Health Participant Behaviour Workbook Change
HealthBehaviourChangeParticipantWorkbookMarch, 2007
The WorkbookThis workbook is designed to help health care providers (HCPs) have conversations with people aboutbehaviour change in healthcare settings where time is often limited. The theories, models andstrategies advocated in this workbook are based on evidence-based practice for how to be mostsuccessful in supporting behaviour change.This workbook contains a model for giving Brief Advice about behaviour change and for conductingbrief Behaviour Change Counselling sessions. These interventions can range anywhere from 3 to 5minutes for brief advice to 15 to 30 minutes for behaviour change counselling, depending on the timeavailable and the context of the encounter between the individual and the HCP. The aim of theseinterventions is to help the individual understand that their behaviour is putting them at risk and toencourage them to consider changing the behaviour. These interventions also offer support to assistwith undertaking the behaviour change, when the individual chooses to make change.The models work for any type of behaviour change, whether the individual is trying to create apattern of behaviour (exercising regularly, taking medications); modify an existing habitualbehaviour (changing to a low fat diet, eating more fruits and vegetables, engaging in protective sexualbehaviours); or stop a problematic pattern of behaviour (quitting smoking or drinking).Contents of this WorkbookWithin this workbook you will find: The rationale for brief behaviour change interventions by a wide variety of health care providers A model of behaviour change that encompasses many theories Principles of motivational interviewing and essential skills for encouraging behaviour change A model for structuring brief interventions, including Brief Advice and Behaviour Change CounsellingIt is more important to understand the ‘Spirit’ of behaviour change counselling than it is to memorizethe strategies and techniques of the model. While strategies and techniques are explained, adoptingthe ‘Spirit’ of the model is a primary goal as you work your way through this workbook.Winnipeg Regional Health Authority - Health Behaviour Change Workbook1
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Table of ContentsIntroduction.1What is Health Behaviour Change? .4Section I - Theoretical Background. 5Transtheoretical Model of Change. 5Motivational Interventions . 23Section 2 - Brief Interventions for Health Behaviour Change. 375 A Model . 38Brief Motivational Interventions–Brief Advice & Behaviour Change Counselling. 43Behaviour Change Interventions Summary. 47AppendicesA - Stages of Change (with Interventions) Summary Charts.B - Typical Counselling Scenarios—Using Motivational Skills to ‘ASSIST’.C - Evidence for Brief Interventions.D - Glossary of Terms.E - References.4955737577ChartsStages of Change Summary Chart.Processes for Behaviour Change.Processes and Techniques of Change .Decisional Balance Worksheet .Transtheoretical Model of Change Summary Chart.Exploring Importance & Confidence.Transtheoretical Model and Motivational Interventions.5-A Model .Comparing 5-A Model & Behaviour Change Counselling.Integrating Behaviour Change Counselling with the 5-A Model.Motivational Interventions & Traditional HCP Interventions Summary Chart.Behaviour Change Interventions Summary ChartBrief Advice & Behaviour Change Counselling.131719212226363941424447Production of this document has been made possible through a financial contribution from Health Canada.The views expressed herein do not necessarily represent the views of Health Canada.Winnipeg Regional Health Authority - Health Behaviour Change Workbook3
What isHealth Behaviour Change?The old paradigm of the health care system, where individuals go to see health care providers to reportsymptoms for practitioners to diagnose and treat, is shifting. There is a more holistic focus on theoverall health of individuals and on preventing illness and promoting health and well-being. There iswide recognition that the illnesses that the symptoms reveal are related, in part, to lifestyle behavioursof individuals. Health care providers are then faced with the need to reveal this to the individual andsuggest changes, often radical changes, to their lifestyles in order to promote health and preventillness.Among the most frequently encountered changes in behaviour that health care providers focus on are: Eat less, eat different things, adjust timing of meals Drink less alcohol, abstain altogether Be more physically active, do particular exercises Smoke fewer cigarettes, abstain altogether Take a new medication, a different one, replace one with another, at a different time Monitor levels of glucose in the blood Ingest more / less liquid Reduce intake of a substance, abstain altogetherConsultations about these changes occur with a wide range of individuals who are: At risk for heart disease Recovering from a heart attack Living