Introduction

This chapter describes the importance of the application of behaviour change principles to improve health and well-being. It focuses on achieving change at the individual level while recognising that this needs to be part of an overall strategy involving interventions at population and community levels.

Context

Human behaviour has been defined as ‘the product of individual or collective human actions, seen within and influenced by their structural, social and economic context’. ¹

Behaviour can have a major impact on mortality and morbidity, and behaviour change interventions have the potential to significantly alter disease patterns. ¹ It is recommended that changes in behaviour, and the social, economic and environmental contexts in which unhealthy behaviours take place, should be at the heart of all disease prevention strategies. ²

Whilst acknowledging social inequalities as a key determinant of health, NICE suggests that changes in behaviour may be more achievable than changes to social circumstances, at least in the short term. ¹ Nevertheless, behavioural changes are hugely challenging for both the individual and the healthcare professional involved.

Interventions to achieve behaviour change can be directed at the individual, community or population level. Changes at any one level can lead to changes at another level—the so-called ripple effect. For example, individuals who change their eating behaviour may have an impact on the rest of the household or other individuals in the community, whilst population strategies to increase activity may encourage individuals to become more active. Clearly a coherent overall strategy operating at all levels is the most desirable. It needs to have clear aims and be based on sound principles and available evidence, and methods for monitoring the effects should be developed hand in hand.

Models of behaviour change provide a framework for planning and delivering behavioural interventions. Relevant theories originating from the world of behavioural sciences include resilience, coping, self-efficacy, planned behaviour, structure and agency, ‘habitus’ and social capital. ¹ Over the past few decades, although a number of behaviour change models have been described, the evidence does not tend to support any one model over and above another. On the whole, these models do not satisfactorily capture the complexities and contradictions in human behaviour and, because they have been developed to explain aspects of the individual’s behaviour, they fail to capture population-level dynamics. ¹

Therefore, even though some psychological constructs can be helpful and interesting when considering an individual’s behaviour, behaviour change interventions are best focused upon therapeutic skills rather than on specific theoretical constructs. Programme development needs to draw on current evidence and be subjected to ongoing evaluation. No single approach will suit everyone. So any intervention should be tailored to the individual, community or population. The focus of the rest of this chapter is interventions with the individual patient or client.

A behavioural approach

‘The main principles of this approach include the modification of current behaviour patterns, new adaptive learning, problem solving and a collaborative relationship between client and the therapist.’³ A behavioural approach seeks to empower clients—to equip them with the knowledge and skills to bring about and sustain desired changes. ⁴ It supports self-efficacy by building competence and self-belief in one’s ability to make changes. ⁵ It acknowledges that change is complex and is influenced by the environment in which someone lives as well as their attitude, level of knowledge and skills. Changing habits that have often been acquired over a long period of time requires a degree of effort, energy, time and commitment. There is no quick fix Collaborative problem solving is the essence of a behavioural intervention.

A problem-solving approach has five easily identified steps:

1. Identify the problem (often described as the ‘assessment’);

2. Explore all possible options for dealing with it;

3. Explore pros and cons of each option;

4. Identify which one is a realistic next step; and

5. Try out the option and review progress.

The next section will focus on the process of helping based on a problem-solving approach. The approach differs from the traditional advice-giving approach in that the client is very much involved in the whole process and ultimately makes the decision to change (or not) and makes the choices for their preferred options.

The process

Assessment

This should start with building rapport, outlining the purpose of the intervention and checking that the person wishes to be involved. In traditional healthcare the assessment has focused on the clinical picture. Using a behavioural approach, the clinical picture is explored along with the aspects likely to influence health behaviour: the reason for the intervention, the targeted behaviour(s), the story so far (history of condition, previous attempts at change, successes/what did not work), motivation, expectations of the intervention and outcomes, current lifestyle including social aspects, possible difficulties. This assessment needs to be undertaken in a skilled and sensitive manner involving the client throughout the process, although guided by the practitioner in order to ensure that a complete picture evolves. Once the assessment has been completed, it is then important to clarify the client’s agenda (preferred outcome) and to be clear about what the practitioner can offer. Both parties can then move forward with a shared agenda.

Explore the options

This involves checking what the client already knows or has tried and often involves providing information to help the person make an informed decision. Providing information needs to be undertaken in a structured manner, firstly, checking what the person knows and indeed if they would like some information (this is part of the respectful nature that threads through the intervention). Provide the information in a way that makes sense to the person and tailoring it to their needs; avoiding jargon and allowing for questions and comments so that it becomes a two-way process; checking what the person thinks of the information as this is likely to influence their decision-making. People may want guidance on what research shows or what works best for others in similar situations, but ultimately, they are the best judge of what will work best for them.

Choose an option (goal setting)

Most practitioners are familiar with the principles of goal setting; yet in practice, this is poorly executed. SMART (specific, measurable, achievable, realistic and time specific) goals can be achieved in practice through the collaborative development of a Change Plan. ⁶ This involves paying attention to the detail of the Change Plan.

• What is the overall target? (desired outcome)

• How is this going to be achieved? (specific behavioural goals/sub-goals)

• What needs to be in place? (e.g. correct food in cupboards, trainers in the car)

○ Support—where from and how to elicit this

○ Rewards—for ongoing effort and achieving new behaviours

○ Monitoring progress

• When is it going to start

• Review.

Implement the plan

Efforts to change do not necessarily succeed at the first attempt. A detailed Change Plan is more likely to help the person succeed but even then, unforeseen difficulties may crop up or simply the effort required to change ingrained habits may be greater than initially realised. Trying it out is the only way to check whether the plan is right for that person. The plan will need to be regularly reviewed and revised throughout the change process. The role of the practitioner is to support clients in developing a realistic Change Plan and to convey optimism and a willingness to re-examine. Efforts to change need to be acknowledged and affirmed. Clients should be encouraged to seek support from significant others and to reward themselves for changes in behaviour. Self-monitoring is a key behavioural tool and it often requires coaching and practice to develop this skill.

Review the plan

Ongoing review is part of the problem-solving process, so it is important to build a regular review into the Change Plan. For the majority of people, it is not enough to discuss it and then expect them to do it. Time needs to be devoted to discussing ongoing review and how this can be tailored to the individual.

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