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Produced by The Alfred Workforce Development Team on behalf of DHS Public Health -
Diabetes Prevention and Management Initiative June 2005
Promoting Behaviour Change
For individuals and populations
Module 4.3
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Presentation purposeTarget audience
Service providers and project workers on DPMI projects
Aim
To explore the concepts of behaviour change and self management
Objectives
Provide an overview of behaviour change and self management Explore best practice models of behaviour change Discuss the key concepts of self management and empowerment Explore self management models and evidence Discuss and workshop problem solving and goal setting
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Communicating risk
Factors influencing thinking on risk People underestimate risk related to
chronic disease overestimate communicable disease
Trust Who is telling me are they trustworthy?
Risk less acceptable if: Imposed Distributed unevenly Resulting from man made Hidden/irreversible
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Behavior change cycleTrigger
Pre-contemplation
contemplation
Preparation
Action & maintenance Awareness raising
Promote benefits
Identify obstacles
Assessment
Goal setting/action plans
Promote self efficacy
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Self efficacy
Promote performance accomplishment Use verbal persuasion Role modelling Identifying feelings and helping work through
strategies to deal with feelings Meaningful to the individual
Promoting self efficacy
• Self efficacy strong predictor of behavior change
• Self efficacy is your belief in your ability to perform a task
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Developing resources to support behavior change Thinking of quitting smoking? Identifying feelings Here are all the facts that show quitting is the right choice.
Verbal persuasion
Make this site work for you. Bookmark the pages that really mean something to you.
Meaningful to the individual For more help, call the Quitline 131 848. Like all good things, it's going to take some time and effort
for you to quit smoking, but thousands of smokers in Australia have already stopped. You can too.
Identifying feelings & verbal persuasion
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Tailoring information to stages of change Deciding to Quit
Getting Ready to Quit
Quitting
Staying a Non-smoker Coping with Setbacks Helping Others Quit
Pre-contemplation
Contemplation
Preparation
Action & maintenance
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Contemplation: Deciding to QuitHere is how to get started with your quitting.You need to knowSmoking KillsCigarettes are full of poisonsSmoking causes diseaseSome benefits of quittingQuit and save a packetMore good reasons to quitDeciding to quit checklistThe internet & stopping smoking - research projectQuit Pack Order FormHow much do you spend on smoking?
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Deciding to quit checklist I’ll reduce my risk of heart attack. I’ll reduce my risk of getting cancer. I’ll feel fitter and my skin will look younger. Within twelve hours, my body will be free of
nicotine. I’ll set a great example for the children around
me. My lungs will start to recover and be able to clean
themselves properly. I’ll have more money to spend any way I choose. I’ll give myself a confidence boost by quitting
cigarettesVerbal persuasion, raise awareness
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Contemplation: Deciding to QuitTry this List all your reasons for quitting, and then number the three
reasons you think are important. Meaningful to the individual & promote
benefits
Try this From the following list, tick the things that you want to do
when you are a non-smoker. Add your own ideas in the space provided.
Having more energy to play sport or keep up with the kids. Knowing I'm back in control and no longer addicted. I'll be free from the hassle of always checking that I have
enough cigarettes. Reducing the risk of getting sick from cancer or heart
disease.Identifying feelings, promoting performance & promote benefits
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Preparation: Getting ready to QuitSmokers who plan before they quit are more successful
than those who don't, and planning can be done quickly
Understand your nicotine addiction The Quit Book Know why you smoke Smoking Record Plan ways to deal with quitting Quit course Set a date to quit Some words about weight gain Getting ready to quit checklist
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Set a date to quit
Unless there is a very good reason, make the date within two weeks from now.
Choose an easy date to stop, one when you will not be under much pressure, but will have plenty to occupy yourself.
Practice Quitting Once you have picked a date to quit, stick to it. Before you quit, you might try a practice smokefree
day to see how you would go. Or you could experiment by not smoking at times
when you normally would; This will help you to work out how much you need
to prepare for these situations when you quit completely.
Goal setting/action planning
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Action: QuittingNow's the time to put all
your work into practice and quit.
