Behaviour change: Principles and Practice Prof Alf Collins Clinical Director for Personalised Care NHS England University of Keele Good Practice day September 13th 2018

What is it like to be you? Identity

Identity Values, beliefs, memories, habits Thoughts, feelings, behaviours

Illness as a threat to identity: the ’common sense model’ of self regulation. Leventhal H 1997

Health information can reinforce adaptive (coping) responses or maladaptive (anxiety/avoidance) responses

Example: cough Socio-cultural context: Cough=TB=death Patient may have heightened vigilance to cues from you that reinforce that ‘common sense’ belief Assess health literacy, understanding and beliefs: ’What do you know about the kind of cough you have?’ Does it concern you in any way?” Offer a helpful explanation if needed: ‘you have a throat infection caused by a virus. Your cough will improve over the next week’

Example: back pain Socio-cultural belief: Pain=damage=seek help Sociocultural belief will drive fear and avoidance behaviours that will promote chronicity Socio-cultural belief: Pain=damage=seek help Severe pain=severe damage Assess health literacy, understanding and beliefs: ’What do you know about back pain?’ Does it concern you in any way?” Offer a helpful explanation: ‘you have a muscular back pain. It can be very painful indeed. The best treatment is gentle exercise to keep the muscles moving- or they can seize up and make the pain worse’

Health literacy

3 simple steps to improving health literacy Remember Leventhal: use ‘common sense’ and helpful/positive/optimistic information that runs a low chance of being misinterpreted: Health professionals tend to speak the language of illness/pathology (arthritis/risk/infection) and much of that language has ‘folk meanings’ that reinforce the health threat axis of the common sense model

3 simple steps to improving health literacy 2. Use chunk and check and pick up on behavioural cues. Consider rephrasing if necessary

3 simple steps to improving health literacy 3. Use teach back. ‘I want to check I’ve explained this well enough: Could you tell me/show me what you have learned/what you plan to do?’

Sharing decisions…..

Shared decision making Angela Coulter 13-12-12 Shared decision making Patients: My circumstances, my preferences Clinicians: Options, benefits, harms, consequences Informed decision Informed demand on system SDM Webinar

The Silent Misdiagnosis Angela Coulter 13-12-12 The Silent Misdiagnosis Patients: unaware of all reasonable options and outcomes Clinicians: unaware of patients’ circumstances and preferences Uninformed decision Uninformed demand on system nb Montgomery SDM Webinar

The 3 talk model

Motivational interviewing/health coaching/relational approaches All rely on: A belief that patients are innately resourceful A belief that untapping innate resourcefulness and resolving ambivalence are key to taking responsibilty and changing behaviour Development of rapport is key

Rapport/trust/challenge

Building rapport

Motivational scaling: importance and confidence

Resolving ambivalence

Decisional balance

Commitment, problem solving, goal setting and follow up It’s difficult to argue with your own plans All trials demonstrate that supporting people to set their own goals and action plans is one of the most powerful tools we have

Your attitude………and how not to burn out! It’s my job to get patients to change their behaviour It’s my job to support people to consider their options and to engage with and develop their own sense of resourcefulness

Behaviour change evidence- look it up. : COM-B Behaviour change evidence- look it up!: COM-B. The behaviour change wheel. Michie et al

Thank you Alf Collins FRCA FRCP FRCGP NHS England September 2018