February 2010 Examining Behaviour Change Interventions The World Health Organisation states that an unhealthy diet and physical inactivity are two of the main preventable risk factors for the major chronic diseases such as cardiovascular diseases, cancer, and diabetes. The 2008 inaugural Zurich Heart Foundation Heart Health Index compares the heart health behaviours of Australians with their perceptions of whether they meet recommended guidelines. Results indicated that sixty per cent of Australians are not meeting Australian Physical Activity Guidelines, ninety-one per cent of Australians are not eating enough vegetables and forty-seven per cent do not eat enough fruit. Research on physical activity and dietary behaviour interventions demonstrates that such interventions have been effective in increasing physical activity levels and nutrition intake. The Biomedical Journal, 2008 published ‘Exercise on prescription for women aged 40-74 recruited through primary care: two year randomised controlled trial.’ This study included 1089 women aged 40-74 who did not undertake 30 minutes of moderate intensity physical activity on at least five days of the week. Participants were recruited through a primary care setting and a randomised control trial was conducted. The intervention used the green prescription model, in which General Practitioners or Practice Nurses briefly counsel (7-13 minutes) patients using motivational interviewing techniques to increase physical activity. A six month follow-up visit was included and monthly telephone support was provided over a nine month period. This program of exercise on prescription increased physical activity and quality of life over a two year period, although falls and injuries increased. These findings support the use of exercise on prescription programs as part of population strategies to reduce physical inactivity 1. ‘The Logan Healthy Living Program,’ published in the Science Direct Journal in 2007 highlighted the results of a similar program. This trial compared a 12-month telephone and print-delivered physical activity and diet intervention against usual care, for patients with type 2 diabetes or hypertension. The 484 participants were recruited from the general practice setting in a socially disadvantaged community. A cluster randomised design was used. The underlying theoretical perspective used to guide the telephone intervention was derived from Social Cognitive Theory (SCT) and the Social-Ecological Model. Eighteen telephone calls were conducted over the 12 month period. Calls were delivered weekly for the first three weeks, fortnightly until four months, and monthly for the final eight months. The study targeted a challenging primary care patient sample and, using a telephone-delivered intervention, demonstrated modest improvements in diet and in physical activity. Results suggest that telephone counselling is a feasible means of delivering lifestyle intervention to primary care patients with chronic conditions— patients whose need for ongoing support for lifestyle change is often beyond the capacity of primary healthcare practitioners. 2 The Nutrition Journal published the ‘Weight, physical activity and dietary behaviour change in young mothers: short term results of the HeLP-her cluster randomised controlled trial’, in 2009. The aim of this study was to evaluate the short term effect of a community-based self-management intervention to prevent weight gain. Two hundred and fifty mothers of young children (mean age 40) were recruited from the community in Melbourne, Australia. The intervention group (n = 127) attended four interactive group sessions over 4 months held in 12 local primary schools in 2006, and was compared to a group (n = 123) receiving a single, non-interactive, health education session. Data collection included self-reported weight (both groups), measured weight (intervention groups only), self-efficacy, dietary intake and physical activity. Both interventions resulted in similar weight loss in the short term, however more participants in the intervention group lost or maintained weight. There were small non-significant changes to physical activity and changes to fat intake specifically replacing high fat foods with low fat alternatives such as fruit and vegetables 3. Health Coaching Australia (HCA) trains health practitioners with a structured system of evidence-based behaviour change protocols that assist patients or clients to adhere to medical and lifestyle recommendations. The HCA model is a practitioner model that has been shaped by thousands of health professionals who have provided feedback and input to the model, its processes and techniques. The HCA model is a structured approach to working with clients (or patients) that enables health practitioners to undertake three critical tasks to empower clients to engage in their own health management. These tasks work on increasing or reinforcing the client’s readiness, importance and confidence in engaging in health behaviour change. They are: 1) providing treatment recommendations and health education in a way that doesn’t inadvertently create resistance, 2) assisting clients to decide that it is in their interests to engage in health behaviour change for their own personally motivating reasons, and 3) increasing clients’ chances of success by identifying and addressing barriers to change and building self-efficacy. Although successful in all aspects of health and lifestyle management, health coaching is proving to be particularly successful in the area of chronic disease prevention and self-management. The following case study illustrates how health coaching and the Health Coaching Australia model can be used to assist people to make changes to their health. A 50 year old male has a history of morbid obesity and back pain and limited enjoyment of daily living and life. His previous occupation involved standing (Chef), then he moved to seated work (Taxi). His debilitating pain caused him to cease all work. His wife also has health