HEALTH BEHAVIOUR

CHANGE

Dr. Raveed Khan

M.B., B.S.,MPH, DM Family Medicine
Lecturer UWI

Outline

• Definitions and Importance

• Models of behaviour change
• Smoking Cessation
• Communication skills
• Application in other behaviours
 Definition

“Health behaviour can be defined as the

actions, responses, or reactions of an
individual, group, or system that
prevent illness, promote health, and
maintain quality of life”*

*DiClemente RJ, Salazar LF, Crosby RA. Health Behavior Theory for Public Health:
Principles foundations and applications. Jones & Bartlett Learning; 1st ed. 2011

Why study Health Behaviour?

• Is there any
evidence to
suggest the
two are
related?
 Why study Health Behaviour? Most behaviours influence diseases but some like congenital and
autoimmune does not.
• How many of these conditions
are behaviour related?

• Can you think of any disease

that is NOT affected by
behaviour?
 Why study Health Behaviour?
• Is there any evidence that we can change
behaviour?

• Does behaviour change improve health?

• Models/Theories have been developed to

answer these questions….

Models of behaviour change

• Health Belief Model
• Transtheoretical - Stages of Change
• Learning and Behaviour Theory
• Social Cognitive Theory
• Personality Theories
 Health Belief Model
• The Health Belief Model (HBM) is one of
the first theories of health behavior.

• U.S. Public Health Service social

psychologists (1950’s) who wanted to
explain why so few people were
participating in programs to prevent and
detect disease.

Health Belief Model

• The model postulates that health-seeking
behaviour is influenced by a person’s
perception of a threat posed by a health
problem and the value associated with
actions aimed at reducing the threat.
 6 major concepts in HBM
• Perceived susceptibility: refers to a person’s Disease is relevant to them.
perception that a health problem is personally
relevant or that a diagnosis of illness is accurate.
• Perceived severity: even when one recognizes Threat has to be severe enough so that it affects their quality of life.
personal susceptibility, action will not occur unless
the individual perceives the severity to be high Eg. Person does not think diabetes is too bad but its complications
enough to have serious organic or social
complications.
such as blindness amputations ect.
• Perceived benefits: refers to the patient’s belief
that a given treatment will cure the illness or help
to prevent it.

6 major concepts in HBM

• Perceived Costs: refers to the complexity,
duration, and accessibility of the treatment.
• Motivation: includes the desire to comply with a
treatment and the belief that people should do
what.
• Modifying factors: include personality variables,
patient satisfaction.
What is the point of undergoing a health change and the patient
cannot afford it. Eg fresh fruit every day.
Family death, Children and family, wanting to live longer to see their
children grow, testimonies of other persons who have went through
the process and came out successful
Someone skeptical about a drug. Bad experience in a hospital so
they would not take advice. Hard headed people
 Example HBM and HIV..
Individuals would be more likely to practice safe
sex if they believe that:
• They are at risk of HIV infection Perceived susceptibility
• Consequences of the infection are serious Perceived severity
• Safe sex practices (e.g., condom use) are
effective in reducing the risk of infection Perceived benefits:
• The benefits of safe sex practices outweigh the
potential costs and barriers Perceived Costs

To get the flu shot or not….

Can you apply HBM to texting/talking
while driving…
 Criticisms of HBM
• Is health behaviour that rational?

• Its emphasis on the individual (HBM ignores social

and economic factors)

• The absence of a role for emotional factors such

as fear and denial.

• Alternative factors may predict health behaviour.

Transtheoretical Model (TTM) of

Change
• Mounting evidence suggests that
behaviour change occurs in stages or
steps.

• Movement through these stages is neither

unitary or linear, but rather, cyclical,
involving a pattern of adoption,
maintenance, relapse, and readoption over
time
 Transtheoretical Model of Change

• Prochaska and DiClemente (1986) and their

colleagues have formally identified the
dynamics and structure of staged behaviour
change

• The TTM defines 5 discrete stages of

change which discriminate people based on
current behavior and the intention to change
this behavior.

