Critically assess the key elements that contribute to successful behaviour change interventions.
The need for change
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Everyone wants a long and healthy life although some young people claim that they do not wish to be old. This is because of the negative connotations of old age. It is also a flippant opt-out of taking responsibility. The rationale behind a healthy style of living is unassailable. So why is it difficult to get people to change their ways? For many people, simply getting them to change at all is a major obstacle. As Niccolo Machiavelli observed more than 500 years ago,[1] “It must be considered that there is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things.”
It is not only innate mule-like conservatism that hampers change. There are also positive attributes to the status quo. The tobacco industry has long attempted to portray smoking as cool, sophisticated and sexy. To the rational person, spending vast amounts of money to ruin your health and smell like an old ashtray cannot be cool, sophisticated or have any trace of sex appeal. Over many decades Hollywood has connived to portray smoking in a positive light and this does have at least a subliminal effect.[2]
Simply giving people information about the risks of adverse lifestyles and the benefits of changing their ways is not enough. The relationship between smoking and lung cancer has been public knowledge since the report of the Royal College of Physicians on Smoking and Health in 1963 although the association was first suggested in 1950[3] and the association with other diseases in 1956.[4] There has to be a sustained approach with a solid theoretical background.
Models for change
The two theories that are most commonly employed in health promotion are the Transtheoretical Model (TTM) and the Health Belief Model (HBM). Both are most commonly employed to produce changes in health promotion but the TTM model can be used to produces changes in other fields including industry. Both these models focus on the decision making process of the individual. Other models include the Theory of Reasoned Action (TRA) and the Theory of Planned Behaviour (TPB). All four have been reviewed by NICE.[5]
Transtheoretical Model
The Transtheoretical Model was devised in the 1980s. It sees five stages of action.
Stage 1 is the pre-contemplative stage. It is defined as having no intention to change in the next six months. To use smoking as an example, the person may not appreciate the true level of risk. They may be aware that there is adverse publicity about tobacco. Perhaps some people around them are giving up but they have not taken it seriously enough to think of doing so themselves. Any desire to change is still at a subconscious level.
Stage 2 is the contemplative level. It is defined as intention to change in the next six months although it may take longer. The people involved are aware of the benefits of changing but they are also acutely aware of the challenges. They must decide the balance between costs and benefits.
Stage 3 is the preparation phase. There is intention to take action in the near future and preparation is in hand. The people involved have already taken some significant steps to prepare for the change. Action is planned for the next month or so. With regard to smoking, they may have discussed it with other people. They may have sought out support groups and discussed prescription of nicotine replacement therapy (NRT) or bupropion. They may have set a date to quit.
Stage 4 is action. The people involved have modified their thinking and behaviour. In this case, they have actually stopped smoking.
Stage 5 is maintenance and focuses on sustaining the success. It is important to ascertain that the people involved do not relapse into the old behaviours and are confident of maintaining the new ones. They may focus on money saved, feeling healthier and enjoying food more. It is also necessary to address negative aspects such as possible weight gain.
Health Belief Model
The Health Belief Model is quite popular amongst healthcare professionals. It was developed in the 1950s in the USA to examine why there was a low uptake of a screening programme for tuberculosis.
There are five steps:
The first is perceived susceptibility. It relates to an individual’s feeling of how likely he is to suffer from a condition. It may run in the family or affect a friend. Many people seem to regard themselves as immune to certain illnesses. We all know the smoker who refuses to give up because he knows someone who smoked all of his life without any overt problem.
Perceived seriousness is the next step. This is similar to susceptibility. Does the patient see lung cancer as curable? Does he see other smoking related diseases as manageable?
The third step is perceived benefits and barriers. Patients weigh up the benefits against the costs of taking action. This means implication rather than financial costs. Fear of being excluded from his group of smoking friends may be a barrier. Uptake of cervical smears may be impaired by potential embarrassment.
Self efficacy is step four. It is sometimes called health motivation. It describes how a person sees the ability to change behaviour. If a person thinks that he is unable to stop smoking this is a barrier.
The fifth stage is cues to action. This is the trigger that initiates change. It may be an intervention from a health professional, an illness or a life event such as a new baby. Becoming pregnant can be a strong cue for women.
