Using Evidence-based Principles To Achieve Sustained Behavior Change
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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.
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