Using Evidence-based Principles To Achieve Sustained Behavior Change
Abstract: This narrative review outlines the potential benefits of supporting clients to successfully change existing patterns of behavior in the context of wound care. In acknowledging the complexities involved in changing deeply ingrained patterns of behavior, the case for developing interventions based on evidence is presented. The evidence-based psychological targets, which are recommended for inclusion in behavior change interventions, are outlined together with their theoretical derivatives. An example of an intervention developed using evidence-based techniques is presented. The challenges of progressing understanding and developing successful interventions in the context of wound care are discussed.
Address correspondence to: Nichola Rumsey, VTCT Centre for Appearance Research, Dept. of Psychology University of the West of England Bristol, UK B516 1Q4 Phone: +44 117 32 83989 Email: firstname.lastname@example.org
The potential benefits of promoting successful behavior change in the context of wound care are considerable. An example of this is the challenge of optimizing outcomes for patients with a diabetic foot ulcer. The road to recovery and the maintenance of good health require the patient to modify many aspects of behavior, which can include patterns of eating, smoking cessation, or the maintenance of the most recent attempt to quit, the need to engage in regular self-examination, attendance at podiatry check-ups, and wearing the necessary protective footwear. Intuitively, it would be reasonable to expect that people would value their health highly, and consequently, would be responsive to straightforward messages about the benefits of behavior change and the serious health risks associated with existing patterns of behavior. However, reality is much more complex,1 and the low rate of success associated with most approaches to health behavior change has preoccupied researchers recently. As long ago as 400 BC, Hippocrates is credited with noting that “Everyone has a doctor in him or her; we just have to help it in its work.”1 It was not until relatively recently, however, that the true complexity of behavior change and the costs associated with failing to achieve it have been recognized and highlighted in policy documents (eg, the UK Government White Paper “Choosing Health” published in 2004).2 Although an acceptance of this complexity is a recent phenomenon in the research literature, it is well recognized among practitioners in wound care and those who manage chronic conditions. These professionals know better than most that for the majority of patients simple approaches (eg, the provision of information about the benefits and risks of certain behaviors) are not sufficient to influence and maintain change in target behaviors. Some of the factors identified as contributing to existence of patterns of health-related behaviors that lead to greater levels of risk for morbidity and mortality, and also to the likelihood that behavior change interventions will succeed, are not amenable to change.3 These factors include sociodemographic variables (eg, gender, age, socioeconomic status, culture), and environmental barriers to change (eg, lack of availability, or cost of healthy foods). A change in a range of psychological factors relevant to health-related risk behaviors, which include beliefs and cognitions, is both possible and achievable. Although it is widely accepted that optimal outcomes would result from simultaneous interventions at population, local community, and individual levels, it is also accepted that this is rarely possible or achievable. In the absence of effective mechanisms for change at all levels, researchers, and policy makers have focused in recent years on the health- related gains that might be achieved by persuading individuals to assume responsibility for his or her own health actions. Despite initial optimism for this approach, it is now apparent that change at an individual level is more difficult to achieve than most policy makers, theorists, and practitioners had expected.4 A key question that has perplexed health psychologists, public health specialists, and others in the recent past is that even when information about the health risks associated with their behavioral patterns is readily available, why do people still fail to behave in ways that promote recovery and maintain health? Experts in the field agree that the reasons people choose to behave in ways that will lengthen rather than shorten recovery are often complex.5 They can include inadequate knowledge (eg, a failure to understand that wounds heal in layers), inadequate skill (belief that dressing change routines are too complex to undertake themselves), or insufficient opportunity (a lack of access—perceived or real—to appropriate dressings). Additionally, the motivation (or desire) at key moments to engage in less helpful patterns of behavior is stronger than the motivation (or desire) to engage in more adaptive ones, as the latter are often perceived as being difficult, boring, or unpleasant, while the former are seen as more enjoyable or as meeting more immediate needs. In view of the acknowledged complexity of encouraging people to change often deeply ingrained patterns of behavior, interventions based on techniques that have been demonstrated to be effective in good, quality evaluations are desirable.5
Evidence-based Approaches to Behavior Change
