Behaviour change

Behavior change.

1. Behaviour

2. Behavioural strategies Problem solving Self-monitoring Goal setting (Plan: what, how, when) Social support Self-rewards (reinforcement) Cognitive restructuring (CBT)

3. Behavioral definition Behaviour - a set of actions; the ways we conduct ourselves; the things that we do.

4. Developing a successful Intervention: key Components Identify and know your target populations Identify the behavioral goals Identify the influencing factors Identifying the appropriate strategy for affecting each influencing factors.

5. Personal Influences that Impact Behaviour Risk Appraisal: What are my chance of becoming infected because of what I do? Self Perception: What do I do about my ability to avoid risk? Emotions and Arousal: How my feelings affect my behaviour ? Relationship/Social Influence: What people, places and things affect me? Environmental: How does society influence my behaviour ?

6. How do I Change my Behaviour ? Identify a behavior you changed or tried to change. What was the impact of the behaviour on your health? How much did the change affect your life? Who/what were the obstacles to changing? What was the reward for changing? Who/what were your helper for change?

7. Behaviour Change List the important changes in the pictures ???

8. Behaviour Change Quit smoking... Tar the roads... NOT your LUNGS! Today its me, because of u... Tomorrow its u, because of me... Fully burnt Cigarette ASH Smokers Lung

9. Behaviour Change Increased interest of behaviour change in different fields with the hope that understanding it will improve the services offered Health Education Criminology Energy International development Behavioural change theories have gained recognition in health for their possible effectiveness in explaining health-related behaviours and providing insight into methods that would encourage individuals to develop and maintain healthy lifestyles

10. Behaviour Change Different terms used for behaviour change Strategic Behavioral Communication (SBC) Information, Education, Communication (IEC) Communication for Social Change (CSC) Behaviour change communication (BCC)

11. Behaviour Change Many theories exist for Behaviour change, the most prevalent are   Learning theories Social Cognitive Theory Theories of Reasoned Action and Planned Behaviour  Trans-theoretical Model  Health Action Process Approach

12. Why Do People NOT Change Behavior? People may not Understand the message See themselves as vulnerable Trust the bearers of the message People may Think the short-term benefits of current behaviors outweigh the long-term risks Some “healthy choices” are costly Recommended behavior may conflict with beliefs After all, people believe that malaria is a common disease and is not so serious Can you name more reasons?

13. Theory of Behaviour Change Pavlov’s Classical Conditioning Skinner’s Operant Behavioursim

14. Smoking Alcohol Dietary Physical Activity Non communicable diseases such as (NCDs) Diabetes Obesity Hypertension, Cancers, etc. Sexual Activity Substance abuse HIV, STD, Hepatitis Rash Driving Road Traffic Accidents Mental Disorders Behaviours Diseases Healthy life Behaviour Change Health-compromising behaviors can be eliminated by self-regulatory efforts, and by adopting health-enhancing behaviors Fortunately, human beings have, in theory, control over their conduct Behaviour Public Health

15. How to change behaviour ??? Five stages of behaviour change Stage 1 Precontemplation Stage 2 Contemplation Stage 3 Preparation Stage 4 Action Stage 5 Maintenance

16. Stages of Behaviour change… Diabetes Stage 1 Precontemplation Stage 2 Contemplation Stage 3 Preparation Stage 4 Action Stage 5 Maintenance Why should I change ???? I want to LIVE... I will save myself Prevention is better then cure Learn regarding healthy practices Filter facts from Myths Doctor calling Dietary changes Physical activity Regular medicines Positive re-enforcement, Negative re-enforcement and awarding Opinion leader I don’t have disease ….. I am no more Happy… I am worried… I am having Diabetes I am ready to change I am doing… I will continue to do….

17. Behavior change is a continuous process It involves strong community participation Refutes myths and corrects misunderstanding Social norms and public policies influence behavior change. A strategic shift must be also be attempted simultaneously. BCC often complements and supports other prevention strategies and approaches

18. Stepped approach to change A  journey  of a  thousand miles  begins with a single  step

19. What influence Behaviour ? Human behaviour is influenced by a huge range of factors. Why we do what we do into some key factors and principles that are important to consider when designing communications aimed at influencing behaviour change. ‘Individual behaviours are deeply embedded in social and institutional contexts. We are guided as much by what others around us say and do, and by the “rules of the game” as we are by personal choice.’

