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empowerment Powered By Docstoc
					                                           Module 4.3




Promoting Behaviour Change
     For individuals and populations



       Produced by The Alfred Workforce Development Team
                           on behalf of DHS Public Health -
            Diabetes Prevention and Management Initiative
                                                 June 2005
Presentation purpose
Target audience

   Service providers and project workers on DPMI projects

Aim

   To explore the concepts of behaviour change and self management

Objectives

 Provide an overview of behaviour change and self management
 Explore best practice models of behaviour change
 Discuss the key concepts of self management and empowerment
 Explore self management models and evidence
 Discuss and workshop problem solving and goal setting



                               DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Communicating risk

   Factors influencing thinking on risk
     People underestimate risk related to chronic
      disease overestimate communicable disease
     Trust
            Who is telling me are they trustworthy?
       Risk less acceptable if:
          Imposed
          Distributed unevenly

          Resulting from man made

          Hidden/irreversible


                            DPMI Workforce Development – The Alfred Workforce Development Team June 2005
 Behavior change cycle
                 Trigger
                                                             Pre-
                                                             contemplation
Action &
maintenance                                                 Awareness raising
Assessment
                                                             contemplation
Goal
setting/action                                             Promote benefits
                     Preparation
plans                                                      Identify obstacles
Promote self
efficacy              DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Self efficacy
 • Self efficacy strong predictor of behavior change
 • Self efficacy is your belief in your ability to
   perform a task

  Promoting self efficacy
       Promote performance accomplishment
       Use verbal persuasion
       Role modelling
       Identifying feelings and helping work through
        strategies to deal with feelings
       Meaningful to the individual
                         DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Developing resources to support
behavior change
   Thinking of quitting smoking?
Identifying feelings
   Here are all the facts that show quitting is the right choice.
Verbal persuasion

   Make this site work for you. Bookmark the pages that really mean
    something to you.
Meaningful to the individual
   For more help, call the Quitline 131 848.

   Like all good things, it's going to take some time and effort for you
    to quit smoking, but thousands of smokers in Australia have already
    stopped. You can too.
Identifying feelings & verbal persuasion
                             DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Tailoring information to
stages of change
   Deciding to Quit                      Pre-contemplation

   Getting Ready to Quit                            Contemplation

   Quitting                                            Preparation

 Staying a Non-smoker
 Coping with Setbacks                                       Action &
 Helping Others Quit
                                                             maintenance

                       DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Contemplation: Deciding to Quit
Here is how to get started with your quitting.
You    need to know

Smoking    Kills

Cigarettes    are full of poisons

Smoking    causes disease

Some    benefits of quitting

Quit   and save a packet

More    good reasons to quit

Deciding    to quit checklist

The    internet & stopping smoking - research project

Quit   Pack Order Form

How    much do you spend on smoking? Workforce Development – The Alfred Workforce Development Team June 2005
                                  DPMI
Deciding to quit checklist

   I’ll reduce my risk of heart attack.
   I’ll reduce my risk of getting cancer.
   I’ll feel fitter and my skin will look younger.
   Within twelve hours, my body will be free of nicotine.
   I’ll set a great example for the children around me.
   My lungs will start to recover and be able to clean
    themselves properly.
   I’ll have more money to spend any way I choose.
   I’ll give myself a confidence boost by quitting
    cigarettes
    Verbal persuasion, raise awareness
                        DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Contemplation: Deciding to Quit
Try this
List all your reasons for quitting, and then number the three reasons
   you think are important.
Meaningful to the individual & promote benefits

Try this
From the following list, tick the things that you want to do when you
   are a non-smoker. Add your own ideas in the space provided.
 Having more energy to play sport or keep up with the kids.
 Knowing I'm back in control and no longer addicted.
 I'll be free from the hassle of always checking that I have enough
   cigarettes.
 Reducing the risk of getting sick from cancer or heart disease.

