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Health Literacy

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Behaviour change

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Learning outcomes

You are able to:

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• explain how behaviour can be changed by the Transtheoretical model,the Com-B-model and the model of Behavioural lenses

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• name determinants that influence behaviour

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• mention interventions how tot change behaviour with the help of the Behavioural lenses

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I. Transtheoretical model of behaviour change �

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• Transtheoretical model of behaviour change is developed by Prochaska and DiClemente's 1984.

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• It describes different stages that individuals go through when behaviour change is required.

[Prochaska & Velicer, 1997]

Stages of change:

Understanding stages of change

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Understanding what stage of change the patient is in with regards to behaviour change is useful as it can help you tailor your intervention to suit that particular stage.

General principles:

1. Assess the individual’s readiness for behaviour change
2. Use motivational interviewing to enhance change
3. Influence their autonomous or intrinsic motivation
4. Elicit ‘change talk’ and reflect patients commitment
5. Offer support and guidance in self-management techniques

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[Prochaska & Velicer, 1997]

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Image 1. Transtheoretical model for designing technologies supporting an active lifestyle [Ferron & Massa 2013].

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Precontemplation:

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• There is no intention to change the behaviour, because they are not aware.
• They don't go to treatment, they just lower pressure and drop out.
• Create a link, increase the level of contradiction so that reasons for concern emerge.
• Avoid resistance, unsolicited information and requests for premature changes

PRECONTEMPLATION

No thinking about changing their

behavior or the potential benefits

[Ferron & Massa 2013].

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Contemplation:

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• They recognize that there is a problem and think seriously about being able to change.
• They have not yet committed to taking action.
• They can remain trapped for a long time, making the ambivalence chronic.
• They are more open to receiving information.

CONTEMPLATION

Thinking about behavior change but not yet acting on intention

[Ferron & Massa 2013].

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Preparation:

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• There is intention and the plan of action begins.
• Commit to making a change.

PREPARATION

Ready to change behavior but not yet acting on intention

[Ferron & Massa 2013].

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Action:

• They modify behaviour or environment with the intention of overcoming their problems.
• Requires a considerable investment of time, energy and increased external recognition

ACTION

Beginning steps towards adapting the behavior but with high risk of relapse

[Ferron & Massa 2013].

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Maintenance:

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• They work to avoid relapse and consolidate the successes achieved during the action
• Considered as a continuation of change
• It implies sustaining the effort to continue the habits that have been modified

MAINTENANCE

Maintaining the behavior risk of relapse remains

[Ferron & Massa 2013].

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The relapse:

• Returns to previous behaviour and previous stages.
• Not considered a failure
• It is part of the normal process of change, learning
• Every relapse is not the same.

Image 2. The relapse

[Ferron & Massa 2013].

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[Prochaska & Velicer, 1997]

Motivational interviewing

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[Prochaska & Velicer, 1997]

BC-Interventions: The behaviour change wheel

• A new method for characterising and designing behaviour change interventions
• Behaviour change interventions can be defined as coordinated sets of activities designed to change specified behaviour patterns.
• Three components of the COM-B model (capability, opportunity, and motivation): the skills necessary to perform the behaviour

Image 3. The COM-B system - a framework for understanding behaviour [Michie et al. 2011]

[Michie et al. 2011]

The behaviour change wheel

• A new method for characterising and designing behaviour change interventions
• The framework links policy categories and intervention functions

Image 4. The behaviour change wheel.

[Michie et al. 2011]

[Michie et al. 2011]

Changing Behaviour: The behavioural lenses

The lenses invite health professionals and clients to consider different sets of determinants that play a role in changing behaviour:

1. Habits and impulses
2. Knowing and believing
3. Seeing and realizing
4. Wanting and being able to
5. Doing and persisting

(sustaining behaviour change).

Image 5. The behaviour lenses approach. [Hermsen, 2019]

[Hermsen, 2019; Van Essen et al. 2016]

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Behavioural change and limited health literacy

Health professionals can support their clients with limited HL in working with the behavioural lenses.

Lens 1: habits and impulses. Use plain language together with clients when looking for their habits and possibilities for behaviour change.

Lens 2: knowing and believing. Use pictures, plain language and teach back.

Lens 3: seeing and realizing. Use feedback and teach back. Perhaps use digital supporting apps.