20. Some factors that influence behavioral change Physical stimuli Rational stimuli Skills Knowledge Social cultural factors Demographic-age, sex, etc Previous experiences Attitudes

21. Steps to Behavior Change Knowledge 1. Recalls family planning messages. 2. Understands what family planning means. 3. Can name family planning method(s) and/or source of supply. Approval 4. Responds favorably to family planning messages. 5. Discusses family planning with personal networks (family, friends) 6. Thinks family, friends, and community approve of family planning. 7. Approves of family planning. Intention 8. Recognizes that family planning can meet a personal need. 9. Intends to consult a provider. 10. Intends to practice family planning at some time. Practice 11. Goes to a provider of information/supplies/services. 12. Chooses a method and begins family planning use. 13. Continues family planning use. Advocacy 14. Experiences and acknowledges personal benefits of family planning. 15. Advocates practice to others. 16. Supports programs in the community.

22. Standard for Behaviour Change

23. Steps to Behavior Change These are the ideal steps one follows towards behavior change. They may apply to health workers or community members Knowledge: • One first learns about a new behavior (injection safety practices) • Recalls messages on Injection Safety and understands meaning of the messages • Can name Injection safety strategies and practices Approval: • One then approves of the new behavior (Injection safety Strategies) • Responds favorably to injection safety messages • Discusses injection safety with personal network (professional, colleagues, family and friends) • Thinks professional colleagues, family, friends and community approves of Injection safety practices.

24. Steps to Behavior Change cont. Intention: • One then believes this behavior is beneficial to them and intends to adopt it. • Recognizes that Injection safety strategies can meet a personal need • Intends to adopt injection safety practices Practice: • One then attempts new behavior and continues to practice. (Practices proposed under each strategy in injection safety) Advocacy • One can then promote the new behavior through their social or professional networks as a satisfied practitioner. • Experiences and acknowledges personal benefits of adopting behaviors that enhance injection safety.

25. Specific Determinants of Behavior What are some of the specific determinants of behavior we can examine? This is another useful checklist that helps to reinforce and reiterate some of the concepts previously covered. If you consider the range of items that determine behavior, it is useful to ask the following questions when designing a social marketing campaign:   Do I know the knowledge and skill levels of my target audience? Do I understand how they view risk? What do they see as the perceived risk to themselves and to others for the suggested behavior? What are their attitudes and beliefs? What consequences do they perceive? Do they feel a sense of self-efficacy whatever their social norms, intentions or demographics? Finally, what are any other relevant or pertinent characteristics we need to know?

26. Variables Underlying Behavioral Performance “Generally speaking it appears that in order for a person to perform a given behavior one or more of the following must be true: 1 . The person must have formed a strong positive intention (or made a commitment ) to perform the behavior; 2. There are no environmental constraints that make it impossible to perform the behavior; 3. The person has the skills necessary to perform that behavior; 4. The person believes that the advantages (benefits, anticipated positive outcomes ) of performing the behavior outweigh the disadvantages (costs, anticipated negative outcomes );

27. Variables Underlying Behavioral Performance 5. The person perceives more social (normative) pressure to perform the behavior than to not perform the behavior; 6. The person perceives that performance of the behavior is more consistent than inconsistent with his or her self image, or that it’s performance does not violate personal standards that activate negative self-actions; 7. The persons emotional reaction to performing the behavior is more positive than negative; 8. The person perceives that he or she has the capabilities to perform the behavior under a number of different circumstances…”

28. Which Determines Behavior: Knowledge and skills? Perceived risk? Attitudes / Beliefs? Perceived consequences? Self-efficacy? Other relevant characteristics?

29. 1. Knowledge and Skills Very briefly, the first thing to look at is the knowledge and skills of our audience What do people know about the program? Do they know how to do the target behavior? Can they access the program or service? What do we need to do to ensure they receive needed information?

30. 2. Perceived Risk Does the target audience believe they are personally susceptible or vulnerable to the kinds of problems or health issues that may incur if they do or do not perform certain behaviors ? How severe do they perceive the condition to be ? While we do not want to frighten people or use their appeals in a non-judicious way, sometimes we need to point out the kinds of risk people face to motivate them to think about behavioral changes.

31. 3. Attitudes What are the attitudes of the target audience? How do they feel about the program, service, or target behavior and the behavior we are offering ? Are there rumors in the community which would affect their attitude?

