L19 health interventions

Question 1

Individual approaches to behaviour change

Answer 1

1. Motivational interviewing
2. Problem solving approaches & implementation planning
3. Modelling and behavioural practice

Question 2

Motivational interview

Answer 2

Person-centred method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Miller & Rollnick 2002)
• The intervention generally considered most likely to be effective for people who are reluctant to engage in change
• Motivational interview (MI) is collaborative, non-confrontational, non-authoritative

Question 3

Key questions within the motivational interview are:

Answer 3

Key questions within the interview are:
• ‘What are some of the good things about your present behaviour?’
• ‘What are the not-so-good things about your present behaviour?’

Question 4

he spirit of motivational interviewing (Hall, Gibbie, Lubman., 2012)

Answer 4

Collaboration: patient-practitioner partnership; joint decision making. Practitioner acknowledges patient’s expertise about themselves
Confrontation: practitioner assumes patient has an impaired perspective and imposes the need for ‘insight’. Practitioner tries to persuade and coerce a patient to change
Evocation: practitioner activates patient’s own motivation for change by evoking their reasons for change- connects health behaviour change to things patient cares about
Education: patient is presumed to lack the insight, knowledge or skills required to change. Practitioner tells the patient what to do
Honouring patient autonomy: Whilst informing the patient, practitioner acknowledges the patient’s right and freedom not to change. ‘It’s up to you’
Authority: practitioner instructs the patient to make changes

Question 5

MI Key elements and strategies include:

Answer 5

• Expressing empathy by the use of reflective listening
• Supporting self-efficacy and optimism for change
• ‘Rolling with resistance’ rather than confronting or opposing it
• Developing an awareness of the discrepancies between the client’s current behaviours and their values/goals

Question 6

RULE

Answer 6

MI guide
Resist the righting reflex; 
Understand the patient's own motivations; 
Listen with empathy; and 
Empower the patient.

Question 7

Hall meta-analysis says:

Answer 7

Recent meta-analyses show that motivational interviewing is effective for decreasing alcohol and drug use in adults and adolescents and evidence is accumulating in others areas of health including smoking cessation, reducing sexual risk behaviours, improving adherence to treatment and medication and diabetes management.

Question 8

Why is it hard to measure MI?

Answer 8

• Goal of MI is to motivate people to consider change

* Most studies focus on whether it can alter behaviour

Question 9

Meta Analysis: Smedslund et al. (2011) MI

Answer 9

o MI in drug overuse setting more successful (substance use behaviour) than no intervention
o Limited differences with other active treatments

Question 10

• Schneider, Casey, & Cohen (2000) older study MI

Answer 10

o Compared MI with confrontational interviewing in persuading substance users to enter treatment
o At 3 & 9 months- equal % of groups had completed their treatment program and had made similar gains in reduced drug use
• HOWEVER» MI was more acceptable and less stressful for both counsellors and clients than confrontational approach

Question 11

• Problem solving approaches & implementation planning

Answer 11

2. Problem focused counselling
   • “Problem oriented”
   • Focused on the issues at hand, in the ‘here and now’
   • Three distinct phases (Egan, 2006):
3. Problem exploration and clarification: detailed exploration of problems individual is facing; breaking ‘global insolvable problems’ into carefully defined solvable elements
4. Goal setting: Identifying how individual would like things to be different; setting clear, behaviourally defined, achievable goals
5. Facilitating action: Developing plans and strategies through which these goals can be achieved

Question 12

• Role of counselor in Problem focused counselling

Answer 12

• Role of counsellor NOT to act as expert solving person’s problems
• Rather to mobilise the individual’s own resources to identify problems and arrive at solutions
• Important to deal with stages sequentially and thoroughly

Question 13

Effectiveness of problem focused counselling

Answer 13

• 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.
Has the potential to be useful in some situations.

Question 14

Problem focused counselling- applied example Smoking

Answer 14

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
Avoidant – sit with no smoking friends at breaks
Coping - “think about things in the room rather than the urge to smoke”
Cognitive re-labelling – these unpleasant symptoms are a sign of recovery

Question 15

Egan’s (2006) last stage of problem focused counselling may be key in problem focused counselling

Answer 15

o 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:
o Increased fruit intake (DeNooijer et al., 2006);
o Cervical cancer screening (Sheeran & Orbell, 2000);
o Quitting smoking (Armitage, 2007);
o Weight loss (Luszczynska et al., 2007)

Question 16

Modelling change

Answer 16

• 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 17

Sanderson and Yopuk (2007) Modelling and behavioural practice study

Answer 17

• 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 use behaviour) from viewing the female presenters’ version (cultural reasons?)