Researchers and policy makers in the field of behavior change agree that interventions based on quality evidence have the greatest potential to optimize outcomes. However, making sense of the evidence base is not a straightforward exercise. To the uninitiated, the picture is confusing at best. Although there has been a proliferation of theories and interventions relating to health behavior change over the past 20 years, the number of high quality evaluations of these theories and interventions are scarce. Devotees of particular approaches may sing the praises of their own methods, but are rarely able to back up their claims of success with quality evidence. Improvements in understanding about which interventions work, how they work, and for whom they work best have been dogged by ad hoc approaches to design, by a lack of rigor in both data collection and interpretation, and by only a token mapping of interventions to theoretical frameworks. As part of a consultancy provided by The British Psychological Society to the UK Department of Health (DH), Michie, Abraham, and Jones reviewed the evidence for behavior change in 2004. In an internal report, the techniques, which were characteristic of successful and unsuccessful interventions, were reviewed and mapped to the theories from which they were derived. This mapping exercise was not easy. Many interventions were found to consist of several different techniques, and often the theoretical derivation was either poorly described and/or poorly implemented. However, although the authors of the report identified gaps in the evidence base, they also found consistent support for a number of techniques derived from social cognitions models, self-regulation models, and from operant conditioning (described in more detail below). Interestingly, however, there was no support for any overall theoretical approach, including the popular and widely used stage models of change. The findings of the Michie, Abraham, and Jones internal report to the DH were subsequently confirmed and reinforced by later publications, including the UK’s National Institute of Clinical Excellence (NICE) Guidance on Behavior Change,6 and a recent paper explaining and amplifying this guidance.7 The NICE Guidance on Behavior Change, in addition to reviewing the evidence base, outlines the skills and competencies required by those involved in the design and evaluation of behavior change interventions. These include the ability to evaluate the evidence for different approaches of achieving the desired outcome, the ability to design interventions working in partnership with members of the target population, the need to take into account the social, environmental, and economic context in which the target behavior is taking place, the necessity of identifying appropriate outcome measures to assess changes in behavior, and the desirability of conducting regular reviews of the intervention over time in light of newly emerging evidence. Abraham et al,7 in their paper discussing the NICE Guidance, summarized the key psychological targets recommended for inclusion in behavior change interventions on the basis of previous research: • Help people to develop accurate knowledge about the health consequences of their behaviors • Emphasize the personal relevance of the health behavior in question (ie, identify the consequences for the individual) • Promote positive feelings towards the outcomes of behavior change • Promote the visibility of the behavior in people’s reference groups (ie, the groups they compare themselves with or aspire to) • Emphasize the social approval that will result from change • Promote the person’s personal and moral commitment to the behavior change (eg, the cost to the health service of nonadherence events) • Enhance people’s belief in their ability to change • Help people to form plans and goals in graded steps, making contingency plans and developing appropriate coping strategies for challenging situations • Invite people to form behavioral contracts by committing to their plan with others • Help people recognize how their social contexts and relationships may affect their behavior • Help people develop skills to cope with difficult situations and conflicting goals once they have initiated change. In common with the Michie et al5 review of the research literature for the DH, later reviews also noted that the evidence does not support the application of any one complete theory.6 Instead, the psychological targets outlined in the NICE Guidance are derived from elements of several theories: 1. Self-regulation theory.7 This approach emphasizes the importance of engaging people in their own behavior change, for example, through the setting of their own behavioral goals, through active engagement in action planning and strategies for relapse prevention, and in the self monitoring and management of their own behavior. 2. Social cognition theories that focus on the role of cognitive processes in health related behavior change. These include theories highlighting the role of beliefs in a person’s level of motivation to initiate change, for example, the concept of health protection and threat avoidance which is a component in the Health Belief Model.8,9 Evidence also points to elements of Social Learning Theory10 as effective in promoting change. This theory emphasizes that in order for change in behavior to take place, a person needs to be confident in his or her ability to make that change (ie, they need to have a high level of self efficacy). The person also needs to expect that change will lead to a desired outcome (outcome expectancy). Social learning theory also emphasizes that in order to maintain confidence, signs of progress during the process of change, even if small, should be noted and reinforced. Again, to maintain confidence, the person should also be encouraged to attribute success to him or herself, and to attribute a lack of success to external factors. An element of a third social cognition theory, Relapse Prevention Theory,11 namely the benefits of engaging people in preparing strategies for dealing with setbacks before they occur, is also supported by the review of evidence. 