  Identifying feelings, promoting performance &
  promote benefits
                            DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Preparation: Getting ready to Quit
Smokers who plan before they quit are more successful than
  those who don't, and planning can be done quickly
   Understand your nicotine addiction

   The Quit Book

   Know why you smoke

   Smoking Record

   Plan ways to deal with quitting

   Quit course

   Set a date to quit

   Some words about weight gain

   Getting ready to quit checklist Workforce Development – The Alfred Workforce Development Team June 2005
                               DPMI
Set a date to quit

Unless there is a very good reason, make the date within
  two weeks from now.
Choose an easy date to stop, one when you will not be
  under much pressure, but will have plenty to occupy
  yourself.
Practice Quitting
 Once you have picked a date to quit, stick to it.
 Before you quit, you might try a practice smokefree
  day to see how you would go.
 Or you could experiment by not smoking at times when
  you normally would;
 This will help you to work out how much you need to
  prepare for these situations when you quit completely.
Goal setting/action planning
                      DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Action: Quitting
Now's the time to put all your
  work into practice and quit.
 You are ready

   Understand withdrawal
    symptoms

   Coping with cravings

   Excuses for not quitting –
    myths and reality

   Quitting checklist

                           DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Action: Quitting
You are ready
 You've made your decision to quit.
 You have any extra information or support you feel you need.
 You've done your planning.
 You've set your quit date.
 Stick to your decision. You're doing the right thing.


Choose an approach that will work for you
 You could go cold turkey. For many people, this is a successful
  method.
 You could cut down by reducing gradually
 If you choose to cut down make sure your quit date is set for two
  weeks after you start reducing your smoking.
 On your quit date, cut out cigarettes altogether.


                           DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Quitting checklist
   I will choose whether to stop suddenly or gradually.
   Withdrawal symptoms are a good sign
   I can confront cravings by remembering the 4Ds:
        Delay
        Deep breathe
        Drink water
        Do something else.
   I will congratulate myself every time I resist the urge for a
    cigarette.
   Reminding myself of my reasons to quit will make it easier to
    refuse cigarettes.
   I have the right to refuse a cigarette and can do so without
    upsetting others
   I can keep my hands busy
   Even if I decide to have alcohol, I’ll stick to my decision to quit.

                              DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Maintenance:Staying a Non-smoker

The worst is over. You'll feel the urge to smoke less and
  less, and soon you'll hardly think about cigarettes.
But the urge to smoke can return when you least expect
  it.
 You can stay stopped, but you need to be prepared.
  There is always something better than a cigarette.
 The new you

   Find new ways to relax & other things to do

   Staying a non-smoker checklist

                        DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Maintenance:Coping with setbacks

Quitting can be hard.
You might be going along OK, and suddenly you feel like
  smoking again.
Sometimes, as you gain confidence, you actually start to
  think quitting is easy, so why not smoke again? Your
  resolve starts to weaken.
 Try this

   If you have a cigarette

   If you go back to regular smoking

                         DPMI Workforce Development – The Alfred Workforce Development Team June 2005
                        Method

Research &     Focus Group                            Individual Interviews
Development

                     Content / Script Dev’t


 Concept
                       Concept Testing
 Development                                               Product Modification

                      Product Testing

     Product                                                  Product Modification
     Development
                        Final Product

                      Promotional StrategyThe Alfred Workforce Development Team June 2005
                          DPMI Workforce Development –
Consumers have had a say !




             DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Empowerment and self management
principles

 HPs provide
   Expertise
   Information
   Psychological support
Individual
    The daily decision making in the treatment of their
    condition
  Adults more likely to make and maintain change if
    they are personally meaningful and freely chosen
                                    Robert Anderson
                      DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Key concepts of self management

   Recognition of problems as seen by the
    person and encouraging them to identify
    solution
       “Identifying problems often means HP needs to
        be silent!!” (Skinner)
 Discovery and enhancement of internal
  reinforcement for behavior change
 Encompasses social learning and behavioral
  theories             DPMI Workforce Development – The Alfred Workforce Development Team June 2005
 How self management differs from
 patient education
                      Self-Management                                             Patient
                                                                                  Education
             Self-Management            Patient
Purpose             To manage life      Education                                 To change
  Purpose:          with
             To Manage Life disease
                                To Change                                         behaviors
             With Disease               Behaviors
             To Increase Skills/Self-   To Increase

