Seven tenets of behaviour change

Evaluating provision of PA advicein primary care

BACR annual conference, Oct 2009

Professor Jim [email protected]

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



Psychological factors (notably beliefs and Psychological factors (notably beliefs and values) influence how people behavevalues) influence how people behave

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.



Behavioural experience can influence individuals’ expectancies and values



Individuals are NOT passive responders; they are proactive in behaviour change

Social relationships and social norms have a substantial influence on how people behave



Behaviour in NOT independent of the context in which it is undertaken.

People influence, and are influenced by, their social environment.



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……

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

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

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

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.

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%)…’

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

Eden et al, (2002) Ann Intern Med,

137, 208-15 Evidence is inconclusive…

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

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’)

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

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

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

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

Inconclusivity issue: What to encourage?Recession; mental health is THE driver of economic wealth

Douglas et al., (2006) BMC Pub H, 6, 136

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

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

• ‘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

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?

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.

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’?

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

Documents

Seven tenets of behaviour change