Curtailing smoking
Smoking cessation is a particularly relevant area to analyse. Smoking is the greatest avoidable contributor to ill health and premature death. Everyone knows of the dangers although perhaps they choose to underestimate them. Even young people still take up the habit. A Cochrane review found limited support for the effectiveness of multi-component interventions in the community to help prevent the uptake of smoking in young people.[6] Smoking tends to be most prevalent in deprived communities. A NICE public health guidance called “Identifying and supporting people most at risk of dying prematurely” focused mainly on smoking cessation and the provision of statins as being cost effective and clinically effective.[7] Both NICE[8] and CKS[9] have extensively reviewed the evidence and made recommendations with regard to smoking cessation. There are also plenty of Cochrane reviews.[10] NICE regards those of lower social class and pregnant women as a priority. Before the dangers of smoking were publicly known there was no difference in smoking habits between social classes. Now there is a distinct gradient[11] and it is said that smoking accounts for a significant amount of the decreased health and increased mortality through the social classes.[12] This is known as health inequalities.
Key elements in changing behavior
The first element of change has to be to implant in the individual’s mind that there is a need for change. With regard to smoking this may come in many ways. Public health messages often preach the wisdom of quitting. Health issues are raised whenever tax is increased and the price of cigarettes rises. This does reduce consumption.[13] Possibly milestones in life such as a 40th or 50th birthday may spur consideration of one’s health. Pregnancy is often a strong incentive to quit and both partners should do so to allow the baby a smoke free home. A Cochrane review was unimpressed at the evidence that getting both of a couple to quit together increased the success rate.[14] However, lack of evidence of efficacy and evidence of lack of efficacy are not the same and it does seem a good idea. The matter may arise during a consultation with a health professional. This may be when reviewing a directly relevant disease such as diabetes, coronary heart disease, hypertension, asthma or COPD or it may simply be brought up as it comes to light on the health promotion template. It has been shown that if GPs simply raise the issue during a consultation this can have an effect.[15] NICE suggests that people who are not ready to quit should be asked to consider it and to seek help in the future.
Some people fail to understand the concept of risk. They need it explained in terms that they can understand. There is no certainty that a smoker will die of a disease related to his habit nor that a non-smoker will have a long and healthy life. It is useful to have some simple figures. About 1 in 5 non-smokers die before 65 years old compared with 2 in 5 smokers. Half of all smokers die of a smoking related disease. If you do the National Lottery in the hope of winning the jackpot the chance of doing so is 1 in 14 million. For young people who cannot imagine being as old as 30, a different approach is needed. Smoking accelerates the aging process in arteries, in the lungs, in bones and in the skin. For those who fear old age, they are bringing it on. Money, fitness and smelling fresh are also positive attributes.
Nicotine is highly addictive.[16] There are other components to the urge. There is the ritual of lighting up and something to do with the hands as well as the image. All these must be addressed to help the individual to cope. Many people find it helpful to set a date to quit. This allows for some counselling before the event and for such matters as NRT or bupropion to be discussed.[17] The forum in which this is done may well be a smoking cessation clinic within primary care. It is usually nurse led. There may be one-to-one counselling but groups may also be helpful.[18] The members give each other mutual support and tips for how to cope.
Having brought the person to the point of quitting it is important to give support through the potentially difficult time ahead. In the early days motivation is high. This must be sustained. Congratulate the person on the achievement. Make him feel good about himself. Reinforce the positive aspects of quitting. Some people collect the money that they would have spent on tobacco each day and put it towards their holiday.
NRT can give a slow release background level of nicotine in the blood to help ameliorate withdrawal. It is very important that the individual does not smoke. Inhalation of nicotine gives a rapid surge and this surge contributes greatly to the addictive mechanism. Some people test that their patients have been abstinent by using a carbon monoxide meter.[19] Carbon monoxide is present in tobacco smoke and it binds to haemoglobin with 210 times the affinity of oxygen. Therefore, carbon monoxide is released slowly for a while after smoking.
At what stage has a person successfully quit? Is it after a week, a month or 6 months?
