Modification of health behaviors

Modifying and developing health behavior both imply change of a conscious and planned nature, as distinct from change that occurs unconsciously in the natural history of growth and adaptation. Therefore, sociologists, psychologists and social scientists have been working for centuries to design various behavior modification techniques, some of which are been discussed here including:
Conditioning
Modeling
Fear & Knowledge Appeals
Readiness to change model
Persuasion

1. MODIFICATION OF HEALTH BEHAVIORS ( with special reference to Pakistani context ) 30 October 2013 1 HEPLING INDIVIDUAL S TO HELP THEMSELVES!!!

2. ROAD MAP Define health behaviors. Examine the factors , that affect a person's behavior change. Discuss the prevalence of health behaviors in Pakistan. Understanding various behavior change techniques with reference to Pakistani context. Apply behavior modification strategies in health care settings. Evaluate health promotion programs in Pakistan in light of behavior modification approaches. Conclude & summarize the presentation 30 October 2013 2

3. WHY DO WE NEED HEALTH BEHAVIOR CHANGE? 100 Years Ago Versus Now 3 30 October 2013

4. What are health behaviours? Health behaviours have being defined by Matarazzo (1984) in terms of either: Health impairing habits, which he called "behavioural pathogens" (for example smoking, eating a high fat diet), or Health protective behaviours, which he defined as "behavioural immunogens" (e.g. attending a health checkups). 30 October 2013 4 (Taylor, 1999)

5. HEALTH BEHAVIOR CHANGE Health behavior change is a complex set of mechanisms and processes comprising of knowledge and beliefs, self-regulation skills and abilities and social facilitation. Health behavior change must occur to manage and prevent the onset of chronic medical conditions which result from an individual’s unhealthy behavior. Health behavior changes occur on three different levels. These are…. 30 October 2013 5 (Catalbiano & Ricciardelli, 2013)

6. TYPES OF HEALTH BEHAVIOR CHANGES 30 October 2013 6 (Catalbiano & Ricciardelli, 2013)

7. PAKISTAN’S SCENARIO Alcoholism : According to WHO report 30 % people in Pakistan are involved in alcohol consumption . Smoking : In the year 2009, the prevalence of cigarette smoking among females was 6.25% and among males was 34.47% in Pakistan. Condom use : 21.8% (46/211) in Lahore and 2.4% (5/24) in Karachi. HIV and homosexuality in Pakistan : According to National Institute of Health, 2008 “Prevalence of HIV among homosexual and bisexual Pakistani men is reaching alarming proportions” 30 October 2013 7 (WHO, 2011) (Saleem, Adrien & Razaque , 2013) (Rajabali, Khan, Warraich, Khanani & Ali, 2008)

8. PAKISTAN’S SCENARIO (CONTD.) Poor Eating Habits And Lower Exercise Rate: Obesity level is found to be 22 % in men and 37 % in women in urban area of Pakistan. Lifestyle changes, high fat and carbohydrate rich diet and lack of exercise are the prime factors . Substance Abuse : An estimated 6.45 million, of the population in Pakistan aged between 15 and 64 used drugs in the last 12 months.. 30 October 2013 8 (Ameen , 2011) (Ministry of narcotic control Pakistan, 2013 )

9. What shapes your behavior? 30 October 2013 9 (Stuart, 2009; Taylor, 1999)

10. FACTORS 30 October 2013 10 (Stuart, 2009; Taylor, 1999)

11. GETTING STARTED! 30 October 2013 11 Conditioning Modeling Educational/Knowledge Appeals Fear Appeals Cognitive Approaches Readiness to change Model/TTM Persuasion

12. CONDITIONING & MODELING Conditioning and Modeling make up one of the earliest principles of behavior change, identified by various researches. Majority knowledge and skills for health behavior change assessment and interventions come from these behavioral approaches. 30 October 2013 12 (Catalbiano & Ricciardelli, 2013) & (Taylor, 1999)