5 stages of Change (TTM)

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
 5 stages of Change (TTM)
• According to the TTM, people can progress
and regress from one stage to another.
Such movements are called stage
transitions

• Cyclical process that involves both

progress and periodic relapse

5 stages of Change (TTM)

• Precontemplation:

• Changing a behaviour has not been

considered (not within the foreseeable 6
months) ; person might not realise that
change is possible or that it might be of
interest to them.
 5 stages of Change (TTM)
• Contemplation:

• Something happens to prompt the person

to start thinking about change (within next
6 months) - perhaps hearing that someone
has made changes - or something else has
changed - resulting in the need for further
change.

5 stages of Change (TTM)

• Preparation:

• Person prepares to undertake the desired change

(within next month)
• Gathering information, finding out how to achieve
the change
• Ascertaining skills necessary, deciding when
change should take place - may include talking with
others to see how they feel about the likely change,
• Considering the impact change will have and who
will be affected.
 5 stages of Change (TTM)
• Action:

• People make changes, acting on previous

decisions, experience, information, new
skills, and motivations for making the
change. (within past 6 months)

5 stages of Change (TTM)

• Maintenance:

• Practice required for the new behaviour to

be consistently (> 6 months) maintained,
incorporated into the repertoire of
behaviours available to a person at any
one time.
 TTM
Behaviour change can only take place in
the context of an enabling or supportive
environment:
• Social/Cultural
• Legal
• Political
• Ethical
• Spiritual
• Resources

TTM applications…
• smoking cessation
• exercise
• low fat diet
• radon testing
• alcohol abuse
• weight control
• condom use for HIV protection
• organizational change
• use of sunscreens to prevent skin cancer
• drug abuse
• medical compliance
• mammography screening, and
• stress management.
 Smoking cessation

Smoking
• # 1 cause of preventable death worldwide

• Half of smokers will die from a smoking

related disease!

• Every eight seconds someone dies from

using tobacco.
 Smoking
• Every year, 5.4 million people lose their
lives due to smoking

• Cigarette smoke contains over 4,800

chemicals, 69 of which are known to cause
cancer.

• Smoking harms nearly every organ of the

body

How common is smoking in Trinidad?

 How common is smoking in
Trinidad?
• 29.9% of children lived in homes where
one or both parents smoked.

• Diabetic outpatient men (20.4%) were 4

more times more likely to smoke cigarettes
compared to women (5.6%)

TTM in Smoking Cessation

• PRECONTEMPLATION STAGE
• Educate the patient about the effects of
smoking.
• Recommend changes in behavior.
• List options for achieving behavioral change. Medications
• Discuss the patient's reactions to the
physician's feedback and recommendations.
• Follow up to monitor and reinforce behavioral
change.
 TTM in Smoking Cessation
• CONTEMPLATION STAGE
• Providing further education about the
effects of smoking and
• Encouraging the patient to consider the
positive aspects of not smoking, such as
improved health, a more positive self
image, and economic savings.

TTM in Smoking Cessation

• PREPARATION STAGE
• Setting a definite quit date.
• Gathering support for smoking cessation.
• Preparing the environment.
• Formulating plans to avoid triggers.
• Selecting a drug to assist in smoking
cessation
 TTM in Smoking Cessation
• ACTION STAGE
• Begins on the quit date. By this date, patient
is on drugs to assist cessation (if used) and
the patient's environment should have been
cleared of smoking-related materials.
• Behavioral support through self-help or
professionally run group meetings, frequent
office visits, and/or telephone calls from
support personnel can enhance the
effectiveness of the cessation attempt.
 TTM in Smoking Cessation
• MAINTENANCE STAGE
• It is important for the patient to report
perceived benefits from having stopped
smoking, side effects of medications, and
current or anticipated difficulty in
maintaining abstinence.
• Healthy substitution behaviors may help to
prevent relapse.

