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Making changes that stick

1. Understand the principals of social cognitive theory and behavior change 2. Apply these principles to quality improvement efforts that will make lasting change

Making change that sticks

Lessons from the six sources of influence Alison Stuebe, MD, MSc astuebe@med.unc.edu

Resources

How do we change behavior?

Beyond Just do it!

Conventional wisdom
Behavior change If we give people information, they will do the right thing

Social Cognitive Theory

Is it worth it? Can I do it?

Albert Bandura

Bandura A (2004). "Health promotion by social cognitive means." Health Education & Behavior 31(2): 143-64.

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Find Vital Behaviors

Dont confuse results with behaviors

Results Increase the breastfeeding initiation rate Reduce formula supplementation Reduce childhood obesity Behaviors Skin-to-skin in the first hour of life Understanding infant feeding cues Purchasing formula Eating at fast food restaurants

How will you motivate and enable change?

Is it worth it? Can I do it?

How to change minds

MOTIVATION
PERSONAL

ABILITY

Is it worth it?

Make the Undesirable Desirable

Surpass Your Limits

Can I do it?

SOCIAL

Harness Peer Pressure

Find Strength in Numbers

STRUCTURAL

Design Rewards and Demand Accountability

Change the Environment

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Intrinsic Satisfaction
Help people to extract intrinsic satisfaction from the right behavior or feel displeasure with the wrong behavior
Try it immerse people in the activity Focus on a sense of accomplishment Reconnect the vital behavior to a persons sense of values Fight moral disengagement MOTIVATION Help resistant people discover links between vital behaviors and their own values Make the
PERSONAL

Personal ability
Devote attention to clear, specific and repeatable actions
Insist on feedback Break tasks into discrete actions and practice in a low-risk environment Build in recovery strategies tell the right stories about setbacks Regain emotional control
ABILITY
PERSONAL

Undesirable Desirable

Surpass Your Limits

Personal motivation, ability and The Habit Loop

Behavior

Personal motivation, ability and The Habit Loop

Cue

Craving

Reward

Harness peer pressure

Respected and connected people can exert enormous influence
Identify and work with opinion leaders Make it safe to talk about high stakes, controversial topics Create a new social network to support the behavior
MOTIVATION
SOCIAL

Find strength in numbers

Build social capital
Include those who are creating the problem in solving the problem Turn disablers into enablers Create and support teams Ensure solidarity

ABILITY
SOCIAL

Harness Peer Pressure

Find Strength in Numbers

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Structural motivation
Use incentives and punishments wisely
Start with intrinsic and social motivators Celebrate small wins & reward good behavior Make sure rewards are linked to vital behaviors, not outcomes Consider small, heartfelt tokens of appreciation Use punishment sparingly
First, take a shot across the bow Follow through if behavior persists
STRUCTURAL

Structural ability
Look for the influence of things
Clues from the environment profoundly influence behavior Make the invisible visible Pay attention to physical space
Create opportunities for informal contact and communication

Make the behavior unavoidable

ABILITY
STRUCTURAL

MOTIVATION Design Rewards and Demand Accountability

Change the Environment

Over-determine Vital Behaviors

To change a vital behavior, draw on at least four sources of influence

Case study: Formula supplementation before 2 days of age*, %

37.9 30.5 25.4

14.2 9.1

North Carolina

Montana

Mississippi

US

HP2020 Goal

*Among infants born in 2007 who were breastfeeding on day 2 of life

First time mother planning to breastfeed

MOTIVATION
PERSONAL

Personal Motivation
When we fail to describe the hazards of artificial feeding, we deprive mothers of crucial decision-making information. The mother having difficulty with breastfeeding may not seek help just to achieve a special bonus; but she may clamor for help if she knows how much she and her baby stand to lose.

ABILITY

Diane Wiessinger

Is it worth it?

Make the Undesirable Desirable

Surpass Your Limits

Can I do it? Benefits of Breastfeeding

Best

Breastfeeding

Normal
Risks of not Breastfeeding

SOCIAL

Harness Peer Pressure

Find Strength in Numbers

STRUCTURAL

Design Rewards and Demand Accountability

Change the Environment

Normal

Risky

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Does fear motivate behavior change?

Barbara Fredrickson Professor, University of North Carolina

Harmonious passion supports nurturing relationships at the breast

The miracle is you and the milk only moms can make.