13. EXAMPLE OF CLASSIC CONDITIONING 30 October 2013 13 Unconditioned stimulus Unconditioned response (Nausea, gagging, vomiting) Unconditioned stimulus Unconditioned response (Nausea, gagging, vomiting) Conditioned stimulus Conditioned stimulus Unconditioned response (Nausea, gagging, vomiting)

14. EXAMPLE OF OPERANT CONDITIONING “Contingency Contracting’ is an example of behavioral change working on Skinner’s principle of Operant conditioning. It involves a formal contract between the patient and the therapist, defining what behaviors are to be changed and what privileges or consequences follow the performance of these behaviors. 30 October 2013 14

15. EXAMPLE OF MODELING “Self-help Program” Operates on Bandura’s concept of Modeling . Self help program includes a self help group in which the client observes others who have successfully stopped smoking, drinking or drug use and he/she can also raise expectancies for achieving the same goal. 30 October 2013 15 (Stuart, 2009)

16. KNOWLEDGE APPEALS Educational appeals make the assumption that people will change their health habits if they have correct information. Unfortunately, it’s usually not enough to make people act. Its affectivity is enhanced when combined with other factors like motivation, self-efficacy etc. 30 October 2013 16 (Taylor, 1999)

17. EXAMPLE 30 October 2013 17

18. FEAR APPEALS EXAMPLE This approach assumes that if people are fearful that a particular habit is hurting their health , they will change their behavior to reduce their fear. However, research shows that fear appeals have only a limited value in modulating health behavior change. Fear appeals are most likely to be effective for individuals who are in a precontemplation stage because they are unfamiliar with a given health risk. 30 October 2013 18 (Stroebe, 2011)

19. 19 30 October 2013 COGNITIVE APPROACHES Visualization Self-Monitoring Self-Observation Cognitive Restructuring Changing self-talk Thought Stopping/Blocking

20. PROCESS OF SELF-MONITORING 30 October 2013 20

21. Identifying and overcoming key barriers to change 30 October 2013 21

22. TRANS-THEORETICAL MODEL OF BEHAVIOR CHANGE Stages of Change Model by Prochaska & DiClemente 1986 30 October 2013 22 PRECONTEMPLATION CONTEMPLATION : PREPARATION : ACTION MAINTENANCE

23. PERSUASION & ITS ELEMENTS “Persuasion is a health promotion strategy widely used to influence individual health beliefs and behavior. People are exposed to more or less complex messages that reflect a position advocated by a source and arguments designed to support that position .” A well-known influential tool used in various behavior modification programs as it almost makes use of all other strategies like knowledge and fear appeals etc. (Stroebe, 2011) 30 October 2013 23

24. PERSUASION: THE SOURCE SOURCE CREDIBILITY : The communicator should be expert, prestigious, trustworthy, likable and similar to the audience in some respect. The communicator appears to have nothing to gain if the audience accepts the message. CONVERT COMMUNICATORS: Are those people who have overcome their undesirable behaviors. They can be very persuasive as they demonstrate a sense of mastery and self-control over their behaviors. 30 October 2013 24 (Baumeister & Bushman, 2011)

25. EXAMPLES OF PERSUASION 30 October 2013 25

26. 30 October 2013 26

27. PERSUASION: THE MESSAGE The message appeals to emotions, particularly fear and anxiety. The message also provides a course of action that will if followed reduce fear or produce personally desirable results. The message states clear-cut conclusions. The message is backed up by facts and statistics. The message is repeated as frequently as possible. 30 October 2013 (Coon & Mitterer, 2013) 27

28. PERSUASION: THE AUDIENCE (Stroebe, 2011) 28 30 October 2013 AUDIENCE: If audience is receptive to changing a health habit, then communication should only include favorable points, but if audience is not inclined to accept the message, the communication should discuss both sides of the issue.

