slides current until 2008 behavioural change. curriculum module i- 4 slide 2 of 47 slides current...

Slides current until 2008

Behavioural change

Behavioural changeCurriculum Module I- 4

Slide 2 of 47


Why education and management?

• Diabetes is a serious and life-long condition

• People with diabetes want information

• People with diabetes want to be in control of their condition

• Diabetes needs to be self-managed

• Diabetes is a personal responsibility


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Evidence for diabetes education

Diabetes self-management

education is effective for

improving psychosocial and

health outcomes, particularly in

the short term.

Barlow 2002, Brown 1999, Norris 2002, Roter 1998


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While no single strategy or

programme shows any clear

advantage, interventions that

incorporate behavioural and

affective components are the most

effective.

Roter 1998, Barlow 2002


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Traditional knowledge-based

diabetes education is

essential – but not sufficient

for sustained behavioural

change.

Piette 2001


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What do people with diabetes need to know?

• Personal goals, values and feelings

• Care and treatment options

• Behavioural change and problem solving

• Role of decision-maker

• How to assume responsibility


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How to educate

Effective patient education has

evolved from primarily didactic

interventions into collaborative

teaching and learning, and is always

centered on the patient.


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• This module will now present very brief overviews of three of the most common behavioural change theory/ models in use in diabetes

• It is not intended that you will be able to implement any of these theories/models from this overview

• You can find references to enhance your learning at the end

Behavioural change models


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Behavioural change models

• Transtheoretical

• Health belief

• Empowerment


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Stages of change

The transtheoretical model of behavioural change

• ‘People are at different stages of readiness to change’

• Four components:– stages– self-efficacy– decisional balance– processes of change

Prochaska 1994


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Stages

• Pre-contemplation I won’t

• Contemplation I might

• Preparation I will

• Action I am

• Maintenance I have been


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Self-efficacy

• Self-defined ability or confidence to engage in the behaviour

• Key determinant of efforts to change

• Confidence increases as people move through stages


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Decisional balance

• Two-part analysis of pros and cons of change

• Initially cons outweigh pros

• Pros gradually increase

• Usually cross in preparation

Pre-c Cont Prep Act Main

Pros

Cons


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Change processes

• Derived from models or theories that have been integrated into this framework

• Actions or interventions which assist the person to make the change


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Processes

• Consciousness raising

• Dramatic relief

• Supportive relationships

• Self re-evaluation

• Environmental re-evaluation

• Self-liberation

• Social liberation

• Stimulus control

• Counter-conditioning

• Reinforcement management


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Pre-contemplation Contemplation Preparation

Action

Self- confidence

Increasing confidence

Higher confidence

Confident temptations

Cons >Pros Cons <Pros

Cons <Pros

• Dramatic relief• Consciousness raising• Supportive relationships

• Self-evaluation• Environmental evaluation

• Self-liberation• Social liberation

• Stimulus control• Counter-conditioning• Relationships

Processes

Cons >Pros


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Stage identification

Question Stage if ‘yes’

Have you been _______ for more than the past six months?

Maintenance

Have you been _______ for less than six months?

Action

Are you planning to start _______ in the next month?

Preparation

Have you been thinking about starting _______ in the next six months?

Contemplation

Do you intend to start _______in the next six months?

Pre-contemplation

Behavioural changeCurriculum Module I-4

Slide 18 of 47ACTIVITY


Determine one goal that would

be appropriate for a person newly

diagnosed with type 2 diabetes


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Pre-contemplation

• No change for at least six months

• Lack of knowledge or conscious decision

• Low self-confidence

• Cons > pros

Interventions

– consciousness raising

– dramatic relief

– supportive relationship


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Contemplation

• Thinking about it

• Self confidence increasing

• Cons > pros

Interventions

– self re-evaluation

– environmental re-evaluation

– list pros/cons


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Preparation

• Preparing to make the change

• Self-confidence increased

• Cons = pros

Interventions

– self-liberation (contract)

– social liberation

– supportive relationships


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Action

• Actively involved in making the change

• Confidence is high

• Cons < pros

Interventions

– stimulus control

– counter-conditioning

– supportive relationships


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Maintenance

• Continuation of change

• Risk of relapse

Intervention

– reinforcement management


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Stages of change - summary

• More than just the stage

• Self-efficacy

• Decisional balance

• The right intervention at the right time


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Health belief model

Factors considered important in healthcare decisions

• Perceived severity

• Perceived susceptibility

• Value of the treatment

• Barriers to treatment

• Cost of treatment – physical and emotional

Richards 1997


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• Health belief model can predict users of healthcare services

• Barriers and costs most significant reasons for not making changes

• People calculate ‘return on investment’ based on own perceptions

Health belief model


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Perceived severity

• Ask people what they know about the condition

• How serious do they think it is

• What they know about complications

Interventions– give basic information on the

condition– do not threaten or scare


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Perceived susceptibility

How likely is it that

• The condition will get worse

• That complications will develop

Interventions– discuss with patient– stay positive - good

management will reduce likelihood


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Value of treatment

• Perception of efficacy

• Knowledge of treatment options

Interventions– discuss possible regimens– explore fears– give choices


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Barriers to treatment

• Time

• Money

• Side effects

Interventions– pros and cons of treatment– resources to confront barriers– long-term support