32. 4. Perceived Consequences What does the target audience believe they will gain if they adopt the target behavior? What does the target audience believe they will lose if they adopt the behavior? How can we address this situation?

33. 5. Self-efficacy Defined: Self-efficacy is An individual’s belief that he/she can do a desired behavior Do consumers believe they can adopt the target behavior the types of behaviors we are asking them to do? Do they feel they would be successfully? We need to make sure everyone has the sense they can succeed and find out what problems would prevent them from succeeding.

34. 6. Social Norms Defined: Social norms are the standards of behavior for attitude accepted as usual practice by groups of people. What do consumers perceive the norms to be? People do not like to act counter to social norms, because they feel a sense of approval and reinforcement through the people around them. Going against social norms may be too steep of price to pay, so we need to know what those norms are before advocating certain kinds of change.

35. 7. Intentions Intentions ask What does the audience already plan to do about the new behavior? How ready are they to change ? We know if people have strong intentions, that means they are fairly ready to change behavior. This predicts behavior far better than we once thought. Therefore, intentions are our important motivator for helping people move to activation.

36. 8. Demographics Race / Ethnicity Where they live Age / Gender Education Religion Marital status Income Sexual orientation Occupation

37. 9. Other Social-Psychological Determinants Self concept / Self esteem - hopes, fears, aspirations Occupational stress Religiosity Recreation and leisure Social support networks Media habits - what they watch, listen, read - how often? where? when?

38. Some Behavior Change Tools Education Effective when goals of society align with those of target audience Benefits are attractive, immediate, obvious , low costs, skills/resources to change are available Law/policy development Effective when citizens are unlikely to change on their own, and society is unwilling to pay the costs associated with risky/unhealthy behavior Marketing Effective when goals of society and those of the citizens are not entirely consistent, but citizens can be influenced to change

39. Changing behaviors: A Practical Framework The person has formed a strong positive intention (or made a commitment) to perform the behaviour. There are no environmental constraints that make it impossible for the behaviour to occur. The person has the skills necessary to perform the behaviour. The person believes the advantages (benefits, anticipated positive outcomes) of performing the behaviour outweigh the disadvantages (costs, anticipated negative outcomes).

40. Changing behaviors: A Practical Framework The person perceives more social pressure to perform the behaviour than to not perform the behaviour. The person perceives that the behaviour is consistent with their self-image and does not violate their personal standards. The person’s emotional reaction to performing behaviour is more positive than negative. The person believes (has confidence) that they can execute the behaviour under a number of different circumstances (i.e., the person has the perceived self-efficacy to execute the behaviour).

41. The Behaviour Change Wheel: hub

42. Intervention Intervention: Activities designed to change behaviors

43. The behaviour Change Wheel: inner ring

44. Behaviour Change Wheel: complete Policies: decisions made by authorities concerning interventions

45. Theories and Models of Behaviour Change There are four categories of theories of behaviour change: Focus on Individuals Social Theories and Models Structural and Environmental Constructs alone and Trans-theoretical Models These theories should be viewed as a continuum of models moving from the strictly individually-centered to the macro-level of structural and environmentally focused.

46. The Behavior Change Spiral Pre-contemplation Contemplation Preparation Action Maintenance Precontemplation : changing a behavior has not been considered; person might not realize that change is possible or that it might be of interest to them Contemplation: something happens to prompt the person to start thinking about change - perhaps hearing that someone has made changes - or something else has changed - resulting in the need for further change Preparation: person prepares to undertake the desired change – requires gathering information , finding out how to achieve the change, ascertaining skills necessary, deciding when change should take place - may include talking with others to see how they feel about the likely change, considering impact change will have and who will be affected Action: people make changes, acting on previous decisions, experience, information , new skills, and motivations for making the change Maintenance: practice required for the new behavior to be consistently maintained, incorporated into the repertoire of behaviors available to a person at any one time

47. The Behavior Change Spiral in the context of the Enabling Environment Pre-contemplation Contemplation Preparation Action Maintenance Social features eg nature of personal relationships ; expectations of class, position, age, gender ; access to knowledge, information. Cultural features - the behaviors and attitudes considered acceptable in given contexts - eg relating to sex , gender, drugs, leisure, participation Ethical and spiritual features - influence of personal and shared values and discussion about moral systems from which those are derived - can include rituals, religion and rights of passage Legal Features - laws determining what people can do and activities to encourage observance of those laws Political features - systems of governance in which change will have to take place - can, for example , limit access to information and involvement in social action Resource features - affect what is required to make things happen - covers human, financial and material resources; community knowledge and skills; and items for exchange 6 Features of the Enabling Environment Personal Behavior Change Spiral