Question 18

Actual practice of a new behaviour example (modelling and behvaioural practice)

Answer 18

Solutions to problems and skills needed to achieve change can be worked out and taught in an educational program
•&raquo_space;Increasing skills and self-efficacy
• E.g. Kelly et al. (1994) reducing risky sexual behaviour: negotiating condom use
• Women at high risk of HIV infection attending an STI clinic
• Program included risk education, training in condom use, practicing sexual assertiveness skills such as negotiating condom use
• More effective than standard education based intervention in improving rates of condom use

Question 19

Potential challenges of mass media campaigns

Answer 19

• 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 Wakefield et al. (2010)

Question 20

• Dark side of tanning ads

Answer 20

• Dark side of tanning ads reached 90% of the target audience and returned an average prompted recognition score of 71%
• There has been a shift in agreement with the statement “Melanoma can be easily treated because it can be cut out” from 36% pre-campaign in 2007/8 to 31% in 2011/12
• Should be noted, self-reported measures
  HOWEVER The tendency to consider advertising campaigns as successful purely based on awareness and attitudes is hugely problematic

Question 21

“Speeding. No one thinks big of you” (Pinkie) campaign

Answer 21

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

• P –plater behaviour changed. In the year following the campaign, p-plater deaths fell by 46%, as did crashes and high-risk speeding infringements. There were 22 fewer p-plate deaths in 2007 compared to 2006
• Road fatalities fell by 10% in 2007 compared to 2006. 58 fewer speed related deaths.
• “I’ve done it (the pinkie gesture) in my neighbourhood with a guy that drives a hotted up car and he slows down now.” Female 22, Western Sydney, May 2008.

Question 22

Wakefield et al. (2010) review- Smoking

Answer 22

• 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:
o Decline in young people starting smoking
o 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 23

Wakefield et al. (2010) review- Alcohol use

Answer 23

• Mass media campaigns to lessen alcohol intake have had little success (other than drink driving campaigns)
• Most campaigns target young people-
o 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
o messages are viewed as ambiguous by recipients

Question 24

Wakefield et al. (2010) review- Conclusions & Recommendations

Answer 24

• Likelihood of success increased by:
o multiple interventions
o Target behaviour being one off or episodic (e.g. screening, vaccination) rather than habitual or ongoing (e.g. healthy food choices, physical activity)
o Availability of / access to key services and products
o Creation of policies that support opportunities for change
• So, do mass media campaigns work?
o Isolation of independent effects is difficult
o “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 25

Evaluation of health behaviour change interventions

• House of Lords Science and Technology Committee 2011 (UK)

Answer 25

• Report identified range of issues related to the way health behaviour change interventions are evaluated:
o Evaluation should be considered throughout the intervention design process
o Interventions should be evaluated against relevant outcome measures
o The evaluation should consider whether the intervention has resulted in long term behaviour change, not just 3-4 months or a year
o Sufficient funds should be allocated for evaluation

Question 26

Maximising the effectiveness of mass media campaigns three methods

Answer 26

• There are a number of potential methods to maximise effectiveness including:

1. Appropriate use of fear messages
2. Information framing
3. Specific targeting of interventions

Question 27

Pros of mass media

Answer 27

• 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

Question 28

Appropriate use of fear messages

Answer 28

• 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

Question 29

Witte (1992) proposed threatened individuals can take two courses of action when presented with fear based messages

Answer 29

• 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

Question 30

Witte argued that the most persuasive Fear messages are therefore those that:

Answer 30

o arouse fear – e.g. unsafe sex increases your risk of getting HIV.
o increase the sense of severity if no change is made – e.g. HIV is a serious condition.
o emphasise the ability of the individual to prevent the feared outcome (efficacy)
– e.g. here’s how you engage in safer sex practices.

Question 31

If the ability of the individual to prevent the feared outcome is not emphasised, any fear messages may actually inhibit behavioural change: How?

Answer 31

o Such messages may increase resistance to the message
o lead to denial that it applies to the individual
o increase engagement in the targeted risk behaviour
Despite these results, health messages frequently emphasise vulnerability and severity and neglect efficacy

Question 32

what is Information framing?

Answer 32

• 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
o Some suggest positive framing is better (e.g. Detweiler et al., 1999 sunscreen study)
o Others suggest negative framing is preferable (e.g. Gerend & Shepherd, 2007 HPV vaccine study)
Cannot make a priori judgement about effect of +/- information framing, should aim to test intervention as a pilot before public launch

Question 33

Targeting the audience

Answer 33

• Mass media campaigns may ‘dilute’ the message
• It is more effective to target your audience
• Media campaigns can be targeted on several factors:
o behaviour
o age
o gender
o socio-economic status
o sexuality
o psychological factors such as their motivation to consider change
e.g. little black dress. The fastest rise of STIs was in women over 40. They had had some period of time without condom negotiation.
Another way to change behaviour is to look at context…

Question 34

• An environment encouraging healthy behaviours should:

Answer 34

• provide cues to action – or remove cues to unhealthy behaviours
• enable health behaviours by minimising the costs and barriers associated with them
• increase the costs of engaging in health damaging behaviours

Question 35

Success of cigarette interventions show:

Answer 35

• Larger and clearer health warnings on cigarette packets more effective (Borland, 1997)
• Graphic imagery rather than text about risks may also be more effective (Thrasher et al., 2007)
• Coping information in addition to risk information (Kessels et al., 2010)

Question 36

Success of

• Australia’s introduction of plain packaging in 2012

Answer 36

• 2014 Tobacco consumption lowest ever recorded in Australia (ABS data)
• Rates of smoking have fallen since 2012 (15.9% in 2010 to 13.3% in 2013) (AIHW data)
• Rates of attempts to quit have increased (20%/month to 27%/month)
• Wakefield et al.’s evaluation (2015, BMJ) reported that since introduction of plain packaging, more people who smoke:
o dislike their packs
o are less satisfied by smoking
o notice the graphic health warnings
o attribute motivation to quit to graphic health warnings