Health and Behaviour.pptx for mjhfjhfjhkjhjhgjkhdjghjh

Health and Behaviour.pptx for mjhfjhfjhkjhjhgjkhdjghjh

1. Why is changing health-related behavior so difficult? See Ming Hong 0341455 Batch 17

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3. Changing individual behavior is clearly seen as “easier” than addressing changes in the broader socio-economic context. But this focus on individual behavioral change, has not led to great success Although much is known, there has been a failure to put into practice what the science shows to be effective . What has been done instead is to employ a range of approaches that are based on nothing much more than anecdote, gut feeling and common sense

4. SIX Common Errors Behavior change have been influenced by six common errors that make it tough.

5. It’s just common sense By common sense we mean the idea that understanding human behavior is so obvious that it needs little or no serious thought . This appeal to common sense is deliberately anti-intellectual and anti-scientific . “It is obvious what needs to be done, so let us just get on and do it.” However, if changing behavior was simply about making common sense changes and good choices then we would all be able to make whatever changes we wanted to whenever we wanted, but we DO NOT . What this kind of thinking ignores is that human behavior is the result of the interplay between habit, automatic responses to the immediate and wider environments, conscious choice and calculation , and is located in complex social environments and cultures.

6. It is about getting the message across Some argue that changing health behavior is simply a matter of getting the messages right. “If we could only get the message out there in some form which people could understand and identify with, then they would change in response. It’s like advertising a product , except we’re advertising a positive or healthy behavior.” However, the psychological sciences demonstrate that simple stimulus-response models explain only a small fraction of human behavior . The key point is that purchasing a car or a tube of toothpaste is not the same kind of behavior as making a decision to stop smoking or not to have unprotected sex. There is a great deal more to it than just getting the message across.

7. It is about getting the message across Campaigns can have an important role and can be effective, but they are only one part of a total strategy and behavioral change is not just about simple messaging.

8. Knowledge and information drive behavior All too often, we believe information from expert sources will drive behavior change. This borrows from a belief in the traditional medical model of the doctor–patient relationship, which is based on the premise that the patient comes to the doctor for their expert knowledge and understanding. This works well for patients with acute conditions, but it tends to work less well for chronic conditions , such as obesity & diabetes. If a doctor tells the patients about the negative consequences of eating too much or exercising too little, then they will change their behavior accordingly. However, this is clearly not true . Giving people information does not make them change.

9. 4. People act rationally A linked misapprehension is that people act rationally, and that they do what they know to be sensible and logical after critical and rational appraisal of the evidence. This assumes that if you tell people what is good for them and what they need to do to protect their health, they will do it . However, they clearly DO NOT. Smoking, eating, drinking and the amount of physical activity people do are activities that are ingrained in their everyday lives, routines and habits. These things help to define someone’s identity. The idea that simply providing people with information will lead to them changing their sense of who and what they are (and prompt them to seek to be a different person to the one they are now) is false.

10. 4. People act rationally Humans are indeed calculating, thinking creatures & act rationally, however only some of our behaviour work this way. There is an automatic system which responds to environmental and social cues in a way that requires very little conscious engagement . Much of our behavior is driven by this system. The ‘nudge’ refers to small changes in the physical or social environment that make specific behaviors more likely – placing fresh fruit and vegetables near the cashier counters. NUDGE

11. 5. People act irrationally Humans are neither irrational. When someone with asthma refuses to stop smoking, we might regard them as very foolish or addicted or both. But what we tend not to see is that this may not be so irrational a decision after all given their lives and experiences. People have their own reasons for doing things . Behaviors that persist tend to be functional for people. Hilary Graham noted that women living in tough circumstances, still found money for cigarettes and when asked why, said that smoking was the only chance to do something completely indulgent for themselves. In their context, smoking was therefore not an irrational thing to do. One person’s rationality is another's irrationality . It is important not to dismiss the explanations people give for what they do.

12. 6. It is possible to predict accurately Although we have made great strides in identifying key factors which shape behavior, it is still very difficult to say with any certainty how individual people will behave in any given situation. Prediction of an individual's behavior and predicting accurately what changes will flow from a specific stimulus are limited to a small number of highly automatic responses and to relatively short time frames . In even the most careful models, a great deal of variance in individual behavioral outcomes remains.