                      To increase skills                                          To increase
             Confidence                 Knowledge
             To Problem Solve  To Use Specific
                      /self confidence
             And Make DecisionsTools                                              knowledge
                                  Kate Lorig

                      To problem solve                                            To use specific
                      and make decisions                                          tools
                                                                                           Kate Lorig
                                               DPMI Workforce Development – The Alfred Workforce Development Team June 2005
How self management differs
from patient education
             Self                                   Patient
             Management                             Education
Needs        Patient                                What patients
Assessment   problems                               need to know

Content      Disease, role,                         Disease
             & emotional                            knowledge and
             management                             behaviors

Leader       Leader is guide                        Leader is expert

                                                                      Kate Lorig
                DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Evidence

   Good evidence to support
    self management
     Improves quality of life
     Supports behavior change

     Decreases health care
      utilisation

        www.cfah.org.au
        Barlow. J et al
        WHO         DPMI Workforce Development – The Alfred Workforce Development Team June 2005
References

   Robert Anderson et al “Using the empowerment
    approach to help clients” Chapter 17 in “Practical
    psychology for diabetes Clinicians” Anderson, B and
    Rubin, R. Published ADA Alexandria Virginia 1996.
   Barlow J. et a “Self – management approaches for
    people with chronic conditions: a review” Patient
    Education and Counseling 48 (2002) 177-187
   “Patients as effective collaborators in managing chronic
    conditions”       www.cfah.org.au
   Adherence to long term therapies www.who.org go to
    publications link


                        DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Diabetes self management education
in Australia
   Norsworthy document reviewed
       8 articles / 153 studies of the effectiveness of diabetes
        interventions.


   Concluding the evidence presented provides
    powerful arguments that diabetes self management
    education is:
       Able to influence behaviour change and improve knowledge
        and skill for diabetes self management
        Can result in a reduction in secondary complication rates
        Can reduce the person’s reliance on health services.


                             DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Diabetes self management education in
Australia
   Access and equity issues
      Rural areas

      Indigenous people

      CALD communities

      People of low socio-economic
       status.

   People in socially
    disadvantaged areas receive
    fewer long consultations than
    people in higher socio-
    economic areas.
                        DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Lois’s Story




               DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Self management models

 Disease – related, education- focus
  provision of information, skill
  development
 Behaviour change focused
    Readiness to change
    Motivational interviewing
    Goal orientated programs
 Psychosocial – focused support
    Support groups
    Social isolation
    Self efficacy
                           DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Delivery of self management
programs
 Provided through a variety
  of modalities
   Face to face
   Telephone
   Email
   Web based


 Principles can be
  incorporated into group or
  individual counselling
  sessions
                   DPMI Workforce Development – The Alfred Workforce Development Team June 2005
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Automated telephone disease
management
 RCT : People with diabetes
 Intervention:
    Received weekly calls from automated telephone system
    To discuss self-care activities and hear self-care tips
 Control: Normal office visits and information

FINDINGS:
 Intervention Group
    Reported fewer depressive symptoms
    Higher self efficacy for self care
    Greater satisfaction with services received
    Improvement in health related quality of life


                         DPMI Workforce Development – The Alfred Workforce Development Team June 2005
 Petitte et al
 Medical Care 38, 2000
Automated telephone disease
management
FINDINGS:
Intervention Group
  Reported fewer depressive symptoms
  Higher self efficacy for self care
  Greater satisfaction with services received
  Improvement in health related quality of life



                   DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Back pain email discussion group

 RCT 580 subjects
 Intervention:
    Closed moderated email discussion group & back pain book
     and video tape
 Controls:
    Non health magazine subscription of their choice