with diabetes Overweight or obese, or underweight Pregnant At risk of contracting STIs Living with chronic pain Having problems with alcohol or other substance use Living with asthmaThe health care providers are usually: doctors, nurses, social workers, nutritionists, dietitians,physiotherapists, psychologists and psychiatrists, kinesiologists and fitness leaders, occupationaltherapists, dentists, health promotion practitioners, health visitors.The settings in which health behaviour change counselling occurs are widespread, and include:primary care, hospital inpatient and outpatient departments, emergency rooms, leisure facilities,occupational health clinics, homes, and counsellor’s offices.4Winnipeg Regional Health Authority - Health Behaviour Change Workbook
The TranstheoreticalModel of Change (TTM)Section ty with the Transtheoretical Model of Change (TTM)What are the 6 Stages of Change?What are the 10 Processes of Change?ExperientialBehaviouralWhat are the 2 Markers of Change?Winnipeg Regional Health Authority - Health Behaviour Change Workbook5
How Do People Change?The Framework4 Key ConstructsThe Transtheoretical Model of Change (TTM)describes how people make behavioural changes.The model is sometimes referred to as the “Stages ofChange Approach”, but to do so is misleading. Thestages themselves are only one of the four keyconstructs of the model, so to refer to the Stages ofChange approach ignores the importance of theother three constructs. The four constructs are:Stages of Change:1. Stages of Change2. Processes (and Techniques) of Change3. Critical Markers of Change4. Context of ChangeThere are ten processes of change thathave been derived from different behaviourchange theories that describe keymechanisms that move individuals throughthe stages of change. There are fiveexperiential processes and 5 behaviouralprocesses.The TTM provides a framework that helps us tounderstand the overall process that individualsengage in when making change, as well asstrategies for how others can support and assistthem to make these behavioural changes. The modelwas developed by James Prochaska and CarloDiClemente and has been refined over the past 20years.The model is one of intentional change—individualsmake a conscious decision to change. It describesreadiness for change, and how people move towardsmaking decisions and behaviour changes in theireveryday lives. It describes what happens to peopleas they change.The TTM is not a single method of change, butrather a model that is inclusive of a wide range oftherapeutic interventions and one that explains whyvarious interventions work at specific points in thechange process. Because it is inclusive of manytheories, it was given the name ‘Transtheoretical’.Carlo DiClemente has described the TTM as “adynamic, developmental, and multidimensionalchange perspective that offers an integrativeframework for understanding change” (DiClemente,2003, p.ix).6The stages highlight the specific tasks thatmark an individual’s passage towardsbehaviour change. The six stages areknown as: Precontemplation,Contemplation, Preparation, Action,Maintenance, and Termination.Processes of Change:Critical Markers of Change:As individuals move through the stages ofchange, their beliefs about how importantthe change is for them and how confidentthey feel that they can make the changeand resist temptations to return to oldbehaviours will fluctuate. It is importantto continuously track how importantchange is for individuals, as well as howconfident they are that they can makethe change.Context of Change:Five areas of functioning comprise thecontext of change. These areas containthe risk and protective factors, andresources and barriers that influenceprocesses and movement through thestages.Winnipeg Regional Health Authority - Health Behaviour Change Workbook
Construct 1Section ITheoreticalBackgroundThe Stages of ChangeTTMLasting changes to long-time behaviours seldom occur suddenly or dramatically. While a change mayappear sudden and dramatic to those observing it, chances are that the individual making the changespent some time thinking about making the change and considering how to do so before they tookaction. Action is the visible part of the change effort. Within the TTM, change is viewed as gradual,logical, sequential and controllable.The model suggests that taking active steps to make change—the dramatic, visible portion of change—is only one stage out of six in the overall process. The TTM makes the point that all six stages areimportant, and none are “bad” stages to be in. The emergence of the TTM into the field of healthpromotion and behaviour change has been likened to “the discovery of a new planet in astronomy,”(Stockwell 1992 in Rollnick, et al., 1999, p. 18).This is important to recognize as Prochaska and DiClemente’s original research indicated that less than20% of individuals who are making changes in their lives are in the action stage at any given time,but about 90% of all programs and interventions offered by professionals are intended for people inthe action stage of change, (Prochaska, et al., 1995). When we offer people assistance to change, weoffer them assistance to act, whether they are ready, willing or able to act.The Stages of Change proposed in the TTM came about after interviews with people who hadsuccessfully made changes to their behaviour without professional help or guidance. Prochaskaand DiClemente studied “self-changers”. They discovered a natural progression through the following6 ingPreparationActionMaintenanceRelapseWinnipeg Regional Health Authority - Health Behaviour Change Workbook7
