Promoting Behaviour Change

By Dr Nik Nor Ronaidi bin Nik Mahdi

Objectives1. Describe different theories of health behavior and

behavior change2. Understand why people engage in health compromising

or health promoting behavior3. Identify the barriers to promote behavior change4. Briefly describe different intervention techniques to

change behavior at both community and individual level

5. State the generic principles that can be used as the basis for planning, delivering and evaluating public health activities in changing health behaviors

6. Aware of the national and international policies implemented in order to change health behaviors

7. Appraise the existing policies i.e. evaluate the outcomes, suggest for improvement

Question:• In reference to different theories and guidelines

to promote behavioral change, critically evaluate the existing national health strategies and policies in changing health behavior and recommend for further improvement.

Content

• Introduction• Principle of planning, delivery, evaluation of

behavior change programs• Framework Convention on Tobacco Control

(FCTC)• National health tobacco control program• Evaluation of measures taken for tobacco

control in Malaysia• Recommendations for tobacco control

Introduction• The major causes of death in the US and other developed

countries are now chronic diseases, such as heart disease, cancer, and stroke.

• Behavioural factors, particularly tobacco use, diet and activity patterns, alcohol consumption, sexual behaviour, and avoidable injuries are among the most prominent contributors to mortality.

• The resurgence of infectious diseases, including food borne illness and tuberculosis, and the emergence of new infectious diseases such as antibiotic resistant infections, HIV/AIDS, Hepatitis C, and human papillomavirus (HPV) are also largely affected by human behaviours

NHMS (1986, 1996, 2006)

21.524.8

21.5

40.9

49.246.4

4.1 3.5 1.605

101520253035404550%

Current Smokers Male Female

1986

1996

2006

Current Adult Smokers in Malaysia

~ 4 mil smokers in Malaysia; consume average 14 cigarettes/day~ 4 mil smokers in Malaysia; consume average 14 cigarettes/day

Principle of planning, delivery, evaluation of behavior change

programs

Planning• Any intervention that aims to change behaviour should:

1. be as specific as possible about its content2. spell out what is done, to whom, in what social and economic

context, and in what way 3. Clarify with underlying theories will help make explicit the key

causal links between actions and outcomes

• Important factors:– the behavior that is about to be changed– target population– The level of the intervention (individual, community or

population) – the barriers and opportunities for change– intended outcomes and outcome measures

The 5 basic ways to help smokers quitSchroeder AS. JAMA 2005;294:482-7

1. Increase the price of cigarettes2. Prohibit smoking in public places3. Create and disseminate effective counter

marketing messages about smoking (media, pack displays)

4. Ban tobacco advertising and promotion

5. Provide cessation aids – Counselling / Behavioural therapy– Pharmacotherapy

• NRT• Bupropion• Varenicline• Nortriptyline, Clonidine

Populationmeasures

(Government initiatives)

Individualmeasures

(Stop Smoking Services)

Examples of theories used• People need to recognise that their health is

threatened, and that the benefits of giving up outweigh the benefits they obtain from smoking (Health Belief Model)

• Intention to change behaviour is influenced by personal attitudes and by the behaviour and attitudes of people around them (Theory of Reasoned Action and Planned Behaviour)

• Smokers go through a series of distinct phases in their attitudes towards smoking cessation (“Stages of Change” model)

• Time and resources should be set aside for evaluation. • Attempts to change behaviour have not always led to

universal improvements in the population’s health.– E.g: different age groups react differently to incentives and

disincentives, or ‘fear’ messages. – No single method can be universally applied to influence all

behaviour and all people.

• The cultural acceptability and value of different forms of behaviour varies according to age, ethnicity, gender and socioeconomic position.

• Changing behaviour may not be a priority for the individuals being targeted. People do not necessarily make their own long-term health a priority and may want to focus on other, more immediate needs and goals.

Planning

• An intervention aimed at changing one behaviour may inadvertently lead to other changes.

• Motivated individuals actively seeking to make changes in their behaviour require a different approach from those who are unmotivated.

• Enabling individuals and communities to develop more control (or enhancing their perception of control) over their lives can act as a buffer against the effects of disadvantage, facilitating positive behaviour change.

Planning

• As well as focusing on individual factors, it is important to address the social, environmental, economic and legislative factors that affect people’s ability to change their behaviour.

• The following mechanisms were successful in some circumstances: – legislation and taxation – mass media campaigns– social marketing – community programmes – point of sale promotions.

Delivery

• Evaluation is the formal assessment of the process and impact of a programme or intervention.

• An effective evaluation is based on clearly defined outcome measures – at individual, community and population levels, as appropriate.

• Methods and outcome measures are identified during the planning phase.

• Effective interventions specify their ‘programme theory’ (or reason why particular actions are expected to have particular outcomes).