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Health belief model - summary

• Determine beliefs

• Respect these beliefs

• Help people to recognize benefits of treatment

• Focus on behaviour


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Empowerment

People discover and use their own

innate ability to master their diabetes

Funnell 1991, 2003


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Self-care and the therapeutic relationship

• Diabetes requires self-care

• People with diabetes provide 99% of care

• Right and responsibility to make decisions

• Continuing support and education encapsulated in a therapeutic relationship

• Internal and external resources to support the desired changes

Behavioural changeCurriculum Module I-4

Slide 34 of 47ACTIVITY


• What decisions would a person take on a daily basis?

• What might influence these decisions?

• How do you feel about people making complex decisions on their own?


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What can we do?

• Use approaches that are appropriate for people’s needs:

– focus of control

– mastery

– self-efficacy

– motivational interviewing

• Re-frame attitudes and behaviours

• Establish self-directed behavioural goals

• Assist people to select goals that are meaningful to them


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Reframe our attitudes and behaviours

• Educate for informed, self-directed decisions and problem-solving

• Ask questions

• Identify problems

• Address concerns


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Five-step model

• Identify the problem

• Explore feelings

• Set goals

• Make a plan

• Evaluate the results

Anderson 2000, 2002


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Determine one behavioural change that you would like to make or have been working on.

How would you answer the following in relation to that behavioural change?

ACTIVITY


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What is the problem?

• Which aspect of your ______ is easiest to manage?

• What is the hardest/worst thing?

• What are your greatest fears and worries?

• What makes this so hard for you?

• Why is that happening?


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How do you feel?

• What are your thoughts and feelings about _______?

• How will you feel if this does not change?

• Do you feel _______ about _______?

Feelings are not problems to be solved!


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What do you want?

• How does ______ need to change for you to feel better about it?

• What will you gain/lose?

• What can you do?

• What do you want to do?

• How important is this?


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What will you do?

• What might work?

• What has and has not worked?

• What is needed to get started?

• Which single step can be taken this week?


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How did it work?

• What did you learn?

• What barriers did you encounter?

• What support did you have?

• What did you learn about yourself?

• Would you do things the same or differently next time?


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Patient-centered education

Interventions are more effective when they:

• Are tailored to people’s preferences

• Are tailored to a people’s socio-cultural environment

• Actively engage people in goal-setting

• Incorporate coping skills

• Provide follow-up supportPiette 2000


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Changing your practice

• Set achievable goals

• Find more positives than negatives

• Solve what you can

• Accept what you cannot solve

• Seek support


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1. Anderson RM, Funnell MM, Arnold MS. Using the empowerment approach to help patients change behavior. In Anderson BJ, Rubin RR, eds. Practical Psychology for Diabetes Clinicians, 2nd edition. Alexandria: American Diabetes Association 2002; 3-12.

2. Anderson RM, Funnell MM. The Art of Empowerment: Stories and Strategies for Diabetes Educators. Alexandria: American Diabetes Association 2000.

3. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient Educ Couns 2002; 48: 17787.

4. Brown SA. Interventions to promote diabetes self-management: State of the science. Diabetes Educ 1999; 25(Suppl): 52–61.

5. Funnell MM, Anderson RM. Patient empowerment: A look back, a look ahead. Diabetes Educ 2003; 29: 454-64.

6. Funnell MM, Anderson RM, Arnold MS, Barr PA, Donnelly MB, Johnson PD, Taylor-Moon D, White NH. Empowerment: An idea whose time has come in diabetes patient education. Diabetes Educ 1991; 17: 37-41.

7. Norris SL, Engelgau MM, Naranyan KMV. Effectiveness of self-management training in type 2 diabetes: A systematic review of randomized controlled trials. Diabetes Care 2001; 24: 56187.

8. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Self-management education for adults with type 2 diabetes: A meta-analysis on the effect on glycemic control. Diabetes Care 2002; 25: 115971.

References


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9. Norris SL. Self-management education in type 2 diabetes. Practical Diabetology 2002; 22: 7–13.

10. Piette JD, Glasgow RE. Education and self-monitoring of blood glucose. In Gerstein HC, Haynes RB, eds. Evidence-based diabetes care. Hamolton: B.C. Decker, Inc. 2001; 20751.

11. Piette JD, Weinberger M, McPhee SJ. The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial. Medical Care 2000; 38: 21830.

12. Prochaska JO, Norcross JC, Diclemente CC. Changing for Good. New York: Wm Morrow & Co 1994.

13. Richards E. Motivation Compliance and Health Behaviours of the Learner in Bastable SB. Nurse as Educator. Sudbury, Mass: Jones & Bartlett Publishers 1997.

14. Roter DL, Hall JA, Merisca R, Nordstrom B, Cretin D, Svarstad B. Effectiveness of interventions to improve patient compliance: A meta-analysis. Medical Care 1998; 36: 113861.

References

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