
plans
Promote self
efficacy

Precontemplation

contemplation
Preparation

Promote benefits
Identify obstacles


Self efficacy
• Self efficacy strong predictor of behavior change
• Self efficacy is your belief in your ability to
perform a task

Promoting self efficacy







Promote performance accomplishment
Use verbal persuasion
Role modelling
Identifying feelings and helping work through
strategies to deal with feelings
Meaningful to the individual

Developing resources to support
behavior change


Thinking of quitting smoking?

Identifying feelings


Here are all the facts that show quitting is the right choice.

Verbal persuasion


Make this site work for you. Bookmark the pages that really mean
something to you.

Meaningful to the individual


For more help, call the Quitline 131 848.



Like all good things, it's going to take some time and effort for you
to quit smoking, but thousands of smokers in Australia have already
stopped. You can too.

Identifying feelings & verbal persuasion

Tailoring information to
stages of change
 Deciding


to Quit

Getting Ready to Quit

 Quitting
 Staying

Pre-contemplation
Contemplation
Preparation

a Non-smoker
 Coping with Setbacks
 Helping Others Quit

Action &
maintenance


Contemplation: Deciding to Quit
Here is how to get started with your quitting.
You

need to know

Smoking

Kills

Cigarettes
Smoking
Some
Quit

are full of poisons

causes disease

benefits of quitting

and save a packet

More

good reasons to quit

Deciding

to quit checklist

The

internet & stopping smoking - research project

Quit

Pack Order Form

How

DPMI
much do you spend on smoking? Workforce Development – The Alfred Workforce Development Team June 2005

Deciding to quit checklist









I’ll reduce my risk of heart attack.
I’ll reduce my risk of getting cancer.
I’ll feel fitter and my skin will look younger.
Within twelve hours, my body will be free of nicotine.
I’ll set a great example for the children around me.
My lungs will start to recover and be able to clean
themselves properly.
I’ll have more money to spend any way I choose.
I’ll give myself a confidence boost by quitting
cigarettes

Verbal persuasion, raise awareness

Contemplation: Deciding to Quit
Try this
List all your reasons for quitting, and then number the three reasons
you think are important.

Meaningful to the individual & promote benefits
Try this
From the following list, tick the things that you want to do when you
are a non-smoker. Add your own ideas in the space provided.
 Having more energy to play sport or keep up with the kids.
 Knowing I'm back in control and no longer addicted.
 I'll be free from the hassle of always checking that I have enough
cigarettes.
 Reducing the risk of getting sick from cancer or heart disease.

Identifying feelings, promoting performance &
promote benefits

Preparation: Getting ready to Quit
Smokers who plan before they quit are more successful
than those who don't, and planning can be done quickly


Understand your nicotine addiction



The Quit Book



Know why you smoke



Smoking Record



Plan ways to deal with quitting



Quit course



Set a date to quit



Some words about weight gain



DPMI
Getting ready to quit checklist Workforce Development – The Alfred Workforce Development Team June 2005

Set a date to quit
Unless there is a very good reason, make the date within
two weeks from now.
Choose an easy date to stop, one when you will not be
under much pressure, but will have plenty to occupy
yourself.
Practice Quitting
 Once you have picked a date to quit, stick to it.
 Before you quit, you might try a practice smokefree day
to see how you would go.
 Or you could experiment by not smoking at times when
you normally would;
 This will help you to work out how much you need to
prepare for these situations when you quit completely.
Goal setting/action planning

Action: Quitting
Now's the time to put all your
work into practice and quit.
 You are ready


Understand withdrawal symptoms



Coping with cravings



Excuses for not quitting –
myths and reality



Quitting checklist

Action: Quitting
You are ready
 You've made your decision to quit.
 You have any extra information or support you feel you need.
 You've done your planning.
 You've set your quit date.
 Stick to your decision. You're doing the right thing.
Choose an approach that will work for you
 You could go cold turkey. For many people, this is a successful
method.
 You could cut down by reducing gradually
 If you choose to cut down make sure your quit date is set for two
weeks after you start reducing your smoking.
 On your quit date, cut out cigarettes altogether.

Quitting checklist




I will choose whether to stop suddenly or gradually.
Withdrawal symptoms are a good sign
I can confront cravings by remembering the 4Ds:











Delay
Deep breathe
Drink water
Do something else.

