The challenge of health behaviour change

1. The challenge of health behaviour change Robert West University College London February 2009

2. Outline • The problem • Prevailing theories • An attempt at a more complete theory • Implications

3. Outline • The problem • Prevailing theories • An attempt at a more complete theory • Implications

4. The problem • We often engage in harmful behaviours and fail to engage in behaviours that would protect us

5. Let’s get personal!

6. Do you ...? • Fail to ensure that you don’t have high blood pressure or cholesterol • Smoke cigarettes • Drink too much alcohol • Take recreational drugs that might harm you • Eat too much • Fail to follow a healthy diet • Fail to take enough exercise • Fail to take adequate protection against the sun • Drive too fast • Engage in unsafe sex

7. Do you think you should ...? • Take more care to ensure your blood pressure and cholesterol are not too high • Stop smoking • Drink less alcohol • Stop taking recreational drugs that might harm you • Eat less • East more healthily • Take more exercise • Ensure better UV protection • Drive more slowly • Stop engaging in unsafe sex

8. Even professionals interested in health behaviour have unhealthy behaviours

9. Why don’t you change? • You are not trying because ... • You like or need what you are doing too much • You are not convinced about the benefit • You think you can do it later • You think it will be too difficult • You are trying but ... • not very hard • it is proving too difficult

10. Because we are conflicted about how far the healthy lifestyle is worth it and it is difficult to sustain

11. Outline • The problem • Prevailing theories • An attempt at a more complete theory • Implications

12. Decision theory • The explanation • We choose what we do by weighing up benefits and costs • We discount future benefits and costs • The solution • Persuade people to give a higher priority to future benefits and costs (e.g. by advertising) • Change the current cost-benefit ratio (e.g. by price rises) • Effectiveness • Good track record (e.g. reducing smoking) • Limitations • Disbelief of or habituation to messages • Public and political acceptability of inducements and coercion

13. Theory of Planned Behaviour • The explanation • Intentions determine behaviour and these are determined by attitude to the behaviour, subjective norms and perceived behavioural control • Attitudes, norms or perceived control can direct behaviour away from healthy choices • The solution • Attempt to change intentions by changing whichever of its determinants differentiate people who engage in the healthy behaviour from those who do not • Effectiveness • Weak track record • Limitations • Intentions often only weakly linked to behaviour • Focus on what differentiates people in populations can be misplaced

14. Health Belief Model • The explanation • Self-protective behaviours depend on perceived threat, perceived benefit of change, personal susceptibility and barriers to change, interacting with cues to action • The cognitions or cues to action often do not favour the healthy choice • The solution • Change people’s relevant cognitions or increase cues to action • Effectiveness • Mixed track record • Limitations • Over-emphasis on beliefs and fails to capture more basic aspects of motivation

15. Learning theory • The explanation • Our actions are controlled by past experience of reward and punishment in the presence of cues • Unhealthy behaviours are rewarded and healthy ones punished • The solution • Reduce exposure to cues for unhealthy behaviours and increase exposure to cues for healthy ones • Reward healthy behaviours and punish unhealthy ones • Effectiveness • Uncertain track record (e.g. uncertain effects of experience of criminal sanctions in deterring drug taking) • Limitations • Difficult to generate enough exposure to powerful rewards and punishments

16. Social learning theory • The explanation • Our actions are influenced by our observations of others’ behaviour and whether it is rewarded or punished • Unhealthy behaviours are normative in our social circles • The solution • Change perceptions of what is normative • Show other people being rewarded for healthy behaviours and punished for unhealthy ones • Effectiveness • Uncertain track record (e.g. uncertainty over effect on smoking) • Limitations • Disbelief of normative messages • Failure to identify with models

17. Self-regulation theory • The explanation • Doing what we ‘ought’ when it conflicts with what we ‘want’ requires self-control and is effortful • Self-control is a limited resource • The solution • Reduce temptations in the environment • Help people develop self-control skills • Help build and preserve mental resources • Effectiveness • Weak track record (No examples yet of strong effects in the population) • Limitations • May be impracticable or too costly to implement in a way that would be effective

18. Social cognitive theory • The explanation • Apart from rewards, punishments and social learning, ‘self-efficacy’ is an important determinant of behaviour • Many individuals lack self-efficacy for engaging in healthy behaviour patterns • The solution • Improve self-efficacy • Effectiveness • Mixed track record (e.g. has been found to be mediator in some behaviour change interventions) • Limitations • May have limited applicability