You are ready Understand withdrawal symptoms
Coping with cravings Excuses for not quitting –
myths and reality Quitting checklist
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Action: QuittingYou are ready You've made your decision to quit. You have any extra information or support you feel you
need. You've done your planning. You've set your quit date. Stick to your decision. You're doing the right thing.
Choose an approach that will work for you You could go cold turkey. For many people, this is a
successful method. You could cut down by reducing gradually If you choose to cut down make sure your quit date is set
for two weeks after you start reducing your smoking. On your quit date, cut out cigarettes altogether.
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Quitting checklist I will choose whether to stop suddenly or gradually. Withdrawal symptoms are a good sign I can confront cravings by remembering the 4Ds:
Delay Deep breathe Drink water Do something else.
I will congratulate myself every time I resist the urge for a cigarette.
Reminding myself of my reasons to quit will make it easier to refuse cigarettes.
I have the right to refuse a cigarette and can do so without upsetting others
I can keep my hands busy Even if I decide to have alcohol, I’ll stick to my decision to
quit.
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Maintenance:Staying a Non-smokerThe worst is over. You'll feel the urge to smoke less
and less, and soon you'll hardly think about cigarettes.
But the urge to smoke can return when you least expect it.
You can stay stopped, but you need to be prepared. There is always something better than a cigarette.
The new you
Find new ways to relax & other things to do
Staying a non-smoker checklist
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Maintenance:Coping with setbacksQuitting can be hard. You might be going along OK, and suddenly you feel
like smoking again.Sometimes, as you gain confidence, you actually
start to think quitting is easy, so why not smoke again? Your resolve starts to weaken.
Try this
If you have a cigarette
If you go back to regular smoking
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Method
Focus Group Individual Interviews
Content / Script Dev’t
Concept Testing
Product Testing
Final Product
Promotional Strategy
ProductDevelopment
ConceptDevelopment
Research &Development
Product Modification
Product Modification
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Consumers have had a say !
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Empowerment and self management principles HPs provide
Expertise Information Psychological support
Individual The daily decision making in the treatment of
their condition Adults more likely to make and maintain
change if they are personally meaningful and freely chosen Robert Anderson
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Key concepts of self managementRecognition of problems as seen by
the person and encouraging them to identify solution “Identifying problems often means HP
needs to be silent!!” (Skinner)Discovery and enhancement of internal
reinforcement for behavior changeEncompasses social learning and
behavioral theories
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
How self management differs from patient education
Self-Management Patient Education
Purpose: To Manage Life With Disease
To Change Behaviors
To Increase Skills/Self-Confidence
To Increase Knowledge
To Problem Solve And Make Decisions
To Use Specific Tools
Kate Lorig
Self-Management PatientEducation
Purpose To manage life with disease
To changebehaviors
To increase skills/self confidence
To increaseknowledge
To problem solveand make decisions
To use specific tools
Kate Lorig
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
How self management differs from patient education
Self Management
Patient Education
NeedsAssessment
Patient problems
What patients need to know
Content Disease, role, & emotional management
Disease knowledge and behaviors
Leader Leader is guide Leader is expert
Kate Lorig
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Evidence
Good evidence to support self management Improves quality of life Supports behavior change Decreases health care
utilisationwww.cfah.org.au Barlow. J et alWHO
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
References Robert Anderson et al “Using the empowerment
approach to help clients” Chapter 17 in “Practical psychology for diabetes Clinicians” Anderson, B and Rubin, R. Published ADA Alexandria Virginia 1996.
Barlow J. et a “Self – management approaches for people with chronic conditions: a review” Patient Education and Counseling 48 (2002) 177-187
“Patients as effective collaborators in managing chronic conditions” www.cfah.org.au
Adherence to long term therapies www.who.org go to publications link
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Diabetes self management education in Australia Norsworthy document reviewed
8 articles / 153 studies of the effectiveness of diabetes interventions.
Concluding the evidence presented provides
powerful arguments that diabetes self management education is: Able to influence behaviour change and improve
knowledge and skill for diabetes self management Can result in a reduction in secondary complication
rates Can reduce the person’s reliance on health services.
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Diabetes self management education in Australia Access and equity issues
Rural areas Indigenous people CALD communities People of low socio-
economic status.
People in socially disadvantaged areas receive fewer long consultations than people in higher socio-economic areas.
