HL7 - Health interventions: Individual and population

Question 1

Individual Approaches

Why is important to inform people about the risks of certain diseases?

Answer 1

• Informing people of their risks for certain diseases may lead to them engaging in long term risk protective behaviour
  
  • E.g. showing an overweight man in his 60’s, who smokes and has high cholesterol- a heart disease calculator which displays high risk of a heart attack
  • Showing a woman in her 20’s with a family history of melanoma who does not wear sunscreen and sunbakes regularly her risk of melanoma
• Hope that calculating risk will implement change through risk models showing risk rate

Question 2

Does informing people about the risk of disease always work to change behaviour?

Answer 2

• Some people strive to change behaviour once aware of risk
  
  • BUT
    
    • Many don’t or the change is not sustained
    • May not foster behavioural change
    • More targeted information interventions are needed and have been developed that take into account motivation

Question 2

What are the main methods to encourage people to change to more healthy behaviour?

Answer 2

• Three main ways
  
  • Motivational interviewing
  • Problem solving approaches & implementation planning
  • Modelling and behavioural practice
• Traditional method of prescription and advice was not enough to make people change
  
  • As people don’t change because they are told to change, need to be motivated to change

Question 3

What are the core ideas of motivational interviewing?

Answer 3

• MI is a person-centred communication approach
• Designed to support an individual’s motivation and commitment to change
• Motivational interview (MI) is collaborative, non-confrontational, non-authoritative
  
  • Requires partnership, acceptance, compassion and evocation.
    
    • Understanding why
• Focuses on eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.
• Main idea is to purposefully create a conversation around change without attempting to convince the person of the need to change or instructing them about how to change
• Spirit of motivational interviewing
  
  • Taps into individual self-efficacy

Question 4

What is motivational interviewing like in practice? (i.e. steps)

Answer 4

• Motivational interviewing in practice
  
  1. Building motivation to change (OARS)
     
     1. Assists in building rapport and establishing the therapeutic relationship
        
        1. Ask Open Ended Questions:
           
           1. The patient does most of the talking
           2. Gives the practitioner the opportunity to learn more about what the patient cares about (eg. their values and goals)
        2. Make Affirmations
           
           1. Can take the form of compliments or statements of appreciation and understanding
           2. Helps build rapport and validate and support the patient during the process of change
        3. Use Reflections
           
           1. Involves rephrasing a statement to capture the implicit meaning and feeling of a patient’s statement
           2. Encourages continual personal exploration and helps people understand their motivations more fully
        4. Use Summarising
           
           1. Links discussions and ‘checks in’ with the patient
           2. Ensure mutual understanding of the discussion so far
           3. Point out discrepancies between the person’s current situation and future goals
           4. Demonstrates listening and understand the patient’s perspective - very important for someone to share their experiences with you
     2. Strengthening commitment to change (phase 2)
  2. Involves goal setting and negotiating a ‘change plan of action’.
  3. Without this more concrete goal directed approach, patient+practitioner can remain stuck
  4. A core principle of MI is that individuals are more likely to accept and act upon opinions that they voice themselves
  5. Clients are encouraged to express their own reasons and plans for change (Change Talk)
  6. Employ strategies to elicit change talk
     
     1. disadvantages of the status quo: What difficulties have resulted from your drinking?
     2. advantages of change: What are the advantages of reducing your drinking?
     3. optimism for change: What strengths do you have that would help you make a change?
     4. intention to change: In what ways do you want your life to be different in 5 years?

Question 5

Is motivational interviewing effective?

Answer 5

• MI appears to be most effective for stopping or preventing unhealthy behaviours e.g. binge drinking, reducing the quantity and frequency of drinking, smoking and substance abuse.
• For promoting healthy behaviours (categorised as Domain 2) where people may have little desire to change, most of the evidence is inconclusive or of low quality.

Question 6

How can motivational interviewing be applied to the COVID-19 vaccination?

Answer 6

• Vaccine hesitancy
  
  • Complex-often numerous factors influence acceptance of vaccine
    
    • Misinformation
    • Distrust
    • Negative experiences with past vaccines
    • Beliefs and attitudes about health and prevention
• If people refuse all vaccines - need to be respectful of their beliefs - need to leave the door open to discussion
• For those more hesitant, use more motivational interviewing techniques

Question 7

What are the key principles of problem focused counselling? What are the phases involved?

Answer 7

• Problem oriented”
• Focused on the issues at hand, in the ‘here and now’
• Three distinct phases (Egan, 2006):
  
  • Problem exploration and clarification: detailed exploration of problems individual is facing; breaking ‘global insolvable problems’ into carefully defined solvable elements
  • Goal setting: Identifying how individual would like things to be different; setting clear, behaviourally defined, achievable goals
  • Facilitating action: Developing plans and strategies through which these goals can be achieved
• Role of counsellor not to act as an expert solving a person’s problems
• Use the individuals own resources to identify problems and arrive at solutions
• Deal with stages sequentially and thoroughly

Question 8

Is problem focused counselling effective?

