seven tenets of behaviour change
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Evaluating provision of PA advice in primary care BACR annual conference, Oct 2009 Professor Jim McKenna [email protected]. Acquiring new (and re-acquiring old) behaviours is a process not an event. It often requires learning through sequences (or approximations to ‘real life’). - PowerPoint PPT PresentationTRANSCRIPT
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Evaluating provision of PA advicein primary care
BACR annual conference, Oct 2009
Professor Jim [email protected]
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Seven tenets of behaviour change
Acquiring new (and re-acquiring old) behaviours is a process not an event.
It often requires learning through sequences
(or approximations to ‘real life’)
JACKSON (1997) H. Educ. Res. 143-150
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Seven tenets of behaviour change
JACKSON (1997) H. Educ. Res. 143-150
Psychological factors (notably beliefs and Psychological factors (notably beliefs and values) influence how people behavevalues) influence how people behave
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The more beneficial and rewarding the experience the more likely that it will be repeated.
The more punishing and unpleasant the less likely that it will be repeated.
Seven tenets of behaviour change
JACKSON (1997) H. Educ. Res. 143-150
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Behavioural experience can influence individuals’ expectancies and values
Seven tenets of behaviour change
JACKSON (1997) H. Educ. Res. 143-150
Individuals are NOT passive responders; they are proactive in behaviour change
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Social relationships and social norms have a substantial influence on how people behave
Seven tenets of behaviour change
JACKSON (1997) H. Educ. Res. 143-150
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Behaviour in NOT independent of the context in which it is undertaken.
People influence, and are influenced by, their social environment.
Seven tenets of behaviour change
JACKSON (1997) H. Educ. Res. 143-150
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Rationale for PA promotion in General Practice
• Over 20 major diseases where PA is helpful (Lynch 2002)• STRRIDE (RCT evidence); inactivity shows within 6 months• An ‘idealised’ settings for prevention• Wide access - 9 in 10 adults registered; attend at least once within 3
years; average consults/yr 4 (m) 5 (f)• Staff have unique influence• Patients are uniquely responsive• Repeated and sequential opportunities• New opportunities using Referrals and different PA messages
BUT……
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0 20 40 60
Percentage
60+
40-59
18-39
Preferred sources of support to start being active;Preferred sources of support to start being active;Inactive respondents (by age groups) Inactive respondents (by age groups)
NoneNone
VideoVideo
TelephoneTelephone
MailMail
Medical adviceMedical advice
Help kitHelp kit
GroupGroup
BookBook
Booth et al., (1997) Preventive Medicine, 26, 131-137 p135
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52
12
0
20
40
60
Intervention Control
Group
Per
cen
tage
Change (%)
PACE Project Percentage of subjects who moved from Contemplator to Action stage of change during the study
Calfas et. al. (1996) Prev Med, 25, 225-33
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0
25
50
75
100
Bas
elin
e
Fol
low
-up
Cou
nts/
hour
ControlIntervention
PACE Project PACE Project Caltrac accelerometer scores at baseline and follow-up
(n=56)Activity counts per hour worn (P<0.05)
Calfas et al., (1996) Prev Med, 25, 225-33.
60.3 vs 83.360.3 vs 83.3
63.3 vs 57.463.3 vs 57.4
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It ‘works’ with adolescents
• Spanish ‘adolescents’ (12-21 years!, n=448) showed encouraging responses to focused PA promotion in General Practice
• 41.5% were more active (3+ days/week, 30 mins(+),
moderate to vigorous) than controls at 6-months– National estimates: 26% (5-15), 17% (16-24 year-olds)
• NNT: 7 (for 6 month effect), 6 (for 1 year effect)
Ortega-Sanchez R. et al., (2004) Preventive Medicine, 38, 219-26.
Ortega-Sanchez R. et al., (2004) Preventive Medicine, 38, 219-26.
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2008 RCT (USA): Christioan et al.,2008 RCT (USA): Christioan et al., Arch Intern MedArch Intern Med, 168, 141-46, 168, 141-46
‘…‘…. . In the intervention group,In the intervention group, recommended levels of PA increasedrecommended levels of PA increased
from 26%... to 53% at 12 months (P<0.001),from 26%... to 53% at 12 months (P<0.001), compared with controls (30% to 37%)…’compared with controls (30% to 37%)…’
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Pinto et al., (2005)Pinto et al., (2005)Am J Prev MedAm J Prev Med, 29, 247-55., 29, 247-55.
Objective activity monitoring also showedObjective activity monitoring also showedsignificantly increased PA among significantly increased PA among
extended-advice versus brief advice participantsextended-advice versus brief advice participants at 3 months at 3 months
+50.79 [minutes/week] vs 11.11+50.79 [minutes/week] vs 11.11
and 6 months and 6 months +42.39 [minutes/week] vs 24.18+42.39 [minutes/week] vs 24.18
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Eden et al, (2002) Ann Intern Med,
137, 208-15 Evidence is inconclusive…
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2002 (Netherlands): 2002 (Netherlands): Pat Educ CounsPat Educ Couns, 48 131-7., 48 131-7.Low levels of performance were found for ….. physical Low levels of performance were found for ….. physical
exercise for patients with exercise for patients with hypertensionhypertension … Discussion on … Discussion on compliance with therapy in case of compliance with therapy in case of angina pectoris… angina pectoris… peripheral artery diseaseperipheral artery disease also showed a considerable also showed a considerable
gap between recommended and actual caregap between recommended and actual care
‘‘Inconclusive’ issue:Inconclusive’ issue: Patient status (even when their clinical Patient status (even when their clinical
needs are PA-responsive) adds uncertainty needs are PA-responsive) adds uncertainty
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We know that GPsCAN effectively
promote PA
So why is the evidence ‘inconclusive?