Lens 4: wanting and being able to. Motivating the client - look which strategies helps to reduce barriers.

Lens 5: doing and persisting. Look for intrinsic and extrinsic strategies for motivating the client.

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[Hermsen, 2019; Van Essen et al. 2016]

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Casus

• Carl, aged 57, single and unemployed for eighteen months
• Former order picker in warehouse, unemployed for eighteen months now. Many shifts: limited social network built up
• Little motivation to go out, especially since the death of his dog
• Important activities: once a week playing darts in the local pub; twice a week eating at his sister's house

Referral physiotherapy

• Goal: physical fitness to reduce step to labour market
• Carl has gained 20 kilos over the past two years
• He tires easily and is short of breath
• Smokes a packet of tobacco every 3 days
• He says he came mainly because the doctor required it.

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What interventions would you make?

Behavioural lens 1: Habits and impulses (1)

Image 6. Behaviour lens 1 – habits and impulses. [Hermsen, 2019]

Behavioural lens 1: Habits and impulses (2)

A large part of our behaviour is automatic. We don’t think about it.

This behaviour can consist of reflex impulses, plus our (well-worn) habits

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Use this lens to detect any automatic aspects in your client’s/target group’s behaviour and to think about how to influence them:

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• What elements in the current behaviour of your client/ target group are habitual or impulse behaviours?
• At what point and in what context does this behaviour occur?
• What triggers the impulsive behaviour? What circumstances evoke the habitual behaviour?
• What are the benefits of the current habit or impulse?

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[Hermsen, 2019]

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Behaviour varies in the extent to which it is consciously controlled or automatically triggered by stimuli from the environment.

'Nudging', Using existing habits, establishing routines

Image 7: Nudging

Image 8: establisch new routines –

p.e. eating fruit

Image 9: unwanted behaviour, but don‘t forbid - establisch new routines

Image 6. Lens 1

Behavioural lens 2: Knowing and believing (1)

Image 10. Behaviour lens 2 – Knowing and believing. [Hermsen, 2019]

We have the ability to control target behavior. Here the knowledge about and attitude toward the target behavior is an essential first step

Education, broadening the frame of mind (e.g. regarding disease perceptions)

Image 10. Behaviour lens 2

Image 11. The behavioural lenses approach [Hermsen, 2019]

Image 12. Seed a plant

Behavioural lens 2: Knowing and believing (2)

Use this lens to see the client’s/ target group’s knowledge of the target behaviour. Investigate how the client feels about the target behaviour, e.g. if he/she experience any resistance.

• What does the client/ target group know and feel about the target behaviour? Do they have sufficient knowledge?
• How are their attitudes and evaluations?
• Does the target group/client feel resistance towards the behaviour?
• (If so, is it active resistance, aimed at the feeling of perceived control (reactance: ‘nobody tells me what to do’); resistance to the content of the message (scepsis: ‘What do they know?’). Or is it passive resistance towards change due to indifference (inertia: ‘whatever’)?)
• How does the target group’s/clients social environment react to the target behaviour? What are the social norms? Do the opinion of society and the social norms of the target behaviour fit the goal? Why do or don’t they?
• What is the effect on the target group/client?

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[Hermsen, 2019]

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Behavioural lens 3: Seeing and realizing (1)

Image 13. Behaviour lens 3 – Seeing and realizing. [Hermsen, 2019]

Technology makes movement easily objectifiable

Comparing current behaviour with the desired goal. The lens is about objectively understanding one's own behaviour and its consequences.

Image 13. Behaviour lens 3

Image 14. smart watch

Behavioural lens 3: Seeing and realizing (2)

Target groups/clients are not always good at perceiving their own behaviour. They can be affected by all sorts of mechanisms that distort their perception, making them see their own behaviour as much more positive (‘I haven’t drunk much tonight’) or more negative (‘I really suck at that’) than is realistic.

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• Use this lens to detect whether your target group/client is well capable of perceiving any discrepancy between their own and the target behaviour.
• Also investigate whether they would need any help in doing so.

