What are the mechanisms and approaches behind changing behavior? - Chapter 6

In the previous sections, the importance of encouraging people to show healthy behavior and to refrain from unhealthy behavior has been discussed. It is also important to examine people preventively for risks and possible illnesses.

What does the development of interventions entail?

General health interventions are designed to change health behaviors in an entire population. The best-known model for this is the PRECEDE-PROCEED model. The PRECEDE element identifies various psychosocial variables that may be the goal of intervention:

• Predisposing factors: knowledge, attitudes, beliefs, personal preferences and existing skills and self-efficacy in relation to desired behavioral change
• Enabling factors: characteristics of the environment that can facilitate behavioral changes and the skills or resources needed to achieve change.
• Reinforcing factors: factors that reward desired behavioral change, for example social support.

The PRECEDE model:

1. Phase 1, social diagnosis: planners get an impression of the health problems that affect the quality of life in a community and what the strengths and weaknesses are.
2. Phase 2, epidemiological, behavioral and environmental diagnosis: the identification and assessment of health issues specific to the community and the related behavioral and environmental influences.
3. Phase 3, educational and ecological diagnosis: setting priorities and determining how behavior from phase 2 can be changed. Identification of predispositions, enabling and reinforcing factors.
4. Phase 4, administrative and policy diagnosis: the aim is to ensure that the program is consistent with the policy of the organization.

The PROCEED model: implementation of the program; the implementation of the planned intervention with three elements of evaluation:

1. Process: did the program do what it intended?
2. Impact: what impact does the intervention have on the outcome?
3. Outcome: what are the long-term effects on health?

What are the approaches to behavioral change?

How do we change behavior? The UK Government Cabinet Office identified several factors (MINDSPACE) that influence behavior and form targets for intervention. 

• The messenger: we are influenced by who spreads the information. 
• Incentives: we tend to strive for short term gains and to avoid losses. 
• Norms: we are influenced by what others do. 
• Salience: our attention is drawn to what is novel and salient from the environment. 
• Priming: our behavior is influenced by subconscious cues. 
• Affect: our emotions influence our behavior. 
• Commitments: we seek to be consistent with our beliefs and values. 
• Ego: we act in ways that make us feel better about ourselves. 

These principles can be applied in practice through what the UK Government cabinet termed the 4Es policy framework.

• Enable: through interventions in the environment, like the design of buildings.
• Encourage: through different approaches such as legislation, regulation, inventives to change, and information.
• Engage: through working with individuals and communities.
• Exemplify: through leading by example, policy consistency and organisational learning.

There are more psychological frameworks that can be used to guide the development of interventions. The best-known model in the UK is by Mitchie and colleagues (Mitchie et al. 2012). The core of their approach is a behaviour system incorporating the following three elements.

• Capability: the individuals psychological and physical capacity to engage in and activity.
• Opportunity: all factors that lie outside the individual that enable, prompt, or inhibit change.
• Motivation: involves the individual being able to make active choices related to engaging in new behaviour and having the energy to engage in them.

Strategies of change

We have seen before that behavioral change doesn't happen overnight, but gradually. The behavior can often be best described on the basis of phases. A phase model from Prochaska and di Clemente is one that is very similar to the phase models discussed earlier in this text and looks like this:

1. Pre-contemplation.
2. Contemplation.
3. Preparation.
4. Change.
5. Maintenance or relapse.

The model appears to be reasonably accurate with regard to predicting behavior. There is of course criticism of this model. The focus is on what is the best type of intervention to conduct within each state of change. For example, it makes no sense to show people how they can change while they are still in the pre-contemplation phase. An individual in the preparation or action phase will appreciate this more.

Motivating change

Providing information is an easy way to increase motivation. If individuals are not aware of the benefits of change, they are not motivated. Yet this is often not enough. The NICE guidelines for behavioral change have a number of guidelines. Key messages for behavioral change should influence:

• Outcome expectancies.
• Personal relevance.
• Positive attitude.
• Self-efficacy.
• Descriptive norms.
• Subjective norms.
• Personal and moral norms.

The Elaboration Likelihood Model (ELM) suggests that attempts to motivate people who are not interested will not succeed if you use rational arguments. Only individuals who are already interested beforehand pay attention to the information and may act accordingly. Individuals will centrally process messages sooner if they are motivated to receive an argument when:

• It is congruent with their pre-existing beliefs.
• It is personally relevant to them.
• Recipients have the intellectual capacity to understand the message.

According to the ELM, peripheral processing takes place when individuals are not motivated for a particular argument, are not really involved and have incongruent beliefs. Peripheral processing is about maximizing the credibility and attractiveness of the source of the message through the use of indirect cues and information.

Another approach to increase the influence of mass media and interpersonal communication is the use of fear messages. The protection motivation theory of Rogers (1993) says that someone behaves adaptively in response to a fear message if they have evidence that such behavior reduces a threat and if they believe they are capable of doing so. In conclusion, the most convincing messages are messages that:

• Arouse some degree of fear.
• Invoke a sense of severity if no change is made.
• Emphasis the ability of the individual to prevent the feared outcome (efficacy).