29. LIMITS TO PERSUASION Research has demonstrated that excessively using persuasion can render the client a passive recipient to expert knowledge combined with advise giving can reduce client autonomy and generate resistance. Persuasion doesn't ensure health behavior change in a long run i.e. no guarantee of maintenance of the change. Many times, persuasive health campaigns do not cater the discrepancy between individual and population perspectives of health risk. Persuasive technologies may violate ethical grounds due to manipulation with audience for reasons other than promoting health change. Persuasion is found to be ineffective in reaching individuals of lower socioeconomic status. 30 October 2013 29 (Chaterjee, Price & M eng, 2008)

30. APPLYING HEALTH BEHAVIOR CHANGE IN HEALTHCARE SETTINGS In this high-tech world, the real challenge for HCPs is to better understand the health behaviors of humans and develop innovative methods to help people overcome their unhealthy behaviors and replace them with healthier ones . MOTIVATIONAL INTERVIEWING, defined as “A patient-centered , directive method for enhancing intrinsic motivation to change”, is the solution to these problems. MI brings about behavior change with the goal that the patient, not the practitioner, expresses concerns about the current behavior and presents arguments for change. 30 October 2013 30

31. 30 October 2013 31 MOTIVATIONAL INTERVIEWING TECHNIQUES Exchanging information Exploring Ambivalence Exploring readiness Listen Reflect Increasing Talk about change Using Interpersonal skills like Empathizing

32. Health Promotion Health Promotion Means Changing Behavior at Multiple Levels. These are: Individual : knowledge, attitudes, beliefs , personality. Example : Readiness to change Model, cognitive restructuring. Interpersonal : family, friends, peers. Example : Self-Help Program, behavior contract etc. Community : social networks, standards, norms. Example : Applying persuasion in Mass Media Campaigns Public Policy: local policies related to healthy practices. Example : Health promotion Programs like OBSI, EPI, NACP etc. 30 October 2013 32

33. HEALTH COMMUNICATION & MOBILIZATION Health communication and mobilization are two core concepts in Health promotion theories. “ Health communication, like health education, is an approach which attempts to change a set of behaviors in a large-scale target audience regarding a specific problem in a predefined period of time .” Community mobilization (CM) brings together community members, leaders and institutions at various levels to work together to identify and solve problems. Although public health sector is not so active in Pakistan, yet, we have managed to have a health education wing at the federal ministry of health comprising of only a health education advisor. 30 October 2013 33 (Qazilbash, 2006)

34. AN OVERVIEW OF HEALTH PROMOTION PROGRAMS IN PKAISTAN Malaria control program and Small pox eradication program were the first that had public health messages . Optimal Birth Spacing Initiative (OBSI 2004 ) is a public health promotional program found to have a strong communication component with an aim h ighlighting the most sensitive issue of family planning. Second is the Women Health Project , an initiative of the Ministry of Health, aims to improve women's health by addressing women issues at all levels through health promotion, community mobilization, advocacy and capacity building. 30 October 2013 34 (Qazilbash, 2006)

35. HEATH PROMOTION PROGRAMS CONTD. The National AIDS Control Program ( NACP)2002 also comes under this category. However , it couldn’t address the issue that in a country like Pakistan, where HIV-AIDS has a very low prevalence, what really was the problem behavior that NACP thought to change ? According to literature, Pakistan is one of the top three countries that have the highest prevalence of unsafe injections in the world (Simonsen et al 1999); a risk factor for spread of HIV-AIDS, yet this issue does not come as part of the problem any where. 30 October 2013 35 (Qazilbash, 2006)

36. POINTS TO PONDER FOR A NURSE Making a helping or therapeutic relationship is the first step in helping clients recognize their undesirable behaviors. Nurses, themselves are seen as role models by patients and their traits and characters are being followed too. Therefore,a nurse should be self aware of his/her own beliefs and attitudes that shape health behaviors. Using a non-judgmental and empathetic behavior also facilitates change in behavior. Nurses, as a CHN or PHN, should design coaching modules, educational campaigns and self help pamphlets to influence individual health beliefs and behavior regarding smoking, drugs and alcohol use etc. 30 October 2013 36 (Qazilbash, 2006)