Obsessive passion narrows a mothers focus, fostering guilt and blame.

http://www.bestforbabes.org

Personal Ability

What do you want? How do I explain this?

WIC program developed by Jane Heinig and the UC Davis Human Lactation Center Teaches families to recognized infant cues for hunger, satiety, and engagement / disengagement

We can help moms to read infant cues

http://www.cdph.ca.gov/programs/wicworks/Pages/ WICCaliforniaBabyBehaviorCampaignDrJaneHeinigsTraining.aspx

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Nichols J, et al. Health Educ Behav. Sep 24 2007.

Nichols J, et al. Health Educ Behav. Sep 24 2007.

Social Ability

Veteran night nurse taking care of this mother

MOTIVATION
PERSONAL
Jane Grassley PhD, RN, IBCLC

Grandmother Breastfeeding Support: What Do Mothers Need and Want?

Health care practitioners need to ask grandmothers about their infant feeding beliefs and practices Help grandmothers find ways other than feeding to support new mothers and to bond with their grandchildren Give mothers permission to breastfeed in family gatherings Confront and understand the cultural sources of their infant feeding practices and beliefs about breastfeeding

ABILITY

Is it worth it?

Make the Undesirable Desirable

Surpass Your Limits

Can I do it?

SOCIAL

Harness Peer Pressure

Find Strength in Numbers

STRUCTURAL

Grassley J, Eschiti V. Birth. Dec 2008;35(4):329-335.

Design Rewards and Demand Accountability

Change the Environment

Personal Motivation

Night nursery supplements and the Habit Loop

Nurse gives bottle

Night nursery supplements and the Habit Loop

Nurse helps mother

Baby cries

Infant sleeping in arms

Baby falls asleep

Baby wakes

Grateful mother thanks nurse

Baby falls asleep

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Personal Ability No Latch in 12 hours: Suggested script The baby steps of learning will come more naturally if we keep him (her) skin-to-skin with you and just practice breastfeeding. There are lots of things we can do to help him (her) learn. Most babies do a lot of sleeping in the first day. Your baby is just recovering from the birth. Your baby is just trying to figure out the world. You are doing a great job. Put on your light if your baby starts moving around or wakes up. Ill come in and help you. This is a learning time for both of you. This is hard now, but it will get easier. http://newborns.stanford.edu/Breastfeeding/PMGs.html#nolatch

Social Ability and motivation: Make sure rewards are linked to vital behaviors, not outcomes Pacifiers use restricted in mother-baby unit

Kair LR et al (2013). "Pacifier Restriction and Exclusive Breastfeeding." Pediatrics 131(4): e1101-e1107.

If you give your healthy newborn a pacifier, it can make it harder for your baby to learn to breastfeed and decrease your milk supply.

MOTIVATION
PERSONAL

ABILITY
No specific script was instituted to verbally instruct parents on infant soothing techniques or use of pacifiers.

Make the Undesirable Desirable

Surpass Your Limits

SOCIAL

Harness Peer Pressure

Find Strength in Numbers

Pacifiers began to be stored in a standard, locked, supply management system.

STRUCTURAL

Design Rewards and Demand Accountability

Change the Environment

Making change that sticks

Changing behavior
To change behavior, we have to answer, Is it worth it? and Can I do it? Address Personal, Social and Structural domains of Ability and Motivation Leverage at least four sources of influence to maximize your impact

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A single hand cannot nurse a child. - Swahili Proverb

Research Partners Kim Andringa Martha Cox Mala Elam Barbara Fredrickson Susan Girdler Karen Grewen Karen Hardy Samantha Meltzer-Brody Kim Newton Chris Raines David Rubinow Brenda Pearson Cort Pederson Cathi Propper John Thorp

UNC Hospital Lactation Consultants Full Time Diane Asbill Robyn Lewis Janet Sligh Part time Rebecca Costello Michelle Davis Rhonda Lanning Wanda Oakley Hannah Pollet Elley Schopler Mary Terrell

University of North Carolina Division of Maternal-Fetal Medicine Department of Psychiatry Center for Developmental Science Frank Porter Graham Institute UNC Hospitals Lactation Department National Institutes of Health

Noah, Sam, Max & Geoff Green

Photo: Quintessence Foundation / http://www.babyfriendly.ca