Increasing Capability to change
Changing behaviour can be thought of as having an initial motivational phase in which people develop their own reasons for and intention to change, and a subsequent volitional phase, in which a person’s motivation is put into action. The motivational phase can be very well supported by motivational interviewing, but other evidence-based behaviour change techniques, primarily relating to self-regulation, are useful in providing to support the volitional phase of behaviour change. They help to support someone’s capability to take the first steps towards change, and to sustain these over time: 8,9
- Self-monitoring - knowing one’s starting point, and getting feedback on the outcome of attempts to change and progress over time,
- Goal setting – more specific goals (e.g., a time and place when one will exercise) and goals related to actions rather than outcomes (e.g., exercising twice a week rather than losing a certain amount of weight) are shown to be more effective,
- Social support – having practical (e.g., having an exercise partner) and emotional (e.g., encouragement) support from others for physical activity, whether from existing friends and family or by forming new contacts with people attempting the same lifestyle changes, at the same time.
The following case study is an example of how motivational interviewing and the inclusion of self-regulatory techniques may help someone to initiate changes to become more physically active:
Sarah
In recent years, 50 year old Sarah has experienced more and more bouts of prolonged unhappiness. She has not been diagnosed with clinical depression and her primary healthcare professional (HCP) has recommended she becomes physically active. She has done little or no purposeful exercise since her teenage years when she used to hate sport and physical education at school, finding it threatening and embarrassing. Sarah is on the borderline between overweight and obese with a BMI of 29 and has been recently been diagnosed with mild hypertension. She has a family history of type 2 diabetes.
Sarah’s primary HCP knows that she doesn’t have time to provide all the support that Sarah may need to take up physical activity herself. However, she is aware that she can still play an important role in helping Sarah to strengthen her motivation to change and encourage her to seek help from other available services. Adopting a guiding approach advocated through motivational interviewing, Sarah’s primary HCP explores with Sarah what she sees as the pros and cons of becoming more active, what benefits she can identify for doing so, and what the barriers for her may be.
During this discussion, Sarah shares her belief that being more active could be important for her and might help her feel more positive about herself and life in general, but that she has not tried to become more active previously as she is not confident that she would be able to do enough to make a difference. Sarah would value the benefits of being more active if it helped her to lose some weight and get her blood pressure down. Sarah has friends who go to exercise classes, but feels she is not confident to join a group at the moment, but she would like to think she could join a group of women with similar kinds of issues at some point.
Sarah does not feel very sporty or athletic and finds it difficult to see ways in which she can be more active. Sarah’s primary HCP asks Sarah if she does much walking at the moment, and if increasing her walking could be a way to get more exercise that Sarah feels is possible for her. Sarah appears surprised and encouraged that walking could be enough. Sarah also suggests she is interested in going to the gym, but is not confident of walking in for the first time. Having endorsed the importance of physical activity for health, and helped Sarah to identify some of other benefits that she may value, Sarah’s primary HCP suggests that she may benefit from talking more about the options with an exercise professional at the local exercise referral service, and Sarah agrees to go along.
Having met an exercise advisor at her local gym, the next important task for Sarah is to set some short-term goals that provide a sense of steady and meaningful improvement. To be effective short term goals have to have a flavour of where, when, and what. They need to be specific and agreed (following the SMART principle of being Specific, Measurable, Agreed, Realistic and Time phased). In addition, goals should be small enough to be achievable but large enough to move a person towards a perceptible change in their health or fitness. Goals that are too demanding at this point may undermine confidence and disappoint if they are not reached, and goals that are too small may be discouraging as they provide little satisfaction or belief that meaningful health or wellbeing benefits will be achieved.
The exercise advisor talks through the process of setting goals with Sarah, taking into account her preferences and the barriers she sees to being more active. Time is a barrier for Sarah as she is holding down a demanding full-time job and finding it difficult to cope. Sarah suggests that her first goal could be to walk part of the way to work, as it may not take much longer than waiting for and travelling by bus as she does now. She commits to start by doing this on three mornings a week, and to review this goal in a few weeks. The exercise advisor then explains that we know that monitoring your own progress and having some social support are important when changing behaviour, and asks Sarah if there are ways in which she could incorporate these. Sarah immediately suggests that she will ask her son for his support, as she knows he enjoys physical activity and would no doubt be very encouraging. She knows he has an app on his phone to count his own daily steps, so she will ask him to install it on her phone too.
(Adapted from an original Case study10 )
Summary
NICE guidelines PH6 on behaviour change, recommend using techniques that create attitude and behaviour change within health care interventions.11 Whilst no single method can be universally applied, a combination of motivational interviewing and techniques to promote self-regulation and social support show good evidence of efficacy in research conducted in a range of settings and populations. 1,2
Take home message: Behaviour change techniques are an important part of any consultation on lifestyle advice.
Consider:
- Attending a course on behaviour change. http://www.ucl.ac.uk/behaviour-change/training
- Read more on this important topic. http://www.fyss.se/wp-content/uploads/2018/01/5.-Motivational-interviewing-about-physical.pdf
- Read NICE guidelines PH49 https://www.nice.org.uk/guidance/ph49/chapter/1-recommendations and PH6 https://www.nice.org.uk/guidance/ph6/chapter/Introduction
- Read, listen and watch from a wide choice of resources on behaviour change http://www.ucl.ac.uk/behaviour-change/resources
- The Royal College of Nursing has a useful set of pages on supporting behaviour change https://www.rcn.org.uk/clinical-topics/supporting-behaviour-change
Patient resources: A work sheet is available on behaviour change from the patient Benefit from Activity website on ‘How do I change’ http://www.benefitfromactivity.org.uk/im-ready-for-change/how-do-i-change/
Benefits for GPs and teams: Greater success and satisfaction in supporting behavioural change with all lifestyle issues, leading to reduced appointments, drug costs and healthier patients.
Acknowledgments: We would like to thank the following authors for contributing their help in making this chapter summary entitled; Physical Activity – Supporting people to change their health behaviour: Fiona Gllison Head of the Department of Health, University of Bath, Prof Stephen Rollnick, co-founder of Motivational Interviewing and Brian Johnson, Honorary Medical Advisor to Public Health Wales.
Chapter 15 - Supporting people to change their health behaviour - Factsheet - download
Now part of the RCGP clinical programme on physical activity and lifestyle
References: Can be found in Chapter 18
These factsheets are endorsed by the Royal College of General Practitioners (RCGP), British Association of Sport & Exercise Medicine (BASEM) and the Royal College of Nursing (RCN).