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[Hermsen, 2019]

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Behavioural lens 3: Seeing and realizing (3)

• What excuses or pretexts does the target group use to rationalise a perceived discrepancy between the desired behaviour and the goal?
• Does perceiving the target behaviour lead to tension regarding self-image or someone’s different social roles?
• Does the target group have sufficient information available about their own existing behaviour and the target behaviour? Is the information relevant and accessible? How could this be improved?
• Does the target group compare achievements, behaviour, beliefs and / or attitudes to others? Who are these others, and what is the effect?
• Does the target group use other people’s behaviour as an excuse for their own?
• How accurate/factual is the target group in perceiving their own behaviour?
• Can the target group/pt. still correctly assess their own behaviour in the presence of others?
• How does feedback affect performance? Can the target group accept this feedback?

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[Hermsen, 2019]

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Behavioural lens 4: Wanting and being able to (1)

Image 15. Behaviour lens 4 – Wanting and being able to. [Hermsen, 2019]

Motivation and skills to change behaviour. Looking ahead to barriers and obstacles

[de Vries, 1988]

Immage 15. Behaviour lens 4.

Behavioural lens 4: Wanting and being able to (2)

• Behaviour change is only possible when people have both genuine motivation, the necessary skills, and the opportunity to perform the desired behavior.

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• Use this lens to detect whether the target group is intrinsically (our internal drive) or extrinsically (focused on outcome) motivated to change their behaviour, whether they have the necessary skills, and will have the opportunity to express the new behavior.

[Hermsen, 2019]

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Behavioural lens 4: Wanting and being able to (3)

• How motivated is the target group to change their behaviour?
• Is the motivation based on:
• Making free choices (intrinsic; autonomy)?
• Maintaining relationships and group membership (intrinsic; relatedness)?
• Being capable, skillful (intrinsic; competence)?
• Being sensitive to rewards or threats of negative consequences (extrinsic)?
• To what extent does the target group have the skills to carry out the target behaviour?
• What are these skills?
• Would it be necessary to learn new skills?
• Or would it be advisable to make the target behaviour more achievable?
• Is there frustration because the tasks are too boring, too easy, or too hard?
• Is there frustration because the tasks take too much time or lack challenge?
• Does the target group have the opportunity to display the desired behaviour?
• What circumstances, barriers, or obstacles prevent them from carrying out the target behaviour?

[Hermsen, 2019]

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Behavioural lens 5: Doing and persisting (1)

Image 16. Behaviour lens 5 – Doing and persisting. [Hermsen, 2019]

Provides insight into the extent to which the desired behaviour is actually implemented and - most importantly - sustained.

[Roordink et al., 2021]

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Image 16. Behavioural lens 5

Image 2. The relaps

Behavioural lens 5: Doing and persisting (2)

To achieve the desired new behaviour requires trying and sticking to achievable steps.

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Use this lens to see how easy and appealing it is to try out, to repeat and to keep drawing attention to the new behaviour (for example, more frequent use of public transport).

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[Hermsen, 2019]

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Behavioural lens 5: Doing and persisting (3)

• Is there competing behaviour? If so, how? How important or appealing is the competing behaviour compared to the desired behaviour?
• How can you ensure that the target behaviour is an ongoing focus and commitment? Are there any circumstances that hinder repeatedly performing the desired behaviour or make it more difficult?
• Are there any external stimuli (impulses) that divert from the target behaviour?
• Is the target behaviour part of a common task or goal?
• Who, or what group, could you involve or is already involved? In what way?
• Can the target group rely on practical, social, or emotional support? If so, how?

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[Hermsen, 2019]

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Summery - Frameworks for Behaviour Change

• Changing behaviour change needs to look at different levels:
• individual,
• organizational,
• community,
• and population levels,
• and any intervention delivered at one level can impact on other levels.
• The most effective interventions are those that target several levels simultaneously and consistently [NICE, 2014]
• There are a variety of types of methods for effective behaviour change interventions and recommendations for practice at population, community, and individual levels.