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Lois’s Story
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Self management models Disease – related, education-
focus provision of information, skill development
Behaviour change focused Readiness to change Motivational interviewing Goal orientated programs
Psychosocial – focused support Support groups Social isolation Self efficacy
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Delivery of self management programs Provided through a
variety of modalities Face to face Telephone Email Web based
Principles can be incorporated into group or individual counselling sessions
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Automated telephone disease management RCT : People with diabetes Intervention:
Received weekly calls from automated telephone system
To discuss self-care activities and hear self-care tips Control: Normal office visits and information
FINDINGS: Intervention Group
Reported fewer depressive symptoms Higher self efficacy for self care Greater satisfaction with services received Improvement in health related quality of life
Petitte et alMedical Care 38, 2000
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Automated telephone disease managementFINDINGS: Intervention Group
Reported fewer depressive symptoms Higher self efficacy for self care Greater satisfaction with services
received Improvement in health related quality of
life
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Back pain email discussion group RCT 580 subjects Intervention:
Closed moderated email discussion group & back pain book and video tape
Controls: Non health magazine subscription of their choice
Findings at 1- year: Significant improvements in pain, disability, role
function and health distress Less physician visits and hospitalisation days
Kate LorigStanford Patient Education Centre
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Behavioural weight loss program
Objective: Determine effectiveness of Internet behavioural weight loss program compared to weight loss education website
RCT 6 months, 91 subjects, 18-60yrs, 81 female, BMI 25-36
Control Group: web based information relating to weight loss
Intervention: as above plus weekly email messages, online submission of diaries, therapist feedback
FINDINGS Mean weight loss in intervention group at 6 months 4.1kg (4.5) Mean weight loss in control group at 6 months 1.6kg (3.3)Tate JAMA March 2001
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Essential elements of self management interventions Disease, medication and health
management Role management Emotional management Support enhancement of self efficacy Problem solving training Follow up Tracking and ensuring implementationThe Robert Wood Johnson FoundationThe Centre for the Advancement of Healthwww.cfah.org
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Ray’s story
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Motivational interviewing Seeks to understand the persons
frame of reference – reflective listening
Expresses acceptance and affirmation
Elicits and selectively reinforces the patients own self motivational statement, expression of problem, concern, desire and intention and ability to change.
Helen LinderLatrobe university
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Assessment/Problem definitionAimTo help clients realise they are
responsible for, and in charge of, their condition
Prioritise problems and identify situations they want to improve
Experience emotional and psychological commitment
Develop a plan of action
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Assessment/Problem definitionInterview questions1. What part of living with your
condition is the most difficult or unsatisfying for you?
2. How does the situation make you feel?
3. How does this situation have to change for you to feel better about it?
Robert Anderson
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Assessment/Problem definition4. Are you willing to take action to improve
the situation for yourself?
5. What are the steps that you can take to bring you closer to where you want to be?
6. Is there one thing that you will do when you leave here to improve things for yourself?
Robert Anderson
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Problem solving and decision making Identifying problemsSet goals Helping find alternative ways of to
accomplish goalsSetting contracts with themselvesChecking the results Making changes as needed
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Goal setting- Getting started
Choose long term goal Goals should be something you want to do
Identify steps needed to reach long term goal
Choose one of those steps to start working towards goal
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
SMART
SpecificMeasurableAchievableRealisticTimely
Flinders University
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Guidelines for helping with - Problem solving
Identify the problemList ideas Select oneAssess the resultsSubstitute another idea (if first didn’t
work)Accept that the problem may not be
solvableKate Lorig
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Behavior Change
Prevention
Chronic disease care
Target Audience Population Individual Group programs
Information
Case Management
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Implementing change Individual practiceProgram changesOrganisational approach Small incremental changes can still have
an effect Can require philosophical shift Education process/skill development Reorganisation of services Systematic approach to assessment and care
planning using tools that support identification of problem & patient generated goals
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Our changing roles Patient: ManagerHealth Professional: Assistant
Responsible to clients rather than for them
Sharing knowledge and expertise to help make informed decisions to about their care
Collaborative approach with client generated
solutions to problems as perceived by client
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
EDWARD DE BONO
It is better to have enough ideas for some of them to be wrong, than to be always right by having no ideas at all.
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