Evaluation

Framework Convention on Tobacco Control (FCTC)

Framework Convention on Tobacco Control (FCTC)

• It is the first treaty negotiated under WHO• It was developed in response to the globalization of the

tobacco epidemic• The objective is to protect present and future

generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke by providing a framework for tobacco control measures

• 150 nations have already ratified the FCTC• First Conference of the Parties—Feb 2006• Second Conference of the Parties—June 2007

• Recommended strategies:1. Demand reduction

• Price & tax measures• Protection from exposure to tobacco smoke• Regulation of the contents of tobacco products• Regulation of tobacco product disclosures• Packaging and labelling of tobacco products• Education, communication, training and public awareness• Tobacco advertising, promotion and sponsorship• Demand reduction measures concerning tobacco dependence and

cessation.

2. Supply reduction• Illicit trade in tobacco products• Sales to & by minors• Provision of support for economically viable alternative activities

1. Demand reduction• Price & tax measures

– tax policies and price policies

• Protection from exposure to tobacco smoke– measures for protection from exposure to tobacco smoke in public

places.

• Regulation of the contents of tobacco products– measures for testing and measuring the contents and emissions of

tobacco products, and for the regulation of these contents and emissions.

• Regulation of tobacco product disclosures– measures requiring manufacturers to disclose to governmental

authorities information about the contents and emissions of tobacco products.

• Packaging and labelling of tobacco products– Avoid false and misleading impressions– Contain health warnings and information on relevant constituents and

emissions of tobacco products.

• Education, communication, training and public awareness

– promote and strengthen public awareness of tobacco control issues, using all available communication tools

• Tobacco advertising, promotion and sponsorship– comprehensive ban of all tobacco advertising, promotion

and sponsorship or at least prohibit false and misleading advertisements

• Demand reduction measures concerning tobacco dependence and cessation

– design and implement effective programmes aimed at promoting the cessation of tobacco use

– establish in health care facilities and rehabilitation centres programmes for diagnosing, counselling, preventing and treating tobacco dependence

2. Supply reduction• Illicit trade in tobacco products

–eliminate all forms of illicit trade in tobacco products, including smuggling, illicit manufacturing and counterfeiting

• Sales to & by minors–prohibit the sales of tobacco products to persons

under the age set by domestic law, national law or eighteen.

• Provision of support for economically viable alternative activities

–Promote economically viable alternatives for tobacco workers, growers and individual sellers.

National Tobacco Control Programme

National Tobacco Control Programme

Vision:It is envisaged that by the year 2020, tobacco will no longer be a major public health concern in Malaysia, where decreasing national prevalence of tobacco use is halved and tobacco attributed diseases and mortality will continuously decline.

Mission:Considerations for achieving the above vision will be realised when there is widespread general public awareness concerning tobacco, its hazards and wastefulness. This appropriate knowledge then becomes the basis for established right societal attitude that translates to behavioural norm of not using tobacco

Objectives:• Decrease the prevalence of tobacco consumption

amongst Malaysians• Reduce the uptake of smoking by young people• Increase the number of smokers giving up smoking• Minimize and eventually eliminate exposure to

environmental tobacco smoke among non-smoking populations in all public and work places

• Reduce the burden of tobacco related deaths and diseases in the country

• Do away with economic and social dependence on tobacco and tobacco products for sustainable livelihood

Strategies:• Legislative control• Health promotion & public advocacy• Tobacco tax policy• Smoking cessation services• Research, monitoring and evaluation• Multisectoral collaboration & capacity

building

Barriers in tobacco control• Economic Dependence on Tobacco

– The extent to which tobacco industry contribute to a state’s economy may play a role in its political will to undertake tobacco control action.

– If a significant proportion of the workforce is engaged in tobacco industry, people may not support tobacco control for fear of job loss. Also, the state government would want to protect its revenue and workers.

– Research suggests that states that have economies that are highly dependent on tobacco are less likely to adopt strong tobacco control measures.

• Genetic and environments– There is evidence that genetic characteristics may play a

role in determining which individuals become dependent smokers (Pomerleau and O. F., 1995)(Li et al, 2003).

– It may also contribute to increased difficulty in quitting for some smokers (Heath et al, 1993)(Madden et al, 1999) or may modify the potential effectiveness of pharmaceutical aids for smoking cessation (David et al, 2003).

– Culture within the family plays a role in smoking behavior.

• Parental smoking is an important determinant of adolescent smoking uptake (Flay et al, 1994)(Distefan et al, 1989).

Barriers in tobacco control

• Interferences by tobacco companies and their business allies

• Addiction• Limited budget

– Research fund– Campaigns

• Limited manpower– Legislative enforcement

Barriers in tobacco control

Evaluation of measures taken for tobacco control

• TAK NAK – Malaysia’s first nationwide anti-smoking campaign.• Launched in February 2004 by the PM of Malaysia in order to reduce the

prevalence of smoking and smoking related morbidity and mortality.• It was a 5-year project with an annual cost of approximately RM 17 million

for the first phase of 2004/2005, RM 9 million for the second phase of 2006/2007 and the last phase was RM 9.2 million for 2008/2009.