I will congratulate myself every time I resist the urge for a
cigarette.
Reminding myself of my reasons to quit will make it easier to
refuse cigarettes.
I have the right to refuse a cigarette and can do so without
upsetting others
I can keep my hands busy
Even if I decide to have alcohol, I’ll stick to my decision to quit.

Maintenance:Staying a Non-smoker
The worst is over. You'll feel the urge to smoke less and
less, and soon you'll hardly think about cigarettes.
But the urge to smoke can return when you least expect
it.
You can stay stopped, but you need to be prepared.
There is always something better than a cigarette.
 The new you


Find new ways to relax & other things to do



Staying a non-smoker checklist

Maintenance:Coping with setbacks
Quitting can be hard.
You might be going along OK, and suddenly you feel like
smoking again.
Sometimes, as you gain confidence, you actually start to
think quitting is easy, so why not smoke again? Your
resolve starts to weaken.
 Try this


If you have a cigarette



If you go back to regular smoking

Method
R
esearch &
Development

F
ocus Group

Individual Interviews

Content /Script Dev’t
Concept
Development

Concept T
esting

P
roduct M
odification

Product T
esting
Product
Development

P
roduct M
odification
F
inal P
roduct
Promotional Strategy – The Alfred Workforce Development Team June 2005
DPMI Workforce Development

Consumers have had a say !


Empowerment and self management
principles
 HPs




provide

Expertise
Information
Psychological support

 Individual


The daily decision making in the treatment of their
condition

 Adults

more likely to make and maintain change if
they are personally meaningful and freely chosen
Robert Anderson

Key concepts of self management
 Recognition

of problems as seen by the
person and encouraging them to identify
solution


“Identifying problems often means HP needs to
be silent!!” (Skinner)

 Discovery

and enhancement of internal
reinforcement for behavior change
 Encompasses social learning and behavioral
theories

How self management differs from
patient education
Self-Management
Purpose
Purpose:

Self-Management

Patient
Education

With Disease

Behaviors

To Increase Skills/SelfConfidence

To Increase
Knowledge

To manage life
To Manage Life disease
with
To Change
To increase skills
To Use Specific
Tools
/self confidence

To Problem Solve
And Make Decisions

Patient
Education
To change
behaviors
To increase
knowledge

Kat e Lor ig

To problem solve
and make decisions

To use specific
tools
Kate Lorig


How self management differs
from patient education
Self
Management

Patient
Education

Needs
Assessment

Patient
problems

What patients
need to know

Content

Disease, role,
& emotional
management

Disease knowledge
and behaviors

Leader

Leader is guide

Leader is expert
Kate Lorig


Evidence
 Good

evidence to support
self management
Improves quality of life
 Supports behavior change
 Decreases health care
utilisation


www.cfah.org.au
Barlow. J et al
WHO


References







Robert Anderson et al “Using the empowerment
approach to help clients” Chapter 17 in “Practical
psychology for diabetes Clinicians” Anderson, B and
Rubin, R. Published ADA Alexandria Virginia 1996.
Barlow J. et a “Self – management approaches for
people with chronic conditions: a review” Patient
Education and Counseling 48 (2002) 177-187
“Patients as effective collaborators in managing chronic
conditions”
www.cfah.org.au
Adherence to long term therapies www.who.org go to
publications link


Diabetes self management education
in Australia


Norsworthy document reviewed




8 articles / 153 studies of the effectiveness of diabetes
interventions.

Concluding the evidence presented provides
powerful arguments that diabetes self management
education is:





Able to influence behaviour change and improve knowledge
and skill for diabetes self management
Can result in a reduction in secondary complication rates
Can reduce the person’s reliance on health services.


Diabetes self management education in
Australia


Access and equity issues
 Rural areas
 Indigenous people
 CALD communities
 People of low socio-economic
status.



People in socially
disadvantaged areas receive
fewer long consultations than
people in higher socioeconomic areas.