19. Addiction/self-medication theory • The explanation • We have powerful ‘needs’ to engage in certain behaviours based on emotional states and drives • Unhealthy behaviours often meet basic needs • The solution • Treat the underlying needs • Effectiveness • Mixed track record (e.g. medication to treat nicotine dependence, appetite suppressants) • Limitations • May be impossible, impracticable or too costly adequately to meet underlying needs

20. Transtheoretical model • The explanation • Changing behaviour requires progression through pre-change stages defined in terms of intentions and post-change stages defined in terms of duration of change • Transition between different stages requires different ‘processes of change’ • The solution • Apply interventions that promote different change processes depending on the recipients’ ‘stage of change’ • Effectiveness • Weak track record (e.g. no added benefit in smoking cessation) • Limitations • The model is descriptively inaccurate and promotes inappropriate tailoring

21. In summary • The decision theory explanation has the strongest track record but it fails to take adequate account of: • the role of habits, drives and emotions • the distinction between thinking and feeling • the importance of the immediate environment in the moment-to-moment control of behaviour

22. Outline • The problem • Prevailing theories • An attempt at a more complete theory • Implications

23. Why attempt a more complete explanation? • It may tell us: • in what circumstances particular approaches to behaviour change are likely to be effective • how best to implement those approaches

24. The PRIME Theory of motivation • At every moment we act in pursuit of what we most want or need at that moment • Wants and needs are mental images of future possibilities (goals) that we feel attracted to • wants: anticipated pleasure or satisfaction • needs: anticipated relief from discomfort • Intentions and beliefs about costs and benefits can only influence our actions if • they generate wants or needs at the appropriate time • that are strong enough to overcome any competing wants and needs that might be present

25. The structure of the motivational system Five interacting subsystems providing varying levels of flexibility and requiring varying levels of mental resources and time p Plans r Responses i Impulses m Motives e Evaluations Higher level subsystems have to act through lower level ones where they compete with direct influences on these

26. Deliberate behaviour change • Form a ‘rule’ (a kind of plan) • For the rule to be effective it must create wants and needs at every relevant moment that are strong enough to overcome any competing wants and needs at that moment • Two key aspects to successful rules: • clear boundaries • link with ‘deep identity’ (aspects of self image to which the individual has strong attachment)

27. Outline • The problem • Prevailing theories • An attempt at a more complete theory • Implications

28. Distinguish between ‘want’ and ‘ought’ • To initiate behaviour change: • generate positive feelings about change not merely beliefs that change is a good thing • Want: positive feelings • Ought: positive beliefs

29. ‘Wants’ and ‘oughts’ to stop smoking • 3173 adult cigarette smokers in the Smoking Toolkit Study • Allowed to endorse either or both of • I want to stop smoking • I ought to stop smoking • In multiple logistic regression, only ‘want’ was associated with past quit attempts

30. Distinguish between ‘want’ and ‘need’ • In the case of behaviours that are motivated by both wants and needs, the two may operate differently in preventing initiation and maintenance of change

31. Wanting and needing to smoke • Wanting to smoke appears to deter attempts to stop while needing to smoke leads to relapse once an attempt is made Data from 1479 smokers in Smoking Toolkit Study, followed up 6 months after ratings or enjoyment and urges were made to find out whether: had attempted to stop and if so had relapsed

32. Do not discourage unplanned attempts at change • Unplanned attempts can reflect strong momentary motivation which might dissipate if not acted upon

33. Planned and unplanned quit attempts • Adult cigarette smokers in the Smoking Toolkit Study who tried to quit in the past year • Reported whether: • made attempt the moment the decision was made • planned the attempt in advance • Those reporting unplanned attempts were more likely still to be abstinent (p<0.05 by chisquared, N=5337) • Effect remained controlling for dependence, age, social grade and sex (OR=1.27, p<0.01)

34. Foster ‘rules’ with clear boundaries • For rules to generate sufficiently strong wants or needs ‘in the moment’ they need to establish clear boundaries around what is permissible on every occasion

35. Abrupt versus gradual cessation • 40% adult cigarette smokers in the Smoking Toolkit Study who tried to quit in the past year reported doing it through cutting down first • Smokers who reported having stopped gradually were less likely still to be abstinent (p<0.001) • This effect remained after controlling for dependence, age, sex and social grade (OR=1.68, p<0.001)

36. Conclusions • Decision theory has been successful in generating effective interventions to promote healthy behaviours but has important limitations • Other theoretical approaches contribute useful insights but it may be possible to develop an integrated theory • PRIME Theory proposes a focus on momentarywants and needs rather than intentions or beliefs • Deliberate behaviour change involves establishing rules as a source of new wants and needs. Those rules will be more effective if: • they have clear boundaries • are linked to ‘deep identity’

37. For more information and readings www.primetheory.com