issues and receives a Carer’s Pension for her husband. He spent 6-7 hours per day watching TV and DVDs which he described as one of his few enjoyments in life. The client was referred from a General Practitioner to the Exercise Physiologist (trained in health coaching, the “health coach”) in May 2007. The client’s current medical conditions include osteoarthritis in his knee (bilateral), back pain, morbid obesity (currently 159 kg), waist 152 cm, hypertension, snoring, Gastro-Oesophageal Reflux Disease (GORD), and depression. The client had Gastric Stapling in early 2005, that was unsuccessful. The health coach was very concerned about the client’s family history of diabetes and lack of ability to play with his young children. The client stated he often attends his children’s primary school to assist with reading and other tasks and this outlet makes him feel useful. His children also enjoy it. The client tried 5-6 various diets but was unsuccessful. Exercise suggestions by GP’s and Specialists were unappealing and unrealistic, including swimming and hydrotherapy. The client was self conscious of his body, and walking caused him too much discomfort. The client understood that his weight was impacting negatively on his health and was fed up with the experts’ advice and being told what to do. The client mentioned that “no one is really able to help him”. The health coach and client discussed the need to develop a strategy that might work long-term and as long as the client continued to maintain hope, the client could move forward. The health coach mentioned that there was no such thing as a failure, just the wrong strategy. The client felt pleased. The health coach’s primary goal was to build rapport with the client and to build his self efficacy. The health coach used the GROW model, to apply the health coaching principles. This includes: G= General Goal, what does the client want to achieve? The general goal is an overall goal which the client wants to focus on. In order to achieve the general goal more specific goals are set in the action plan. R=Reality, what is the current/past/ future situation? How likely is the client to achieve the goal? O= Options, what are all the possible solutions? Are there barriers preventing the client from achieving the goal? W=Written Goals and Action Plan, the course of action. Written specific goals and a step-by-step action plan to achieve the general goal. General Goal The client set a general goal to weigh 140 kg by Christmas (from 159- 140kg over 7 months) but to eventually weigh 110 kg. Reality The client was high in readiness to lose weight and it was important to the client but the client was low in confidence to achieve the goal. The client was ready to try something new “but not dieting”. The health coach invited the wife to come to future consultation sessions with the client. Options The client agreed to explore options with the health coach by only working on one thing at a time so it was manageable. They also discussed the possibility of using a stationary exercise bike during television time. The health coach talked to the wife and client about energy intake by focusing on specific goal options of a combination of better food choices (healthier take away and reduced fat intake) and finding a suitable avenue for more movement that does not cause pain in order to burn more energy. Written Goals and Action Plan An action plan was constructed at the consultation. The client did not seem comfortable writing things down so the health coach wrote the action plan using the client’s words. The Client identified his intrinsic motivators to achieve the goal: 1) to be a good role model for children 2) to contribute to family life (mow lawns at home and contribute more financially) 3) to feel good about himself, look good at the family Christmas party this year 4) to be available for his children and not limited by pain. Short term outcome The client lost weight slowly. He reduced his fat intake, although he could not increase his energy expenditure at that point in time. The client lost approximately 4.5 cm at the neck and the client reported that he felt less ‘jowly’. Although not a traditional place of measurement, this was an important place to gauge progress for the client and helped to build confidence as he could measure progress. The client had lost 4 centimetres from his waist although he was far prouder of his neck girth progress because it was more visible. Barriers and facilitators identified during attempted goal pursuit The barriers for the client included very limited income, reliance on others for financial support (food parcels), thinking “all movement will cause more pain”, does not plan meals, impulse high energy food buying, always has snack foods for the children at home (chips, twisties etc). Some factors the client identified as facilitating change included a supportive family (wife and children), positive comments from his family, and extra roles at school assisting the teachers with day-to-day tasks. Progress Five months after the client’s first health coaching session the client called the health coach and said that he was ready to buy a stationary exercise bike. The health coach had done considerable research on where he could purchase a bike that could accommodate his weight and methods to finance it. The health coach asked the client what had happened to make purchasing this bike his number one priority, his response demonstrated the power of intrinsic motivation. He had been asked by the primary school and his children to cook sausages at the local school fund raiser and found that he had to return home after 1.5 hours of work due to pain and pins and needles in his legs. He felt that he let his children down as other parents were able to work for longer periods. He also felt that he let the school and himself down and realised that he had to do something more to achieve his goal. Currently the client is cycling 2-3 times per day at low intensity for 5 minutes and will build up by 