13. Conclusion Predicting behavior and supporting behavior change is neither obvious nor common sense. Careful, thoughtful science that leads to a deep understanding of the nature of what motivates people and the social and economic pressures that act upon them is required . If we can understand these, we can better support those want to change.

14. References Kelly MP, Barker M. Why is changing health-related behaviour so difficult? Public Health. 2016 Jul;136:109-16. doi : 10.1016/j.puhe.2016.03.030. Epub 2016 May 13. PMID: 27184821; PMCID: PMC4931896. https://www.theborneopost.com/2020/06/23/obesity-overweight-rates-remain-high-in-malaysia/ https://bernama.com/es/infographics/index.php?v=7148 https://www.thestar.com.my/news/nation/2019/10/31/heart-attack-leading-cause-of-death Graham H. When life's a drag: women, smoking and disadvantage. 1st ed. London: HMSO; 19931993.

15. Thank You

16. Should Early Childhood Experiences be viewed as Public Health Issue? SOHMALALITHA A/P CHANDRASEKARAN 0341337 BATCH 17 MBBS 16

17. Childhood is a process of transition from vulnerability and high dependence towards autonomy. Early childhood experiences play an important role in determining what type of person we become in adulthood. Childhood development is an important determinant of health over a lifetime of a person. Early developmental opportunities can provide a foundation for children’s academic success, health, and general well-being. Preschool-aged children experience profound biological brain development and achieve 90 percent of their adult brain volume by age 6. This physiological growth allows children to develop functional skills related to information processing, comprehension, language, emotional regulation (anxiety, depression) and motor skills. Positive experiences support children’s cognitive, social, emotional, and physical development whereas adverse experiences can hinder it. introduction 17

18. Central role Building a strong and healthy attachment with a child is fundamental for parents The child with parents who are loving and tolerant yet able to enforce clear and reasonable limits is likely to develop a high self esteem and secure attachment to the parents that will provide a template for secure attachments to others in later life. The theory of ‘attachment’ was first described by John Bowlby in the 1950s. It derived from his study of young children separated from their mother in hospital. Attachment behavior begins at around 7 months and consists of clinginess and unwillingness to be separated from the main carer, usually mother. It serves to strengthen the bond between mother and child. A securely attached child is able to use the mother as a safe base from which exploration of the outside world can begin and will also be able to cope well with brief separations. If the attachment is insecure because the parent fails to respond to the child's need for attention or holding, the child will have difficulty exploring and separating. This pattern of insecure attachment may persist throughout life affecting adult relationships. role of parents 18

19. Early Childhood Experiences Shape The Well-Being Throughout Life Family income and education, neighborhood resources, and other social and economic factors affect health at every stage of life but the effects on young children are particularly dramatic, 15 to 20 years of accumulated research shows. Those impacts able to accumulate over time and can be transmitted across generations as children grow up and become parents themselves. All parents want the best for their children but not all parents have the same resources to help their children grow up healthy. Parents’ education and income levels can create or limit opportunities to provide their children with nurturing and stimulating environments and to model healthy behaviors. “The earliest years of our lives set us on paths leading toward or away from good health.” 19

20. A large body of research also has shown that experiences in early childhood affect children’s brain, cognitive and behavioral development. Studies tracking children’s development have documented environmental factors and interactions of parents and other caregivers with children while measuring cognitive, behavioral and physical development and in some cases physical health; some of these studies have followed children into adulthood. The results consistently link children’s development with socioeconomic advantages and disadvantages in the home environments of young children. Neighborhood conditions such as safety, presence of parks and playgrounds can have a significant impact as well. 20

21. Parents’ social and economic resources can affect the quality and stability of their relationships with their infants and this could affect children’s emotional development and the cognitive stimulation they receive. Maternal depression which can inhibit mother-infant bonding is more prevalent among low-income mothers than among those with higher incomes. Higher income and/or educational attainment among parents are associated with more stimulation and response to infants and young children which are directly linked to brain development. Research also shows that however higher income generally means lower levels of chronic stress in the home as well as greater resources to cope with stressors, both of which enable parents to interact more often and more favorably with their children. This issue explains in detail how economic and social conditions can directly influence child development, shaping their health and well-being throughout their lives. 21

