Using Evidence-based Principles To Achieve Sustained Behavior Change
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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.
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