There is a joke that goes, “Giving up smoking is easy. I’ve done it many times.” This emphasises the great problem of recidivism. It is a problem with smoking, alcohol and drug abuse. Those who counsel drug addicts and alcoholics continue for a long time after abstention to ascertain that it continues. Alcoholics Anonymous will invite people to their meetings even years after they last had a drink. They know how precarious the position is. People who stopped smoking may restart 6 months, a year or even a couple of years after they quit. It is often said that ex-smokers are the most intolerant of the smell of tobacco smoke and this is good. People may choose to start again in times of stress or crisis. A typical scenario is when out drinking. Smokers often try to undermine those who have successfully quit. Perhaps they emphasise their own inadequacy. “Go on. Just have one. It will do you good!” are the sort of thing that alleged friends say. In the words of Alcoholics Anonymous, “One is too many and 100 is not enough.” One night out drinking can lead to complete reversion. This is less likely to happen now that smoking in pubs and bars is illegal but it is still a risk and should be discussed in counselling. Forewarned is forearmed.
Reflection on learning in health promotion
It is easy enough to read and learn the theories of health promotion but putting them into practice is another matter. There will always be surprises and there will always be areas to learn. No isolated incident comes to mind but there are a number of issues that have emerged with accumulated experience.
Any reasonable person will look at the health issues involved and will conclude that the healthy way of life is the logical option. This applies particularly to not smoking. However, not everyone is reasonable and this includes highly educated people. Matters that are not much emphasised in health promotion advice and the literature are peer pressure and denial.
It used to be said that the prevalence of smoking was higher amongst nurses at the completion of their training than at the start although the true incidence of smoking amongst nurses is uncertain.[20] There is no doubt that peer pressure within a school of nursing is high. Stress is also given as a reason for smoking.[21] However, stress is a subjective experience and it may be used as an excuse to conform to peer pressure.
Practice what you preach is a common proverb. An obese healthcare professional who advises weight loss or one who advises cessation of smoking whilst be known to indulge personally, lacks credibility. However, the “sinner” is also less likely to attempt health promotion.[22] Nurses who smoke are less likely to believe the compelling arguments about the dangers of smoking.[23] This is unlikely to represent an objective scepticism about the evidence but simply denial.
If all this applies to nurses, it is unsurprising to find that it is at least as true when dealing with patients. People have to be ready to change. The mere noting of the fact that a patient smokes and the raising of eyebrows is another cue for it to sink in. There is no point in trying to pressurise the person who is not yet ready but leave an invitation to return when the time is right.
What makes a person believe? It is not the level of evidence. People will find all sorts of excuses to doubt the overwhelming evidence about smoking or to pretend that it does not apply to them. On the other hand it seems much easier to convince people that the MMR vaccine causes autism when there is not a shred of evidence to support the allegation.[24] The convenience of a belief is important.
We must lead by example. The “sinner” as a “preacher” is unconvincing although the reformed “sinner” may be more credible. It is important not to appear as sanctimonious with a “holier than thou” attitude. We need to show empathy with those we try to help. This applies not just to the physical addiction to nicotine but to the demands of peer pressure. The latter is especially important for young people.
It is very easy for the non-smoker to see only negative images of smoking. Ask the patient to make a list of all the good things about smoking and all the bad things about it. A similar technique is used when counselling drug abusers. There must be something positive about taking drugs or no one would do it. Similarly, there are positive aspects to smoking. This shows that there is empathy towards the positive aspects. It also allows the patient to see the balance and to believe that he is making his own decision. He is not being coerced or bullied.
It is also important to be realistic about the negative attributes of smoking cessation. Honesty gives credibility. It is often not so much the nicotine addiction that is a problem. This wanes with time. It is the gain in weight.[25] Weight gain is much more visible than damage to lungs or arteries. Many teenage girls say that they smoke to aid weight control. In fact, starting to smoke as a teenager probably does not help at all whilst the later in life that smoking is stopped the more marked weight gain is likely to be. Exercise rather than smoking is much healthier and much more effective. Nicotine has a nauseating effect and so when it is withdrawn there is likely to be increased appetite. Food now tastes better and some people suck sweets to occupy their mouth. It is important to discuss the matter. Weight gain is bad for health but unless the gain is enormous the benefit of smoking cessation will greatly outweigh the dangers of weight gain. If the patient decides to start smoking again the result will be a fat smoker. The weight will not melt away.
Health promotion is a very personal matter. It requires a relationship on a one-to-one basis. It requires trust and respect. The health promoter must be seen as an honest broker rather than an evangelist. This requires empathy and it requires respect of the patient too. It is an important and difficult decision and he needs help and support.
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