Lois’s Story


Self management models


Disease – related, education- focus
provision of information, skill
development



Behaviour change focused



Motivational interviewing





Readiness to change
Goal orientated programs

Psychosocial – focused support


Support groups



Social isolation



Self efficacy

Delivery of self management
programs
 Provided

through a variety
of modalities





Face to face
Telephone
Email
Web based

 Principles

can be
incorporated into group or
individual counselling
sessions

Automated telephone disease
management



RCT : People with diabetes
Intervention:





Received weekly calls from automated telephone system
To discuss self-care activities and hear self-care tips

Control: Normal office visits and information

FINDINGS:
 Intervention Group





Reported fewer depressive symptoms
Higher self efficacy for self care
Greater satisfaction with services received
Improvement in health related quality of life

Petitte et al
Medical Care 38, 2000


Automated telephone disease
management
FINDINGS:
 Intervention Group
Reported fewer depressive symptoms
 Higher self efficacy for self care
 Greater satisfaction with services received
 Improvement in health related quality of life



Back pain email discussion group


RCT 580 subjects



Intervention:




Closed moderated email discussion group & back pain book
and video tape

Controls:


Non health magazine subscription of their choice

 Findings at 1- year:


Significant improvements in pain, disability, role function
and health distress



Less physician visits and hospitalisation days

Kate Lorig
Stanford Patient Education Centre

Behavioural weight loss program
 Objective: Determine effectiveness of Internet

behavioural weight loss program compared to weight loss
education website
 RCT 6 months, 91 subjects, 18-60yrs, 81 female, BMI 25-36
 Control

loss

Group: web based information relating to weight

 Intervention: as above plus weekly email messages,

online submission of diaries, therapist feedback

 FINDINGS



Mean weight loss in intervention group at 6 months 4.1kg (4.5)
Mean weight loss in control group at 6 months 1.6kg (3.3)

Tate

Essential elements of self
management interventions
 Disease,

medication and health management
 Role management
 Emotional management
 Support enhancement of self efficacy
 Problem solving training
 Follow up
 Tracking and ensuring implementation
The Robert Wood Johnson Foundation
The Centre for the Advancement of Health
www.cfah.org


Ray’s story


Motivational interviewing


Seeks to understand the persons
frame of reference – reflective
listening



Expresses acceptance and affirmation



Elicits and selectively reinforces the
patients own self motivational
statement, expression of problem,
concern, desire and intention and
ability to change.

Helen Linder
Latrobe university

Assessment/Problem definition
Aim
 To help clients realise they are
responsible for, and in charge of, their
condition
 Prioritise problems and identify situations
they want to improve
 Experience emotional and psychological
commitment
 Develop a plan of action

Interview questions

What part of living with your condition
is the most difficult or unsatisfying for
you?
2. How does the situation make you feel?
3. How does this situation have to change
for you to feel better about it?
1.

Robert Anderson

4.

Are you willing to take action to improve the
situation for yourself?

5.

What are the steps that you can take to bring
you closer to where you want to be?

6.

Is there one thing that you will do when you
leave here to improve things for yourself?
Robert Anderson

Problem solving and decision making
 Identifying

problems

 Set

goals
 Helping find alternative ways of to
accomplish goals
 Setting contracts with themselves
 Checking the results
 Making changes as needed

Goal setting- Getting started


Choose long term goal


Goals should be something you want to do

 Identify

steps needed to reach long term

goal
 Choose

one of those steps to start
working towards goal

SMART
 Specific
 Measurable
 Achievable
 Realistic
 Timely

Flinders University

Guidelines for helping with - Problem
solving
 Identify

the problem
 List ideas
 Select one
 Assess the results
 Substitute another idea (if first didn’t
work)
 Accept that the problem may not be
solvable
Kate Lorig


Behavior Change
Information

Prevention

Chronic disease care
 Target




Case Management

Audience

Population
Individual
Group programs

Implementing change
 Individual

practice
 Program changes
 Organisational approach
 Small incremental changes can still have an
effect
Can require philosophical shift
 Education process/skill development
 Reorganisation of services
 Systematic approach to assessment and care planning
using tools that support identification of problem &
patient generated goals



Our changing roles
 Patient:

Manager
 Health Professional: Assistant


Responsible to clients rather than for them



Sharing knowledge and expertise to help
make informed decisions to about their care



Collaborative approach with client generated
solutions to problems as perceived by client

EDWARD DE BONO
 It

is better to have enough ideas for
some of them to be wrong, than to be
always right by having no ideas at all.


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