Precontemplation Stage of Change“I don’t need to change.”People in the Precontemplation stage ofchange are not thinking about change. Theydo not believe that they need to change.However, other people in their lives haveidentified a problem with their behaviour andbelieve they need to change.It is common for individuals to seek medicalassistance for one issue, even an annualphysical, and then discover that there issomething else to be addressed. It is often theresponsibility of a health care provider toidentify this need for change.Individuals tend to remain in thePrecontemplation stage of change until someexternal force or event gets them movingtowards thinking about change. An externalevent could be a health crisis (e.g. heartattack). This external event may expose theindividual to information that she/he had notpreviously been aware of and that getshim/her thinking.It is useful to think about individuals in thePrecontemplation stage as being there for oneof four possible reasons, each of whichrequires a slightly different strategy from theHCP to overcome.What Kind of Precontemplation?Reluctant Precontemplation: Individuals aresimply unwilling to consider change. They arecomfortable with their current situation and donot want to risk the potential discomfort theymay feel if they try to change. Usually, they arenot aware of experiencing too many negativeconsequences of their behaviour. Focus of workis increasing importance of change.Rebellious Precontemplation: Individuals areheavily invested in being independent andmaking their own choices. They do not like to betold what to do. They often appear hostile andresistant to suggestions for change. They mayhave a great deal of knowledge about theirbehaviour and its possible consequences. Focuson factual information to increase importance ofchange.Resigned Precontemplation: Individuals feelhopeless and helpless about change. They areresigned to continuing their behaviour, oftenbecause they feel overwhelmed by their lives andtheir problems. They may have attemptedchange in the past and been unsuccessful, andnow feel like failures. Instilling hope for andconfidence to change is focus by identifying andovercoming barriers.Rationalizing Precontemplation: Individualshave created a protective rationalization for whytheir behaviour does not pose a risk tothemselves. They will often engage in point—counterpoint debates with anyone who suggestschange. While it may feel the same as rebellionto HCPs who speak with them, it is important todistinguish between the two types. Rebellion isall about emotion, while Rationalizing is allabout thoughts. Increase importance for changeby focusing on the emotional impact of thebehaviour, perhaps by identifying value conflicts.8Winnipeg Regional Health Authority - Health Behaviour Change Workbook
Contemplation Stage of ChangeSection ITheoreticalBackground“I might change”TTMIn order to move from the Precontemplation stage of change to the Contemplation stage, individualswill have received an adequate amount of information about their behaviour and identified someconnection on a personal level to that information. They are now considering making a change,though they are still uncertain about that change.It can be useful to remember that individuals in the Contemplation stage are feeling ambivalent—theyfeel two ways about their behaviour. On one hand, they want to continue as they always havebecause that is most comfortable, while on the other hand, they now are aware that there are somereally important reasons for them to make changes. Ambivalence is the hallmark of theContemplation stage of change.Individuals who are ambivalent are experiencing stress. This stress helps to motivate them to dosomething. Doing something in the Contemplation stage could mean making a decision to change, orit could mean finding a rationalization to stop thinking about it—or moving back into thePrecontemplation stage (A move back to an earlier stage of change in terms of thinking and behavingis known as recycling in the TTM.)Individuals in the Contemplation stage of change often feel stuck.Preparation Stage of Change“I will change, just not yet”Individuals in the Preparation stage of change have decided that making the behaviour change isimportant to them and that they are capable of making the change, but they are not yet ready to startactively changing. There