37. TO SUMMARIZE All HCPs, especially nurses should realize that the existence of close family ties and extended family structure in Pakistani culture implies that we conduct culturally appropriate behavioral reforms with patients . Another underlying principle in health behavior change is the joint decision-making by the family sometimes involving the entire community in health care-seeking behavior. In near future, nurses also need to tackle the challenges of weak capacity, scarcity, in availability and inaccessibility of social media resources, minimal involvement of target audience etc. prevailing in our country. 30 October 2013 37 (Shaikh & Hatcher, 2007)

38. GUESS THE TECHNIQUE I quit smoking because I know it will damage my lung parenchyma cells. In psychiatric ward, nurses provide extra time to watch TV to patients who have successfully lessen cigarette smoking and limit the timing of watching TV for those patients who have not successfully limit their smoking habit. Mr. X verbalized that “I started wearing condoms during sexual intercourse when I watched Junaid Jhamshad on commercial of reducing STI’s” Mr. Y opt for nicotine patches to reduce his alcohol consumption when he analyzed that his friend has successfully withdrawn from alcohol by using this technique 30 October 2013 38 Knowledge appeal Operant Conditioning Persuasion: source credibility Modeling

39. CONCLUSION 30 October 2013 39 “Bad habits are like a comfortable bed, easy to get into, but hard to get out of.”-Anon “Yet People change if they come to believe it is both of value and achievable, so HCPs should keep encouraging and motivating their clients.”

40. TAKE HOME MESSAGE I promise to work on these behaviors: I will avoid high fat diet I will have 8 hours sleep at night I will avoid procrastination Reward for meeting these expectations: (list down your own rewards) Consequences for not meeting these expectation: (list down your own consequences)

41. REFERENCES Ameen, Y. (2011). Obesity increasing at alarming rate in Pakistan. The News Tribe . Retrieved from: http :// www.thenewstribe.com/2011/11/05/obesity-increasing-at- alarming-rate-in-Pakistan/ Baumeister, R. F., & Bushman, B. J. (2011). Social psychology and human nature (2 nd ed.). Wadsworth, Cengage Learning. Catalbiano, M. L., & Ricciardelli, L. A. (2013). Applied topics in health psychology (1 st ed.). Wiley-Blackwell Publishers Chaterjee, S., Price, A., & Meng, E. (2008). Healthy living with persuasive technologies: Framework, issues, and challenges. Journal of the American Medical Informatics Association, 16(2), 171- 178. Coon , D., & Mitterer, J. O. (2013). Introduction to psychology: Gateways to mind and behaviour (13 th ed.). Wadsworth, Cengage Learning. Ministry of narcotic control Pakistan. (2013). Drug use in Pakistan 2013: technical report summary. Retrieved from: http://www.unodc.org/documents/pakistan/2013.03.01ab_Sum mary_Report_Drug_Use_in_Pakistan_SvdV_v1.pdf 30 October 2013 41

42. REFERENCES Rajabali A., Khan S., Warraich H. J., Khanani M. R., & Ali S. H. (2008). HIV and homosexuality in Pakistan. Lancet Infect Diseses,8(8), 511- 515 . Saleem , N. H., Adrien, A., & Razaque, A. (2013). Risky sexual behavior, knowledge of sexually transmitted infections and treatment utilization among a vulnerable population in Rawalpindi , Pakistan . Journal of Pakistan Medical Association , 63(1 ), 1-5 . Shaikh, B. T., & Hatcher, J. (2007). Health seeking behaviour and health services utilization trends in National Health Survey of Pakistan: what needs to be done? Pak J Med Association, 57(8), 411-414. Stroebe, W. (2011). Social psychology and health (3 rd ed.). New York, NY : McGraw-Hill Stuart, G. W. (2009). Principles and practice of psychiatric nursing . (9 th ed .). St . Louis: Mosby. Taylor, E. S. (1999). Health psychology . (4 th ed.). New York, NY : McGraw-Hill World Health Organization. (2011). Global status report on alcohol and health. Retrieved from http://www.who.int/substance_abuse/publications/global_alcoh ol_report/msbgsruprofiles.pdf 30 October 2013 42

43. ANY QUESTIONS??