48. Audiences along a Behavior Change Continuum: Possible Communication Strategies Unaware Aware, concerned, knowledgeable Motivated to Change Tries New Behavior Sustains New Behavior Raise awareness Recommend a solution Identify perceived barriers and benefits to behavior change Provide logistical information Use community groups to counsel and motivate Provide information on correct use Encourage continued use by emphasising benefits Reduce barriers through problem solving Build skills through behavioral trials Social support Remind them of benefits of new behavior Assure them of their ability to sustain new behavior Social support

49. Theory of Subjective Culture and Interpersonal Relations “…the likelihood of performing a given behavior is determined by intentions , habits and facilitating factors. Intentions are, in turn, viewed as a function of: - perceived consequences of performing the behavior (outcome expectancies) - social influences (including norms, roles and the self concept) and - emotions

50. Community-level Structural Models “Suggests that environmental forces beyond the control of the individual constrain or help the knowledge-behavior link:[for example] Presence or absence of legal restrictions - eg availability of condoms Wage scales - which define what proportion of people will have the resources to purchase STD medication Access - to clinics capable of diagnosing and treating STDs Each of these would make it either harder or easier for an individual who learned about a practice to realize it. Programming Implication Also suggests that while individual education may be one strategy for achieving behavior change, change in societal level structures may be a more effective starting point - eg availability of condoms ”

51. Social Expectation Models “Suggests that behavior which appears to be individual may be viewed as a social behavior .. Individual practices are substantially the result of conformity to the expectations of others. Two paths through which private acts may be socially influenced : Direct Experience - the social network communicates the private experience - for example expected and acceptable sexual practices through sexual experience with particular partners Outside of Direct Experience - for example through conversation amongst those in asocial network, mass media, books, observation of others, all may provide as to what is expected or acceptable May be that people are unable to articulate, or example, why they use condoms, they just do it. Their conformity reflects the demands of their social network without any reflective process producing awareness of those demands. Need to ask the question - ‘how do groups change their behavior?’ rather than ‘how do individuals change their behavior?’

52. Health Communication

53. Client Expectations To be heard and understood The opportunity to tell their story To gain information To feel able to cope Failure to meet expectations leads to frustration

54. Empathy “The ability to empathise is key. Those with empathy have the ability to put themselves in others shoes, to see things from others perspectives and to gauge the likely impact of their behaviour.” “Empathy is not just nice to have – it’s a crucial and sophisticated skill. Without it we diminish our ability to influence; we create needless conflict and resistance”

55. Key Skills Active Listening Skills Greeting/opening the interview Non-verbal communication Reflection (min. encouragers, paraphrasing, reflecting feelings, summarising) Ending the interview

56. The Evidence The single most important factor for an effective helping relationship is the practitioners possession of strong interpersonal skills There is good evidence that a client centred approach: Improves clinical outcomes Increases client satisfaction Improves compliance Reduces patients concerns

57. The Evidence ‘Good Communication is Good Evidence-Based Medicine’ ‘The therapists style can and does influence motivation and change’

58. But I have no time…. The use of good listening skills can be very effective – even in a short space of time.

59. Understanding motivation Brain processes that energise and direct behaviour Not limited to choice and goal pursuit Needs to include drive habit desire instinct self-regulation etc. 59

60. Motivation Motivation is not something you can do to people It has to come from within It is not an ‘all or nothing’ state It is influenced by the helping style of the health practitioner

61. Motivating Change The goal of motivational interviewing is that the patient, not the practitioner, expresses concerns about the current behaviour and presents arguments for change .

62. Specific Motivational Strategies Exchanging information Explore current behaviours Explore Ambivalence Explore motivation/readiness

63. Exploring Motivation/Readiness Importance Reasons Confidence Obstacles

64. Motivation: reflective and automatic 64 Beliefs about what is good and bad, conscious intentions, decisions and plans Emotional responses, desires and habits resulting from associative learning and physiological states Automatic Reflective

65. PRIME Theory: the structure of human motivation 65