1 minute per week. The stationary exercise bike also measures energy expended (calories). It also helped reinforce the concept that more daily movement would increase circulation, mobility and manage pain. The ‘Go for your life’ Infoline Telephone Health Coaching Program also utilises the Health Coaching Australia model. All of the health coaches have been trained in the model. Clients are referred from General Practitioners and Allied Health Professionals. Upon referral, the health coach works with the client over the phone for 6 months. Follow up calls are scheduled 1, 2, 4 and 6 months after the initial call. A report is sent to the referrer after 2 months and 6 months. The support of the health coaches has resulted in client progress in the areas of; decreased portion sizes, increased water intake, increased energy levels, reduction of sedentary behaviour and reduced energy consumption. The Health Coaching Australia principles can be used in a variety of different settings. The effectiveness of individuals changing their behaviour is very dependent on the readiness of the client, barriers, the clients’ thought processes, confidence, and the reality of changing the behaviour. The health coaching principles focus on goal setting and behaviour strategies for behaviour change to occur. The health coach does not tell the client how to change their behaviour- it is about the client adopting the principles to make the changes themselves. References 1. Beverley A Lawton, Sally B Rose, C Raina Elley, Anthony C Dowell, Anna Fenton, Simon A Moyes. Exercise on prescription for women aged 40-74 recruited through primary care: two year randomised controlled trial. Biomedical Journal December 2008. http://www.bmj.com/cgi/content/full/337/dec11_3/a2509 2. Elizabeth G. Eakin a, Marina M. Reeves a, Sheleigh P. Lawler a, Brian Oldenburg b, Chris Del Mar c, Ken Wilkie d, Adele Spencer a, Diana Battistutta e, Nicholas Graves. The Logan Healthy Living Program: A cluster randomized trial of a telephone-delivered physical activity and dietary behavior intervention for primary care patients with type 2 diabetes or hypertension from a socially disadvantaged community—Rationale, design and recruitment. Science Direct October 2007. http://www.goforyourlife.vic.gov.au/hav/admin.nsf/Images/the_logan_healthy_eating_program.pdf/$File/t he_logan_healthy_eating_program.pdf 3. Catherine B Lombard, Amanda A Deeks, Kylie Ball, Damien Jolley and Helena J Teede. Weight, physical activity and dietary behavior change in young mothers: short term results of the HeLP-her cluster randomized controlled trial. Nutrition Journal May 2009. http://www.nutritionj.com/content/8/1/17 Resources Zurich Heart Foundation Heart Health Index, Meida release 15 October, 2008. Available from: http://www.heartfoundation.org.au/SiteCollectionDocuments/HHI%20Media%20Release.pdf Health behaviour change: Eating habits and physical activity, The Australian Psychological Society, 2007 National Psychology Week (NPW) survey investigated two aspects of health behaviour: eating habits and physical exercise. An online survey was developed to gain information on the process individuals undertake when making changes to eating habits and physical activity, their level of success in making and maintaining changes and the strategies they adopt. The survey results highlight the difficulties individuals experience in making and maintaining behaviour change. The findings also demonstrate the under-utilisation of psychologists to assist in this process. The important contribution that psychologists can make in lifestyle change appears to be overlooked or not well understood by the community. There is a need to promote recognition of the role of psychologists in the physical health domain. Understanding successful behaviour change: the role of intentions, attitudes to the target and motivations and the example of diet- OPEN ACCESS, Health Education Research, 2007 The study aimed to assess differences between different types of changes in eating behaviour and to evaluate the best predictors of successful behaviour change with a focus on behavioural intentions, attitude to the target and motivations. Stages of Change for Healthy Eating in Diabetes- Relation to demographic, eating- related, health care utilization, and psychosocial factors- OPEN ACCESS, Epidemiology/ Health Services, Psychosocial Research, 2003 The study identified diabetes-related characteristics of individuals at different stages of readiness to change to healthy and low-fat eating. This data validates the Transtheoretical Model, where those in the action stages displayed healthier eating. They also indicate that demographic and psychosocial factors may mediate readiness to change diet. Pre-contemplators were a heterogeneous group and may need individually tailored interventions. Low-income groups and behaviour change interventions: a review of intervention content, effectiveness and theoretical frameworks, Epidemiology and Community Health, 2009 Interventions to change health-related behaviours have the potential to increase health inequalities. This review investigated the effectiveness of interventions targeting low-income groups to reduce smoking or increase physical activity and/or healthy eating. This review shows that behaviour change interventions, particularly those with fewer techniques, can be effective in low-income groups, but highlights the lack of evidence to draw on in informing the design of interventions for disadvantaged groups. The Good Life Club project, Telephone coaching for chronic disease self management, Australian Family Physician, 2005 The Good Life Club project was a 3 year demonstration project funded by the Commonwealth Department of Health and Ageing (DOHA). The project utilised a number of interventions to support people with diabetes to improve self management of their condition and to effectively utilise existing local health services. This project has given good evidence for positive outcomes for this type of intervention.