are other things that must be taken care of before they can begin to makethe change. For example, someone who is changing their diet may want to rid the fridge andcupboards of all the ‘wrong’ foods. Often, there are barriers or obstacles to change that must beovercome.It is important not to rush individuals through this stage. It is vital for success that individuals takethe time necessary to plan and prepare for change.There are three major tasks that must be completed in the Preparation stage. One is to answer thequestion “Why am I doing this?” Answering this question resolves the ambivalence and firmlyestablishes key reasons for change. The second task is to develop a detailed plan of how they willmake the change. The plan includes identifying supports and resources, as well as how and when touse them. The third task is to prepare the significant others in their lives for the change they areabout to make. Preparing others involves soliciting support as well as identifying potential barriers toovercome, as not everyone will support their changes.Winnipeg Regional Health Authority - Health Behaviour Change Workbook9
Action Stage of Change“I am changing”Action is the stage of behaviour change that is the most obvious to those outside the change effort.Actions are visible. Others can see the old behaviours being eliminated or modified, as well as the newbehaviours being adopted. Because others can see an individual doing something different, this is thestage in which individuals often get the most support from others. Visible change is often equatedwith progress.Action, however, is not the only time of progress; it is only one of the stages in the change process.Alterations in thought, awareness, emotions and self-image occur in preceding and following stagesand are just as important to overall success.Another important thing to remember about the Action stage is that it requires the most in terms ofcommitment of time and energy from the individual making change. It is hard work to changebehaviours, an
Precontemplation Stage of Change “I don’t need to change.” 8 Winnipeg Regional Health Authority - Health Behaviour Change Workbook People in the Precontemplation stage of change are not thinking about change. They do not believe that they need to change. However, other people in their
Health-seeking behaviour practice is recognised as an essential tool to prevent the menace of hypertension. The association among health and human behaviour is a major area of interest in public health. Kasl and Cobb 1966 identified three types of health behaviour: preventive health behaviour, illness behaviour, and sick-role behaviour.
out that behaviour comes about from an interaction of ‘capability’ to perform the behaviour and ‘opportunity’ and ‘motivation’ to carry out the behaviour. New behaviour or behaviour change requires a change in one or more of these. As COM-B is an overarching framework of behaviour, it can supplement the CBT model in PWP
3 ACO Participant List 2 . 3.1 Introduction to the ACO Participant List 2 . 3.2 ACO Participant List Requirements 4 . 3.2.1 Sole Proprietor ACO Participants 5 . 3.2.2 Merged or Acquired ACO Participant Requirements 6 . 3.2.3 Merged or Acquired TIN Documentation 8 . 3.3 ACO Participant List
2. Social-psychological theories of behaviour and change Tim Jackson (2005), in his review of evidence on consumer behaviour and behavioural change, lists a total of 22 different theories and models that explain people [s behaviour. Andrew Darnton (2008a) reviews over 60 social-psychological models and theories of behaviour.
your convenience, the Reading Questions in the Participant Workbook include page number references for both the online and PDF versions of the tutorial. Training Hours Based on a pilot test of the tutorial, participants may take 3.25 to 4.5 hours to complete the introduction, the five modules, and the Reading Questions in the Participant Workbook.
The link between children‘s non-attendance and behaviour 78 Evidence from research 78. Playground behaviour – practical ideas 84 Playtime 84 Buddy schemes 85 . The more attention the teacher gives to a child‘s behaviour the more likely it is that that behaviour will be repeated. 8 Practical approaches to behaviour management in the .
NCLEX Review Participant 17 Virtual-ATI Module 3. A Day in the Life of a Virtual-ATI NCLEX Review Participant. 18. Virtual-ATI Module 3. A Day in the Life of a Virtual-ATI NCLEX Review Participant. 19. Virtual-ATI Module 5. Attainment of 50% Mile-Marker. A Day in the Life of a Virtual-ATI NCLEX Review Participant. 20 .
year [s ATSMUN, in my beloved hometown Patras, I have the honour to serve as Deputy P resident of the Historical Security Council, a position I long to serve with major gratitude an d excitement, seeking to bring out the best. In our committee I am highly ambitious to meet passion ate young people with broadened horizons, ready for some productive brainstorming. In this diplomatic journey of .