Answer 8

• Effectiveness of problem focused counselling
  
  • Despite generally acknowledged effectiveness of problem focused counselling styles- surprisingly little examination of effectiveness
  • Gomel et al. (1993) risk factors for heart disease study:
    
    • 3 groups: risk education; problem focused counselling; no intervention
    • Problem solving intervention had greatest effect&raquo_space; greater reductions in blood pressure, BMI, smoking than in education only or no intervention groups

Question 9

What is an applied example of problem focused counselling?

Answer 9

• Many behaviour change programs have an element of problem identification and resolution
• Most smoking interventions use combination of nicotine replacement therapy and problem solving approaches
  
  • Example: smoking cessation strategies

Question 10

What are the most important/effective parts of problem focused counselling?

Answer 10

• Egan’s (2006) last stage of problem focused counselling may be key therapeutic element:
  
  • Facilitating action: Developing plans and strategies through which these goals can be achieved
• Similarly, HAPA (Schwarzer & Renner, 2000) & implementation intentions (Gollwitzer & Schaal, 1998) identified planning as important determinant of behavioural change
• Approaches encourage individuals to plan how they will engage in their behaviour of choice
• Positive results in interventions for:
  
  • Increased fruit intake (DeNooijer et al., 2006);
  • Cervical cancer screening (Sheeran & Orbell, 2000);
  • Quitting smoking (Armitage, 2007);
  • Weight loss (Luszczynska et al., 2007)

Question 11

What is modelling change?

Answer 11

• Problem focused and planning strategies can help- BUT achieving change can still be difficult
• Particularly where individual lacks skills and confidence in their ability to cope with demands of change
• Potentially overcome by learning skills or appropriate attitudes from observation of others performing them- vicarious learning
• Optimal learning and increases in self efficacy can generally be achieved through observation of people similar to the learner succeeding in relevant tasks

Question 12

What research supported modelling change?

Answer 12

• Sanderson and Yopuk (2007)
  
  • 220 University students assigned to receive either:
    
    • 30 min condom promotion video (+ve attitudes about condom use, modelling appropriate strategies for negotiating use; male vs female presenter versions)
    • Waitlist control
  • Intervention (video) participants reported:
    
    • stronger intentions to engage in protected sex
    • higher self efficacy in refusing to have unprotected sex
    • higher levels of condom use four months after seeing the videos
    • Both male & female students benefited more (condom us behaviour) from viewing the female presenters version

Question 13

What are mass media campaigns?

Answer 13

• Mass media campaigns
  
  • Print advertising, television advertising, radio, billboards, online
  • Potential to reach hundreds of thousands/millions
  • Exposure generally passive - resulting from incidental, routine use of media
  • May be of short duration or extend over long periods
  • May be stand alone or linked to other organised program components (e.g. clinical outreach, new products/services, policy changes)
  • Multiple methods of dissemination may be used in some initiatives

Question 14

What are the potential benefits of mass media campaigns?

Answer 14

Define behaviourally focused messages to large audiences repeatedly at a incidental manner, at a low cost per head

Question 15

What are the potential limitations of mass media campaigns?

Answer 15

• Campaign messages can fall short (or even backfire)
• Exposure of target audience may be suboptimal
• Funding may be inadequate/ceased
• Inappropriate or poorly researched format may be used (e.g. age inappropriate content)
• Homogeneous messages might not be persuasive to heterogeneous audiences
• Campaigns might address behaviours that audiences lack the resources to change

Question 16

Are mass media campaigns successful?

Answer 16

• Tanning campaign
  
  • Reached 90% of audience
  • Recognition score of 71%
  • Shift in agreement with the statement that melanoma can be easily treated
  • 90% made them think that someone may die from melanoma
  • Unclear if it is linked to behavioural change rather than just awareness
  • Tendency to consider advertising campaigns as successful purely based on awareness and attitudes is problematic
  • • “Speeding. No one thinks big of you” (Pinkie) campaign
• An independent survey, commissioned by the RTA’s Road Safety Marketing, found:
  
  • 53% of young males (17-25 years) said that they would be more likely to comment on someone’s driving as a result of seeing the ‘Pinkie’ campaign.
  • 63% of young male drivers, believed the campaign to have some effect in encouraging young male drivers to obey the speed limit.
  • 75% of young males revealed strong recognition of the anti-speeding message
  • Did it actually change speeding behaviour?
    
    • High-risk speeding decreased
    • P-platers deaths fell
    • Can’t necessarily attribute this to one intervention

Question 17

What did Wakefield et al. (2010) review of smoking find most effective in campaigns?