Smoking cessation -Pharmacotherapy

• Seven first-line medications (5 nicotine and

2 non-nicotine) reliably increase long-term
smoking abstinence rates:
• Nicotine gum
• Nicotine inhaler
• Nicotine lozenge
• Nicotine nasal spray
• Nicotine patch
• Bupropion SR
• Varenicline
Smoking cessation -Psychotherapy
• Cognitive Behavioural Therapy
• Group Therapy
• Telephone quitlines

• Combination better that single modality of

treatment

How the various methods compare?

Easy way to remember how to counsel
any patient on smoking cessation

• 5 A’s and 5 R’s of smoking cessation

• Communication skills

quit?
5 As video
 5 Rs video

Scenario 1
• Mr. M is a 36 yr old gas station attendant
who visits Dr. S for his 5th respiratory tract
infection for the year. Mr. M smokes 1 and
½ packs cigarettes each day but has given
no thought to stopping smoking as all he
expects from Dr. S is a prescription for
anitbiotics to get over the infection.

• As Dr.S what would you say to Mr. M?

 Scenario 2
• Mrs. R is a 28 yr old who visits Dr. R in
antenatal clinic. She is 12 weeks pregnant
and Dr. R is surprised to learn that she is
still smoking 2-3 cigarettes every day. Mrs.
R is however willing to stop within the next
week but admits she doesn’t feel she can
do it on her own
• As Dr. R what would you advise.

Scenario 3
• Mr. T is a 60 yr old COPD hypertensive
who stopped smoking 3 months ago with
the help of Chantix. (varenicline) He visits
Dr. T.

• What should Dr. T do?

 TTM and Exercise
• A patient is going to buy a treadmill to start
exercise next week.
• What is the stage of change?
• What can you do to assist?
1. Encouragement
2. Tell relatives/Get exercise partner
3. Exercise prescription
4. Set realistic (small and attainable) goals
5. Contract
6. Follow up
 TTM and Exercise
• A patient has been exercising for the past year.
• What is the stage of change?
• What can you do to assist?
1. Congratulate
2. Review benefits
3. Reinforce decision to exercise
4. Anticipate events that may hinder exercise
5. Form a support group
6. Follow up

TTM and Exercise

• An obese diabetic patient comes to CDC for a
prescription. She does not give any thought to
exercising!
• What is the stage of change?
• What can you do to assist?

1. Discuss reasons for not considering exercise

2. Motivation: success stories
3. Educate about the benefits
4. Discuss lab values and risk of disease
5. Follow up
 Summary

• Behaviour is strongly linked to disease

• As physicians we can change behaviour

• Stage of change model and its application.

Questions

Comments?
 References
• Mahvan T, Namdar R, Voorhees K, Smith PC, Ackerman W. Clinical Inquiry: which
smoking cessation interventions work best? J Fam Pract. 2011 Jul;60(7):430-1.
• The top 10 causes of death. World Health Organization. [cited 2014 Oct 29] Available
from: http://www.who.int/mediacentre/factsheets/fs310/en/
• United Nations Population Division, World Population Prospects 1950-2050 (2000
revision). TRINIDAD AND TOBAGO. REGION OF THE AMERICAS. [cited 2014 Oct
29] Available from: http://siteresources.worldbank.org/INTPH/Resources/
Trinidad_Tobago.pdf
• Ministry of Health, Trinidad and Tobago. Facts on Tobacco Smoking. . [cited 2014 Oct
29] Available from: http://www.health.gov.tt/sitepages/default.aspx?id=179
• Monteil MA, Joseph G, Chang Kit C, Wheeler G, Antoine RM.
• Smoking at home is strongly associated with symptoms of asthma and rhinitis in
children of primary school age in Trinidad and Tobago. Rev Panam Salud Publica.
2004 Sep;16(3):193-8.