3. Goal theories12 that stress the need to help people form plans and goals in graded steps and to make plans for the implementation of these plans in specific contexts. 4. Operant conditioning.13 This theoretical approach highlights the importance of identifying influences in a person’s environment that trigger and reinforce behavior. In order to establish new habits and routines (eg, new patterns of eating), there is a need to unpick old patterns of reinforcement. This theory also highlights the need to focus on the benefits and rewards of change, to reinforce progress and the need to repeat new routines over time, allowing them to become new habits. 5. Evidence also supports the efficacy of additional techniques, including encouraging the person making the change to identify and engage with sources of social support (derived from social psychological theory), the need to boost motivation to change (derived from motivational interviewing), and the advantages of teaching those facilitating change effective communication skills. Once again, the evidence for techniques derived from the stage theories of change, most notably the Transtheoretical Model,14 is not impressive. This conclusion is echoed elsewhere in the recent literature on health related behavior change. Although there is some support for the usefulness of a distinction between the motivational and volitional phases of change,1 many flaws in the model have been highlighted and some have argued that it should be abandoned completely.15,16 Of course, it is one thing to know which elements might work, but altogether another to undertake to put them together. One example of how an evidence-based intervention has been developed in practice is the NHS Health Trainer Intervention.
The NHS Health Trainer Intervention
Socially disadvantaged groups in the UK remain more likely than other groups to engage in health compromising behaviors such as smoking, poor diet, excessive alcohol consumption, physical inactivity; they also experience greater morbidity and mortality.17 As part of the ongoing consultancy from the BPS to the DH, Michie and Rumsey—in conjunction with a team from the DH—have been involved in developing and implementing a new behavior change intervention, the NHS Health Trainer Programme. Initially proposed in the White Paper “Choosing Health: Making Healthier Choices Easier,”2 NHS Health Trainers (HTs) deliver an intervention, which contributes to the broad cross government agenda on health inequalities. The White Paper outlined a series of proposals to empower people in disadvantaged groups to make healthier choices. The Health Trainer approach uses the evidence based principles of behavior change outlined above to assist people at greater risk of poor health to assess their health and lifestyle risks, build their motivation to change their behavior patterns, develop a personal health plan to guide their efforts to change, and encourage them to implement this plan. Many HTs are recruited from the communities they support with the aim of capitalizing on their local knowledge and understanding of the day-to-day concerns within their own communities. By 2009 there were 169 HT services in 144 Primary Care Trusts (PCTs) throughout England. The 2160 HTs were engaged in delivering one-on-one interventions or sign-posting clients to appropriate specialist services (eg, smoking cessation). During the year 2008–09, 67,000 clients were seen with 30,000 setting and engaging with plans to change a chosen health behavior. Forty-six percent of the clients were drawn from the most deprived areas in the country. The service achieved a 69% success rate of clients achieving either all or part of their goal, or being sign-posted to other specialist services.18 In developing this intervention, the evidence-based techniques outlined above were combined to produce an intervention with three distinct stages, namely motivating change, initiating change, and maintaining the change. The stages and component techniques are described briefly below using examples relevant to wound care when possible. The NHS Health Trainer handbook, which details the techniques used, offers advice on how to implement the intervention, suggests appropriate outcome measures, and provides the evidence base for the approach is available through the DH website.19 Motivating change. This stage involves establishing positive expectations of outcome in the potential recipient of the intervention (life will be much better without an amputation); boosting confidence (self efficacy) in the client’s ability to achieve the change (look how well you did with your smoking, you can do this too); boosting motivation to do the change now (this is a great time to initiate the change, as if you do it now, it will significantly shorten your recovery time); modeling or offering positive examples (this is how you can do this yourself; others have done it successfully and been able to dispense with their dressings much more quickly). Initiating change. This second phase of the intervention involves engaging