22. Joan Kaufman, director of the Child and Adolescent Research and Education (CARE) programme recently analyzed DNA in the saliva of happy, healthy children and of children who had been taken from abusive or neglectful parents. The children who’d experienced chronic childhood stress showed epigenetic changes in almost 3,000 sites on their DNA and on all 23 chromosomes altering how appropriately they would be able to respond to and rebound from future stressors. The adversity a child faces doesn’t have to be severe abuse in order to create deep biophysical changes that can lead to chronic health conditions in adulthood. “Kids who’ve had early adversity have a drip of fight-or-flight hormones turned on every day – it’s as if there is no off switch” 22

23. Mental health problems Children experiencing mental health problems are at increased risk of a range of adverse outcomes ranging from school exclusion and educational underachievement to relationship problems and poorer physical health. There is a high rate of continuity between child and adult mental health disorders where around half of adults with a psychiatric disorder aged 26 years first met diagnostic criteria between the ages of 11 and 15 years old. Mental health and well-being in children is influenced by individual factors such as genetics but is also affected by the wider home and community environments. While a secure home and supportive parenting build resilience, a number of factors represent risks to mental health. Such factors may be present even before the child is conceived or born and include the following ( WHO, 2012 ): Substance use in pregnancy Parental mental illness Family violence or conflict Physical ill health Poor housing and overcrowding Trauma and abuse Adverse learning environment 23

24. REFERENCES Skochelak S.E., Hammoud M.M., Lomis K.D, et al. (2021). Health System Science , Elsevier Ltd. Stevens L., Rodin I. (2011). Psychiatry (2 nd Edition), Elsevier Ltd. Advisory Board. (2019). Childhood trauma is a public health issue, CDC declares. Retrieved from Childhood trauma is a public health issue, CDC declares (advisory.com) Robert Wood Johnson Foundation. (2011). Early Childhood Experiences and Health. Retrieved from https://www.rwjf.org/en/library/research/2014/08/early-childhood-experiences-shape-health-and-well-being-througho.html 24

25. Adverse Childhood Experiences (ACEs) SOR PEE YEE (0339866) BATCH 17 MBBS 25

26. Learning Outcomes Adverse Childhood Experiences - Definition - Effects - Prevention 26

27. Definitions ABUSE Emotional Sexual Physical Domestic violence Bullying Institutional LOSS Death Neglect Separation Natural Disaster Accidents War CHRONIC STRESS Poverty Racism Invasive medical procedure Community trauma Potentially traumatic events that can have negative, lasting effects on health and well- being. 27

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29. Cases of sexual crimes against children is increasing each year 29

30. Early childhood development and ACES Early childhood = critical and sensitive period Experiences during early childhood have a disproportionately strong impact on health across the lifespan Critical period : a limited time window in which an exposure can have adverse / protective effects on development and subsequent disease outcome Sensitive period : a time period when an exposure has a stronger effect on development and hence disease risk than it would at other times 30

31. Relationship between early childhood trauma and health and well being problems in later life SOURCE: WHO 31

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34. Impacts 34

35. 1. Changes Child’s Brain Activate survival part of brain (flight & fight) Repeated / Chronic stress Interrupts normal development & impairs complex thought and learning 35

36. 2. Changes in Child’s behaviour Aggression, irritable, whiny, clingy, moody Difficulty in : communicating needs Focusing Result in : Low self efficacy Hopelessness Fear about future Lack of control 36

37. 3. Causes Long Term Problems Health issue Cardiovascular disease Diabetes Cancer Stroke Asthma Kidney disease Mental Problems Anxiety Depression Others Academic issues Drugs & alcohol abuse Smoking Unsafe sex Violence Crime 37

38. Mechanism – chronic stress lead to developing of psychopathology HPA Axis A core stress system , response to many stressor End product = receptors for cortisol ( widespread on systems that underlie developmental processes and mental and physical health) Function : contain and reverse the effects of stress responses in others system Paraventricular nucleus (PVN) Receives input from brainstem nuclei  forms hypothalamic component of the HPA axis  activate the system in response to physical stressor 38