 Findings at 1- year:
    Significant improvements in pain, disability, role function
     and health distress
    Less physician visits and hospitalisation days
                              DPMI Workforce Development – The Alfred Workforce Development Team June 2005
   Kate Lorig
   Stanford Patient Education Centre
    Behavioural weight loss program

   Objective: Determine effectiveness of Internet
    behavioural weight loss program compared to weight loss
    education website
 RCT 6 months, 91 subjects, 18-60yrs, 81 female, BMI 25-36
 Control Group: web based information relating to weight
    loss
   Intervention: as above plus weekly email messages,
    online submission of diaries, therapist feedback
   FINDINGS
     Mean weight loss in intervention group at 6 months 4.1kg (4.5)
     Mean weight loss in control group at 6 months 1.6kg (3.3)
    Tate                    DPMI Workforce Development – The Alfred Workforce Development Team June 2005
    JAMA March 2001
Essential elements of self
management interventions
   Disease, medication and health management
   Role management
   Emotional management
   Support enhancement of self efficacy
   Problem solving training
   Follow up
   Tracking and ensuring implementation
The Robert Wood Johnson Foundation
The Centre for the Advancement of Health
www.cfah.org


                             DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Ray’s story




              DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Motivational interviewing

   Seeks to understand the persons
    frame of reference – reflective
    listening

   Expresses acceptance and affirmation

   Elicits and selectively reinforces the
    patients own self motivational
    statement, expression of problem,
    concern, desire and intention and
    ability to change.

Helen Linder
Latrobe university

                              DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Assessment/Problem definition

Aim
 To help clients realise they are
  responsible for, and in charge of, their
  condition
 Prioritise problems and identify situations
  they want to improve
 Experience emotional and psychological
  commitment
 Develop a plan of action
                 DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Assessment/Problem definition

Interview questions
1.   What part of living with your condition
     is the most difficult or unsatisfying for
     you?
2.   How does the situation make you feel?
3.   How does this situation have to change
     for you to feel better about it?
                                                         Robert Anderson

                   DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Assessment/Problem definition

4.   Are you willing to take action to improve the
     situation for yourself?

5.   What are the steps that you can take to bring
     you closer to where you want to be?

6.   Is there one thing that you will do when you
     leave here to improve things for yourself?

                                                                    Robert Anderson

                     DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Problem solving and decision making

 Identifying problems
 Set goals
 Helping find alternative ways of to
  accomplish goals
 Setting contracts with themselves
 Checking the results
 Making changes as needed

                 DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Goal setting- Getting started

 Choose long term goal
  Goals should be something you want to do


Identify steps needed to reach long term
 goal

Choose one of those steps to start
 working towards goal
                  DPMI Workforce Development – The Alfred Workforce Development Team June 2005
SMART

 Specific
 Measurable
 Achievable
 Realistic
 Timely


                      Flinders University

               DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Guidelines for helping with - Problem
solving

 Identify the problem
 List ideas
 Select one
 Assess the results
 Substitute another idea (if first didn’t
  work)
 Accept that the problem may not be
  solvable
                                                                    Kate Lorig
                  DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Behavior Change

          Prevention                      Information


Chronic disease care                      Case Management

   Target Audience
       Population
       Individual
       Group programs
                         DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Implementing change

   Individual practice
   Program changes
   Organisational approach
   Small incremental changes can still have an
    effect
          Can require philosophical shift
          Education process/skill development
          Reorganisation of services
          Systematic approach to assessment and care planning
           using tools that support identification of problem &
           patient generated goals

                           DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Our changing roles

Patient: Manager
Health Professional: Assistant
  Responsible to clients rather than for them

  Sharing knowledge and expertise to help
   make informed decisions to about their care

  Collaborative approach with client generated
   solutions to problems as perceived by client
                  DPMI Workforce Development – The Alfred Workforce Development Team June 2005
EDWARD DE BONO

   It is better to have enough ideas for
    some of them to be wrong, than to be
    always right by having no ideas at all.




                   DPMI Workforce Development – The Alfred Workforce Development Team June 2005

				
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