the client in a health stock take. Together the “trainer” and client discuss all the behaviors, which are targets of change, the relative gains and costs of changing each (if I regularly engage in self examination my recovery time will be quicker and the less I will need to see my doctor). The client is helped to choose one target behavior to start with. (If multiple behaviors are chosen, the chances of failure are greater). The client then engages with the trainer in the process of setting goals for change. In order to optimize the chances of success, the goals should be SMART,12 ie, specific (there should be clarity about exactly what the goal is), measureable (the client should know when the goal has been met), achievable (the goal must be do-able), relevant (the goal should be seen as important by the client), and timely (the client should understand that this is the right time to achieve the goal). The client is then helped to develop an action plan to guide them toward their goal (what, where, when, and with whom they will do it), and to institute a system of self monitoring, such as a simple daily diary in which relevant activity is recorded. The client is encouraged to develop a means of reinforcing his or her own positive outcomes, for example, through generating a list of “treats” that can be self administered when progress is made. (It is of course counterproductive if the treats undermine other aspects of the behavior change—for example, the choice of a treat that takes the form of calorific food in those who need to lose weight should be avoided) The trainer also takes care to praise any signs of progress, however small, in order to boost confidence and motivation in the client. Maintaining change. Having facilitated successful change, the next challenge is to support the client in maintaining this change. In this phase, existing goals are regularly reviewed, and changes are made as necessary (eg, changing the frequency of dressing changes). The client should be encouraged to access support from others to maintain their new behavior patterns, and should be helped to identify situations, which put them at high risk of relapse. “If-then” plans should be developed to deal with these situations (eg, if my dressing becomes dirty so I am tempted to change it too frequently, then I will still wait until the next scheduled change). New behavior patterns can be considered “habits” once the new regime has been maintained for 6 weeks. During this time, regular boosts to the client’s confidence and motivation to maintain the change should be offered.
The Need for Further Research
Although evidence for the success of this intervention in other contexts is growing and the potential for this type of approach in the wound care field is evident, much remains to be done. The path to developing a successful behavior change intervention in this area is unlikely to be smooth. Research and evaluation will be necessary to improve understanding of the techniques—why they work, in what combinations, and for whom they work best. The training needs of practitioners in the field will also need to be identified. Adherence to treatment regimes is often complex, involving multiple behaviors, yet the evidence derived from work in goal setting indicates that better outcomes will be achieved if patients tackle change in one behavior at a time.12 This will make the process of successful behavior change longer. Additionally, each type of behavior (eg, dressing changes, self examination, attendance for check-ups, healthy eating) has different characteristics. Although the components of interventions may be broadly applicable across a wide range of behaviors, optimal outcomes may be more easily achieved if the emphasis varies depending on the particular target behavior. For example, in relation to self examination, considerable effort may need to be focused on getting the behavior going. Operant techniques, linking cues with rewards, are likely to be particularly effective in this case, whereas in relation to healthy eating, there may be a need to inhibit previous patterns of behaviors and then to keep things on track over time, thus self- regulatory techniques may be better.4 Progress in refining knowledge about behavior change has been slow thus far. This is in large part due to the poor quality of data collection and evaluation.20 Therefore, the importance of evaluating outcomes in the future cannot be overstated. In order to enhance patient outcomes and improve practice for the long term, greater quantities of good quality evidence are needed. With this evidence, the frameworks underpinning effective interventions can be refined and tested in specific contexts. Advances in knowledge also require greater coordination between practitioners working in the field. Progress will be contingent upon achieving greater commonality in the content and methods of delivery of the behavior change interventions. Where possible, and to facilitate large-scale comparisons, practitioners should employ the same outcome measures to assess the effectiveness of their efforts.
Behavior change in the context of wound care remains a formidable challenge, but the implications of using evidence-based techniques are considerable. These techniques are worthy of consideration as they have the potential to contribute to efforts to maximize adherence to treatment regimes. More positive outcomes and shorter recovery times will enhance the wellbeing and satisfaction of patients, thus improving the experience of care for both patients and healthcare professionals.