39. During stress : Information about psychological stressors reaches the PVN Hippocampus response to psychological stressors and modulate stress response PVN releases corticotrophin-releasing hormone (CRH) and arginine vasopressin (AVP) into the portal system connecting PVN to the anterior pituitary gland  stimulates the productive and release of adrenocorticotrophic (ATCH)  release of cortisol Normal HPA axis Negative feedback loop  PVN supress the activity of HPA axis Coordinates the mobilization of the body’s resources to ensure survival Prolonged/chronic stress Lead to prolonged / repeated cortisol elevation Mechanism evolved to downregulation the HPA axis Supressed levels and blunted reactivity of cortisol Impact on physical / mental health 39

40. SOURCE: National Estimates based on 2017  Health Outcome linked to Childhood Adversity 40

41. Preventions 1. Positive Childhood Behaviours SOURCE: Journal of America Medical Association Article 41

42. 2. Government Public investments in early childhood development Adverse childhood events are preventable with appropriate social services and improvement of home conditions. Nobel laureate economist James Heckman: produced an important longitudinal study known as The Abecedarian Project. every $1 invested in intensive early childhood development would return approximately $2.50 in avoided costs. concluded that such investment would “prevent costly chronic diseases, increase productivity and potentially reduce health spending.” 42

43. References : Hawkins RE, Lawson LE, Starr SR, Borkan J, Gonzalo JD. Health Systems Science. Skochelak SE, editor. Elsevier; 2016. Bethell C, Jones J, Gombojav N, Linkenbach J, Sege R. Positive childhood experiences and adult mental and relational health in a statewide sample: Associations across adverse childhood experiences levels: Associations across adverse childhood experiences levels. JAMA Pediatr . 2019;173(11):e193007. Merck A. intro to adverse chilhood expereinces [Internet]. 2019. Available from: https://slidetodoc.com/intro-to-adverse-childhood-experiences-ppt-created-by/ Kalsea J. Koss and Megan R. Gunnar. Anual Research Review : Early adversity, the HPA axis, and child psychopathology. 4/2018. 43

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45. Should Rogerian Humanism be more prominent in medical practice? By: Tey Jin Kiat 0341224 Batch 17 By: Tee Kiat Yee 0341480 Batch 17 &

46. Learning Outcome: State and discuss Rogerian Therapy in psychotherapy. State the necessary core conditions used in Rogerian Therapy. Outline the significance and challenges of practicing Rogerian Humanism in medical practice.

47. Rogerian Humanism Person-Centered Therapy Definition A humanistic approach Deals with the ways individuals perceive themselves consciously Rather than how counselor interpret their unconscious thoughts or ideas (Smith 2019) Founded on the belief of ‘Actualizing Tendency’ by Carl Rogers Carl Rogers (1902-1987)

48. Rogerian Humanism Core Conditions Empathy Referred to as a frame of reference Counsellor tries to understand the thoughts and the feelings of client ‘Walking in someone else’s shoes’ Congruence Genuine and real counsellor Build trusting relationship between client with the counsellor Reduce negative attitudes that others placed on client Build self-esteem and trust in client’s own judgement

49. Rogerian Humanism Core Conditions Unconditional Positive Regard (UPR) Allows the client to open up and speak Without fear or being criticized or judged Counsellor accept the client in nonjudgmental warmth and compassionate way Develops ability to accept client themselves unconditionally (Hopper 2020)

50. Rogerian Humanism Uses Who can benefit from it? Relationship problems Phobias Dementia Panic attacks Substance abuse Personality disorders Low self-esteem linked to depression Stress management Eating disorders Trauma recovery

51. Rogerian Humanism Significance in Medical Practice Improved health and well-being of client Increase self-esteem, self-efficacy, quality of life and empowerment In older patient : freedom of choice, self-determination, purposeful living (Li & Porock 2014) Reduced symptoms of dementia, depression and medication use Improved cost-effectiveness Costs are lower than those in conventional care group Reduced length of hospital stay by 2.5days (Ekman et al. 2011) Increase confirmed discharge planning and discharge rate ( Ulin et al. 2016)

52. Rogerian Humanism Significance in Medical Practice Improved mutual interaction in relationships Shared-decision making Raise the understanding in clinical practice and expand social networks Improved work environment Relieve staff’s stress due to job satisfaction Shift from organizational routines to providing PCT that promotes good life Increases healthcare professionals’ resources (time, support and safety) Higher proportion of staff continue education in dementia care