Answer 17

• More studies done on effectiveness of smoking campaigns than any other health related issue
• Controlled field experiments/population studies show mass media campaigns associated with:
• Decline in young people starting smoking
• Increase in number of adults stopping smoking
• Although more effective when integrated with programs/policies (e.g. tax, smoke-free policies, school programs)
• Hard to determine actual effectiveness because of lack of formal
  control groups

Question 18

What did Wakefield et al. (2010) review of alcohol find most effective?

Answer 18

• Mass media campaigns to lessen alcohol intake have had little success (other than drink driving campaigns)
• Most campaigns target young people-
  
  • overshadowed by widespread unrestricted alcohol marketing strategies and the view of drinking as a social norm
• Safe drinking campaigns sponsored by alcohol companies have been ineffective in changing drinking behaviour
  
  • messages are viewed as ambiguous by recipients

Question 19

What does Wakefield et al. (2010) ultimately recommend?

Answer 19

• Likelihood of success increased by:
  
  • Application of multiple interventions
  • Target behaviour being one off or episodic (e.g. screening, vaccination) rather than habitual or ongoing (e.g. healthy food choices, physical activity)
  • Availability of / access to key services and products
  • Creation of policies that support opportunities for change
• So, do mass media campaigns work?
  
  • Isolation of independent effects is difficult
  • “Whilst in isolation study findings are not strong, aggregate yield of the body of research shows support for the conclusion that mass media campaigns can change health behaviours

Question 20

What did the evaluation of health behaviour change interventions by the house of lords suggest?

Answer 20

• House of Lords (UK)
  
  • Report identified range of issues related to the way health behaviour change interventions are evaluated:
    
    • Evaluation should be considered throughout the intervention design process
    • Interventions should be evaluated against relevant outcome measures
    • The evaluation should consider whether the intervention has resulted in long term behaviour change
    • Sufficient funds should be allocated for evaluation

Question 21

What are the three methods that can be used to maximise effectiveness of mass media campaigns?

Answer 21

• Despite the (potentially) limited effect of single media campaigns– remain an attractive and frequently used means of influence
• > > reach large numbers of people with relative ease
• There are a number of potential methods to maximise effectiveness including:
  
  • Appropriate use of fear messages
  • Information framing
  • Specific targeting of interventions

Question 22

What is the appropriate use of fear messages?

Answer 22

1. Popular approach
   
   • High levels of threat proven relatively ineffective in engendering behavioural change
   • e.g. fear arousal campaign for HIV/AIDS
   • > > increased HIV/AIDS anxiety but did not increase knowledge or trigger behavioural change
2. Witte (1992) proposed threatened individuals can take two courses of action:
   
   • Danger control: reducing the threat- actively focusing on solutions
   • Fear control: reducing the perception of risk, often by avoiding thinking about the threat
   • For danger control to be selected:
     
     • person needs to consider that an effective response is available (response efficacy)
     • they are capable of engaging in the response (self efficacy)
     • > > > Otherwise fear control will become dominant coping strategy
       • Witte argued that the most persuasive messages are therefore those that:
   • arouse fear – e.g. unsafe sex increases your risk of getting HIV.
   • increase the sense of severity if no change is made – e.g. HIV is a serious condition.
   • emphasise the ability of the individual to prevent the feared outcome (efficacy) –e.g. here’s how you engage in safer sex practices.

• If the ability of the individual to prevent the feared outcome is not emphasised, any fear messages may actually inhibit behavioural change:
  
  • such messages may increase resistance to the message
  • lead to denial that it applies to the individual
  • increase engagement in the targeted risk behaviour
• Despite these results, health messages frequently emphasise vulnerability and severity and neglect efficacy

Question 23

What is information framing?

Answer 23

1. Information framing
   
   1. Health messages can be framed in either positive (stressing positive outcomes associated with action) or negative terms (emphasising negative outcomes associated with failure to act)
      - Negative frames may be more memorable, but positive frames may enhance information processing
      - Conflicting results of studies
      
      • Some suggest positive framing is better (e.g. Detweiler et al., 1999 sunscreen study)
      • Others suggest negative framing is preferable (e.g. Gerend & Shepherd, 2007 HPV vaccine study)

Cannot make a priority judgement about effect of +/- information framing, should aim to test intervention as a pilot before public launch

Question 24

How can we specifically target campaigns?

Answer 24

1. Targeting the audience
   
   1. Mass media campaigns may ‘dilute’ the message
      
      • It is more effective to target your audience
      • Media campaigns can be targeted on several factors:
        
        • behaviour
        • age
        • gender
        • socio-economic status
        • sexuality
        • psychological factors such as their motivation to consider change