• The campaign’s slogan “Every puff you take damages your body” was aimed at discouraging teenagers and women from starting to smoke, smokers from continuing and, friends and families to support activities to curb tobacco smoking.

• The information and attitude/belief-change efforts were communicated through multiple media channels (tv, newspapers, magazines, radio, cinema billboards, and through collateral items such as t-shirts).

UNDERSTANDING THE INFLUENCE OF THE MALAYSIA-WIDE MEDIA CAMPAIGN "TAK NAK" ON INTENTIONS TO QUIT AND PERCEIVED RISK

OF SMOKING: FINDINGS FROM THE ITC SOUTHEAST ASIA SURVEY

• The ITC Project is an international collaboration of tobacco control researchers whose mission is to evaluate the psychosocial and behavioural effects of national-level tobacco control policies throughout the world.

• This study attempted to understand what psychological processes Malaysians underwent after being exposed to aspects of the media campaign.

• Face-to-face survey• Baseline year (Jan-Mar 2005) included a cohort of

N=2006 adult male and female smokers randomly selected from six states throughout Malaysia including Kedah, Selangor, Johore, Terengganu, Sabah, and Sarawak.

Mediational model

(p<.001)

TAK NAK Exposure

Fear

Perceived Risk

Intention to Quit

(p<.001)

(p=.042)

(p=.012)

(p=.106) / (p=.187)

• Result:– Malaysian smokers who reported being more exposed to

the TAK NAK campaign had higher levels of perceived risk of the health harms of smoking and more likely to worry (feel fear) of smoking, and perceived risk and worry, in turn, were associated with having intentions to quit.

• Conclusions:– TAK NAK campaign was associated with greater quit

intentions through both enhancing perceived risk and increasing fear/worry about the health consequences of smoking.

• Every cigarette pack sold in Malaysia is required to be printed with pictorial health warning effective 1 January 2009.

• The pictorial health warnings on all cigarette packs must not be obstructed from view by any object and by any means, when displayed or offered for sale. A penalty will be imposed on any person who violate the law and be liable to a fine not exceeding RM10,000 (US$3,000) or to imprisonment for a term not exceeding two years or both.

• Malaysia ranked the fourth country in the ASEAN region to implement pictorial health warnings after Singapore (2004); Thailand (2005) and Brunei (2008).

Tobacco Industry: Circumventing the Law

• No specification of size of the pack, thus allowing the tobacco industry to introduce cigarette packs in the shape of small ‘lipstick’ boxes or ‘button’ pack.– Distortion of the picture warning as the cigarette

packaging is smaller in size and reduces the impact of pictorial health warnings significantly

• Specification of the printing of outer packaging has been exploited by tobacco industry where innovative designs were printed at the bottom on a transparent sleeve to be placed on the cigarette pack.

• Smokers can switch the position of the sleeve with the design to the top of the pack to obscure the surface of pictorial health warning.

Tobacco Industry: Circumventing the Law

• No specification of banning the use of colour and design to add a graphical component at the bottom half of the packs.

• This has led to direct exploitation by tobacco industry through utilizing colours and graphic design to distract viewers from looking at the health warnings and therefore diluting the effect of pictorial health warnings.

Tobacco Industry: Circumventing the Law

• No specification on the thickness of the black border width where the words “AMARAN” and “WARNING” and the health message text shall be printed on each unit packet and unit carton.

• The tobacco industry has capitalized on this weakness by increasing the border width with the aim to reduce the size of the pictorial health warning.

Tobacco Industry: Circumventing the Law

Recommendations for tobacco control

• Anti-smoking media campaigns should be continued.

• The tax on all tobacco products should be increased to 75% of retail price as recommended by the World Bank to make them unaffordable to youth. It is also recommended that the government introduce a 2% dedicated tax on tobacco products to support health promotion and increase anti-smoking campaigns to reduce smoking among young people.

Recommendations

(Southeast Asia Tobacco Control Alliance, 2009)

• Ban duty-free sales on tobacco products• To protect the Malaysian populace from the harms

of exposure to secondhand smoke, the government should legislate and implement 100% smoke-free environments (all private workplaces and entertainment outlets such as pubs, nightclubs, discos, karaoke lounges, casinos and nonair-conditioned eating outlets).

• Establish permanent government units with staff working full-time on tobacco control

Recommendations

(Southeast Asia Tobacco Control Alliance, 2008)

• The government should ban the display of cigarette packs at all retail outlets.

Recommendations

• New technology:– Electronic cigarettes

Recommendations

• Total ban of tobacco sales– Is it possible?

Recommendations

Thank YOu