Both positive and negative framing of messages is sometimes effective.

Motivational interviewing

Another technique to motivate people is the so-called motivational interviewing. It's goal is to increase an individual's motivation to consider change, not to show how to change. During the interview, the interviewee (if all goes well) will be in a state of cognitive dissonance.

Cognitive dissonance means that someone does things that he actually disagrees with. An individual has conflicting thoughts. To get rid of the dissonance, he / she must reject a certain set of thoughts. During the interview, a smoker may realize that quitting smoking would actually be better because he has become aware of the adverse effects. Only when someone has decided to change their behavior, the interview will be focused on that.

The questions in the interview are not intended to put pressure on people. A question that could be asked is "what are the negative things about your current behavior?" Additional strategies for changing behavior are:

• Consideration of the disadvantages of the status quo.
• Consideration of the benefits of change.
• Evoking the intention to change.
• Evoking optimism about change.

Problem-solving approaches

These strategies focus primarily on how behavior can be changed and not so much why behavior should be changed. A good example is the approach of Egan (2001) and is a problem-oriented counseling approach. Counseling emphasizes the importance of a proper analysis of the problem and consists of three phases:

1. Problem exploration and clarification.
2. Goal setting.
3. Facilitating action.

An important element of his strategy is a thorough analysis of the problem. This is done by asking direct questions, descriptive questions and by giving empathic feedback. Then a suitable solution can be found.

Quit smoking

That people keep smoking is caused by two factors:

1. A conditioned response to a variety of cues in the environment (such as drinking coffee: many people smoke a cigarette with their cup of coffee).
2. A physiological need for nicotine: smoking to increase the nicotine level or to prevent the onset of withdrawal symptoms.

When someone has quit smoking, he may have trouble paying attention and concentration and become very restless. A good anti-smoking program takes this into account, as well as the difficulty that someone may have with the environmental cues and the biological withdrawal symptoms. The withdrawal symptoms are the worst for the first two to three days, and after two weeks they have virtually disappeared. However, the risk of relapse is not over yet.

One way to get rid of the behavior without any withdrawal symptoms, is to use nicotine gum or patches. This is called nicotine replacement therapy (NRT). This method often works well as long as the patches or chewing gum is used, but as soon as it is stopped, someone often falls back. The best approach is therefore a combination program: nicotine replacements and problem-oriented intervention.

Implementing plans and intentions

Planning change can be effective. These are called implementation intentions and include an if-then approach. The action must be specified in terms of when, where and how.

Following Bandura's theory of observational learning ( social learning theory ), programs have been developed that want to provoke behavioral change by showing the good example on video. Modeling can be effective, as well as practicing new behaviors.

Cognitive interventions

Cognitive theories assume that our thoughts have a major influence on the behavior that we display. If we take drug use as an example, we clearly see that the cognitions at the start of use are very different from when someone has been using drugs for a long time. In the beginning, someone is mainly focused on the positive effects. Curiosity will be satisfied and the use itself is fun. When someone becomes dependent on the substance, his cognitions will be dominated by thoughts such as "I need a shot now to feel better".

Cognitive intervention tries to make people aware that their cognitions are hypothetical. Alternative thoughts and alternative outcomes are possible, such as 'it has already been possible to have fun without the drug, so maybe it will work again'.

Beck (1976) introduced the Socratic dialogue. This is a structured conversation in which the therapist asks questions about the views on, for example, drug use. The intention is that the individual starts to wonder if he has the right cognitions about the subject. When you ask someone about why he is using something and ultimately summarize it, the reason for use is not seldom illogical, even in the patient's ears.

Changing the environment

The health belief model suggests that an environment that encourages healthy behavior should:

• Provide cues to engage in healthy behaviors or remove cues to unhealthy behavior.
• Minimize the costs and barriers associated with engaging in healthy behavior.
• Maximize the costs of engaging in health-damaging behavior.

Environmental strategies are central to the PRECEDE model.

Spreading the word

To spread new behavior in the population, individuals or groups are used to promote change. Rogers divided the population into these groups:

• Innovators: a small group of individuals with usually high status. They test new ideas.
• Early adopters: a larger group that has a wider sphere of influence than innovators. They are also described as opinion leaders.
• Early majority: this group adopts ideas reasonably early, but does not have the power to influence the rest of the population
• Late majority: the people who adopt the innovation only after adopting by the early majority. It is a careful group.
• Laggards: adopt the change as last, or not at all.

Problem-oriented strategies include:

• Goal setting.
• Action planning.
• Barrier planning / problem solving.
• Set graded tasks.
• Prompt review of behavioral goals.
• Prompt review of outcome goals.
• Prompt rewards contingent on effort or progress towards behavior.
• Prompt rewards contingent on successful behavior.