53. Rogerian Humanism Challenges faced in Medical Practice Increased personal and financial costs due to fall Increased risk of patient falls in PCT clinical settings due to presence of environment enhancement such as plants and animals (Coleman 2003) In creased patient expenses for hospital care and rehabilitation Unfairness due to empathy Affect decision making due to the nature of empathy Unfairly favour patients who happen to be within the health provider's span of attention or who are similar to themselves 

54. Rogerian Humanism Challenges faced in Medical Practice Exclusion of staff's personhood Diminish the value of the staff as autonomous persons (challenges care workers’ self-worth and self-efficacy ) Result in poor working conditions , negatively affects the delivery of PCT and high turnover rates Risk for compassion fatigue Too much compassion may lead to gradual lessening of compassion and exhaustion Constant stress and anxiety for staff

55. Rogerian Humanism Should it be more prominent in medical practice? Conclusion: Yes, client- centered therapy bring about positive changes and are more effective than usual care if challenges faced when implementing PCT can be overcome A good quality therapeutic relationship can have an enormous impact for most people However, nothing is necessary and sufficient for everyone. Some practitioners might find it difficult to orientate themselves to work in a PCT fashion, preferring their traditional paternalistic approach, with all the inherent downside , at least now they have a choice, which until recently they did not have.

56. Reference List Smith. E, 2019, What are the advantages of person-centered therapy?, HealthyPlace . Retrieved May 27 2020 from shorturl.at/ nwBGH Rogers. C, 1957, The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, Vol. 21(2), page 95-103 Hopper. E, 2020, Unconditional Positive Regard., ThoughtCo. Retrieved May 28 2020 from shorturl.at/dhwT5 Li. J & Porock . D, 2014, Resident outcomes of person-centered care in long-term care: a narrative review of interventional research. International Journal of Nursing Studies. Retrieved May 28 2020 from shorturl.at/SX467 Ulin . K et al., 2016, Person-centered care: an approach that improves the discharge process. European Journal of Cardiovascular Nursing. Retrieved May 28 2020 from https://academic.oup.com/eurjcn/article/15/3/e19/5933158?login=true Coleman. E, 2003, Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the Americans Geriatrics Society. Retrieved May 30 2020 from https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1046/j.1532-5415.2003.51185.x Ekman. I et al., 2012, Person-centered care: ready for prime time. European Journal of Cardiovascular Nursing. Retrieved May 31 2020 from https://journals.sagepub.com/doi/abs/10.1016/j.ejcnurse.2011.06.008

57. Motivational Interviewing Wong Jun Shin (0335463) Yee Kar Chin (0341022) Batch 17

58. Learning outcomes Know what is motivational interviewing Learn the core skills needed to use MI Learn the stages of change Understand the theory of the model Learn the Spirit of MI

59. Motivational Interviewing Developed by William R. Miller and Stephen Rollnick (1995). It is a directive, client-centered counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. Focused and goal-directed, therapists attempt to influence clients to consider making change

60. Motivational Interviewing MI engages clients, elicits change talk and evokes patient motivation to make positive changes

61. Core skills

62. Affirmations Awards, Attempts, Achievements, Accomplishments, “This is hard work you are doing” “You were successful in changing the past” “You really care a lot about your family”

63. Reflections Understand what the client is feeling and then say it back to the client “I don’t think I have PTSD” “You’re unsure about the diagnosis of PTSD” “I’ve been this way for so long I think it’s just my personality” “So all of this seems normal to you?” “Well I don’t like the road rage or getting angry with my wife” “Road rage and getting angry at your wife are a couple things you’d like to change”

64. Summarising Long reflections of more than one client statement. “I don’t want to move” “I’d have to find a new doctor” “I like my house” “I could be closer to my grandchildren” “I might be safer in a senior housing” “If I understand you correctly, you’ve been thinking about moving to a senior housing. There’s a downside in that you’d have to find new doctors and it would be unfamiliar. You also think you’d be safer in senior housing and you’d be closer to your grandchildren”

65. Key Constructs Express empathy Develop discrepancy Avoid arguments Roll with resistance Support self-efficacy

66. Stages of Change Based on a Transtheoretical model, it is a cycle of change that has 6 stages. A person must progress through each stage of the cycle before the next but can relapse to any of the previous stages. (Prochaska and DiClemente 1977)