Profound influence of diverse powerful, subjective factors, including the strength
of the treating physician's recommendation
(Jackie Taylor spoke of ‘referral failure’)
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2003 (USA) Am J Pub Health 93, 635-41: 2003 (USA) Am J Pub Health 93, 635-41: ‘‘Inconclusive’ issue:Inconclusive’ issue:
Competition with other preventive options
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Flocke et al., (2006) Flocke et al., (2006) Am J Prev MedAm J Prev Med, 30, 243-51, 30, 243-51
Post intervention higher discussion rates for diet (25.7% vs Post intervention higher discussion rates for diet (25.7% vs 20.2%), exercise (27.8% vs 16.9%)….20.2%), exercise (27.8% vs 16.9%)….
No changes in patient motivation to improve behaviourNo changes in patient motivation to improve behaviour
‘‘Inconclusive’ issue:Inconclusive’ issue: Intervention does not shift behaviour Intervention does not shift behaviour
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Adding to ‘inconclusivity’• Doctors (often) question their role in H-P• Few ‘real’ chances to discuss health• Not obliged to promote PA• Doctors have to initiate most (60%+) PA discussions
• European Action on Secondary and Primary Prevention by Intervention to Reduce Events !!! (EUROASPIRE !!!): neither clinicians nor patients pay sufficient attention to lifestyle risk factors, including PA; only 23.9% of patients reported following specific advice from a health or exercise professional after their coronary event.
– Patient self-report; moderate (16.4%) and intensive (13.4%) PA
Kotseva et al. (2009) Eur. J. Cardiovasc. Prev. Rehabil. 16, 121–37
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Adding to ‘inconclusivity’
• GPs prefer to initiate discussion through ‘Illness’
• ‘Illness’ dominates the tone and content of discussions. It limits what can be said (Nordby, 2004)
• Illness is transitory; unlikely to sustain PA
• ‘Illness’ may not motivate PA in many (esp. young) people
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Inconclusivity issue: What to encourage?Recession; mental health is THE driver of economic wealth
Douglas et al., (2006) BMC Pub H, 6, 136
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Finland (2006): Hirvensalo et al.,Finland (2006): Hirvensalo et al.,Prev MedPrev Med, 41, 342-7., 41, 342-7.
34% recalled PA advice, 34% did not 34% recalled PA advice, 34% did not Recalling warnings AGAINST PA was more common Recalling warnings AGAINST PA was more common
among those having among those having heart conditions.heart conditions.Recall was lowest among sedentary, those with fewest Recall was lowest among sedentary, those with fewest
health problems, or those with no mobility issues.health problems, or those with no mobility issues.
‘‘Inconclusive’ issueInconclusive’ issue:: Patient recall variesPatient recall varies
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Women in Norway 2009:Werner and Materud. Soc Sci Med.
The ‘hard work’ of not appearing too strong or too weak, too healthy or too sick, too smart or too disarranged
Inconclusivity issue:patient consultation behaviour
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• ‘Unchangeingness’ of male body 15-35 may limit ‘self-surveillance’
• This may contribute to reputation for being ‘hard-to-reach’ (why not ‘unreached’?)
• How to follow-up people who are residentially /domestically unstable?
Adding to ‘inconclusivity’: Access
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Lack of time(in consultations)Patient implication?
Prioritisation of clinical reasons for visit‘Rule of rescue’
Lack of training(PA or behav change)
Poor reimbursement
Low counselingself-efficacy(What to encourage, How to do it? Lack of +/- feedback)
Diagnostics is more satisfying and rewarding
OBJECTIVESystematic and
effective PA promotion
(Lack of/ Concern to maintain positivity in)Patient relationship
PA attitudes and personal behaviour
What effects CAN result from an average of just 45 seconds
spent discussing PA in consultations?
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Step % accurately estimated
Odds Ratio 95% CI
Variable
Own activity stage of change
Step 1 86.5% 4.77 1.48 to 15.35
Consultation time (1-4) Step 2 87.3% 1.61 1.02 to 1.62
Lack of success (1-5) Step 3 88.1% .66 0.16 to 1.17
Lack of time (1-5) .77 0.46 to 1.42
Lack of resources (1-5) 1.02 0.55 to 1.93
McKenna et al., (1998).BJSM 32, 242-7.
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Boorman report (2009)PA among NHS staff
18 22 21 10 13 5 9
So, 71% (18 + 22 + 21 +10) of NHS staff are ‘under-active’?
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Conclusion
Even though the data are
i n c o n c l u s i v eyet emerging
…live with that,keep doing the good work you’re doing,
help someone else to do the sameand
do it with them