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[NICE, 2014; Abraham & Michie, 2008]

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Aspects for Behaviour Change

1. Knowledge and outcome expectancies (improving people’s knowledge about the health consequences of their behaviours),
2. Personal relevance (drawing people’s attention to what health behaviour change would mean for them),
3. Positive affective attitudes (promoting positive feelings about behaviour change),
4. Descriptive norms (increasing the visibility of positive health behaviours in the social environment),
5. Subjective norms (improving social approval of positive health behaviours),
6. Personal and moral norms (promoting personal commitments to behaviour change),
7. Self-efficacy (increasing people’s belief in their ability to change their behaviours),
8. Intention/goal setting and the formation of concrete plans (helping people set goals and form plans on how to achieve them)
9. Behavioural contracts (facilitating that people share their plans and goals with others),
10. Social relationships (drawing attention to the social influences on health behaviours), and
11. Relapse prevention (helping people develop skills to cope with difficult situations).

[NICE, 2014; Abraham & Michie, 2008]

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Image 1. Ferron, M. & Massa, P., 2013. Transtheoretical model for designing technologies supporting an active lifestyle []. Paper presented at the Proceedings of the Biannual Conference of the Italian Chapter of SIGCHI. https://dl.acm.org/doi/10.1145/2499149.2499158

Image 2. The relapse designed by dihard, free license by freepik

Image 3. Michie et al. 2011. The COM-B system - a framework for understanding behavior. https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42?report=reader

Image 4. Michie et al., 2011. The behavior change wheel. https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42?report=reader

Image 5. Hermsen, 2019. The behavioural lenses approach. https://doi.org/10.17605/OSF.IO/6FRSY

Image 6. Hermsen, 2019. Behaviour lens 1 – habits and impulses. https://osf.io/yhq8d

Image 7: Nudging designed by eamosbot, free license by freepik

Image 8: establisch routines – p.e. eating fruit by alinaindi, free license by freepik

Image 9: Unwanted behaviour, but don‘t forbid - establisch new routines by wayhomestudios, free license by freepik

Image 10. Hermsen, 2019. Behaviour lens 2 – Knowing and believing. https://osf.io/yhq8d

Image 11: Hermsen, 2019. The behavioural lenses approach. https://doi.org/10.17605/OSF.IO/6FRSY

Image 12. Seed a plant by freepik, free license by freepik

Image 13. Hermsen, 2019. Behaviour lens 3 – Seeing and realizing. https://osf.io/yhq8d

Image 14. Smart watch designed by macrovector, free license by freepik

Image 15. Hermsen, 2019. Behaviour lens 4 – Wanting and being able to. https://osf.io/yhq8d

Image 16. Hermsen, 2019. Behaviour lens 5 – Doing and persisting. https://osf.io/yhq8d

All icons/pictograms from PowerPoint® for Microsoft 365 MSO (Version 2205 Build 16.0.15225.20172) 64 Bit

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References

• Abraham, C., & Michie, S. (2008). A taxonomy of behavior change techniques used in interventions. Health Psychol, 27(3), 379-387. doi:10.1037/0278-6133.27.3.379
• De Vries, H., Dijkstra, M., & Kuhlman, P. (1988). Self-efficacy: the third factor besides attitude and subjective norm as a predictor of behavioural intentions. Health education research, 3(3), 273-282
• Ferron, M. & Massa, P. (2013). Transtheoretical model for designing technologies supporting an active lifestyle. Paper presented at the Proceedings of the Biannual Conference of the Italian Chapter of SIGCHI.
• Hermsen, S. (2019). The behavioural lenses approach . https://doi.org/10.17605/OSF.IO/6FRSY
• Michie, S., van Stralen, M. M., West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci, 6, 42. doi:10.1186/1748-5908-6-42
• NICE. National Institute for Health and Care Excellence (2014). Behaviour change: individual approaches. Public health guideline [PH49]. Retrieved from www.nice.org.uk/guidance/ph49
• Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. Am J Health Promot, 12(1), 38-48. doi:10.4278/0890-1171-12.1.38
• Roordink, E. M., Steenhuis, I. H., Kroeze, W., Schoonmade, L. J., Sniehotta, F. F., & van Stralen, M. M. (2021). Predictors of lapse and relapse in physical activity and dietary behaviour: a systematic search and review on prospective studies. Psychology & Health, 1-24.
• Van Essen, A., Hermsen, S., Renes, RJ. (2016). Developing a theory-driven method to design for�behaviour change: two case studies. Conference paper. Design Research Society 50^th Anniversary Conference. https://www.researchgate.net/publication/304989547_Developing_a_theory-driven_method_to_design_for_behaviour_change_two_case_studies/figures?lo=1

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Literature