67. Theory of The Model It involves the combination of Client-Centered Therapy , the Self-Determination Theory , and the Transtheoretical Model (TTM) of behavior change. Client-Centered Therapy Developed by humanistic psychologist Carl Rogers Emphasizes on having unconditional positive regard with clients This concept is highlighted as absolute worth in the MI spirit of acceptance (explained later) This attitude of acceptance is without judgement & allow people to feel accepted for who they are, allowing them the space to naturally make changes that benefit them & align with their values

68. Theory of The Model 2. Self Determination Theory Emphasizes the distinction between types of motivation, intrinsic or extrinsic, and how that influences behaviour The theory considers the client’s autonomy to choose, perceived competence to make a change, and the social context When someone feels autonomous to control their own behavior and has the knowledge and skills to achieve the desired outcome, then they are more likely to put in the effort and persist in changing that behavior 3. Transtheoretical Model (TTM) To understand how ready people are to change TTM relates to MI such that the client’s readiness, or what stage of change they’re in, can be considered throughout the four processes of MI (Engaging, Focusing, Evoking & Planning) Understanding the TTM helps in assessing where individuals are in terms of readiness for change & different MI techniques can be used depending on the individual’s readiness for change

69. Main Element of The Model: The 4 aspects of the MI spirit The MI spirit consists of partnership, acceptance, compassion & evocation

70. Main Element of The Model: The 4 aspects of the MI spirit Partnership Partnership emphasizes how MI is used with and for someone to engage in an active conversation between two experts. In MI, there is a collaboration between the provider and the client. Providers must sit with the reality that they don’t have all the answers and need their client’s expertise on how change would look in their lives. The provider is not trying to convince, trick, or argue why a client should change. Instead, providers are guiding, listening, and trying to understand the client’s circumstances.

71. Main Element of The Model: The 4 aspects of the MI spirit 2. Acceptance highlights the importance of respecting what a client contributes to the partnership. There are four aspects/client-centered conditions that make up the MI spirit of Acceptance: Absolute Worth Accurate Empathy Autonomy Support Affirmation

72. Main Element of The Model: The 4 aspects of the MI spirit Absolute Worth emphasizes the concept of unconditional positive regard, such that when people are accepted without judgment, they are free to make changes. Accurate Empathy emphasizes efforts to understand a client’s perspective without feeling pity or identifying with them. Autonomy Support highlights the importance of respecting a client’s autonomy to choose, not to control, persuade, or coerce. This can facilitate change by decreasing a client’s defensiveness and emphasizes the client’s freedom of choice. Affirmation emphasizes recognition of the client’s strengths and efforts.

73. Main Element of The Model: The 4 aspects of the MI spirit 3. Compassion To highlight the importance of using MI to promote the wellbeing of others and not for our own self-interest or to exploit others. To actively promote the other’s welfare & give priority to the client’s needs It is not about emotional experiences such as sympathy which are neither necessary nor sufficient because one need not to literally “suffer with” in order to act with compassion It is different from other 3 aspects which is possible to practice in pursuit of self-interest by a skillful person

74. Main Element of The Model: The 4 aspects of the MI spirit 4. Evocation It is used to assist clients in identifying the wisdom and reasons for changing their behavior. The spirit of MI assumes that clients want and are capable of change. The provider can evoke from their clients why and how to change by paying attention to their current strengths and resources and also focus on detecting deficits to be corrected. The implicit message is “You have what you need, and together we will find it.” The assumption here is that people truly do have wisdom about themselves and have good reasons for doing what they have been doing. They already have motivation and resources within themselves that can be called on

75. Reference What is Motivational Interviewing? A Practical Theory of Change. (November 11, 2020). Retrieved from https://positivepsychology.com/motivational-interviewing-theory/ William R. Miller, Stephen Rollnick. (2012) Motivational Interviewing, Third Edition: Helping People Change. The Guilford Press Rollnick, Stephen; Miller, William R. (October 1995). "What is Motivational Interviewing?". Behavioural and Cognitive Psychotherapy . 23 (4): 325–334. doi : 10.1017/S135246580001643X Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51 (3), 390–395. https://doi.org/10.1037/0022-006X.51.3.390