Self empowerment

Produced by The Alfred Workforce Development Team on behalf of DHS Public Health -

Diabetes Prevention and Management Initiative June 2005

Promoting Behaviour Change

For individuals and populations

Module 4.3

DPMI Workforce Development – The Alfred Workforce Development Team June 2005

Presentation purposeTarget audience

Service providers and project workers on DPMI projects

Aim

To explore the concepts of behaviour change and self management

Objectives

Provide an overview of behaviour change and self management Explore best practice models of behaviour change Discuss the key concepts of self management and empowerment Explore self management models and evidence Discuss and workshop problem solving and goal setting


Communicating risk

Factors influencing thinking on risk People underestimate risk related to

chronic disease overestimate communicable disease

Trust Who is telling me are they trustworthy?

Risk less acceptable if: Imposed Distributed unevenly Resulting from man made Hidden/irreversible


Behavior change cycleTrigger

Pre-contemplation

contemplation

Preparation

Action & maintenance Awareness raising

Promote benefits

Identify obstacles

Assessment

Goal setting/action plans

Promote self efficacy


Self efficacy

Promote performance accomplishment Use verbal persuasion Role modelling Identifying feelings and helping work through

strategies to deal with feelings Meaningful to the individual

Promoting self efficacy

• Self efficacy strong predictor of behavior change

• Self efficacy is your belief in your ability to perform a task


Developing resources to support behavior change Thinking of quitting smoking? Identifying feelings Here are all the facts that show quitting is the right choice.

Verbal persuasion

Make this site work for you. Bookmark the pages that really mean something to you.

Meaningful to the individual For more help, call the Quitline 131 848. Like all good things, it's going to take some time and effort

for you to quit smoking, but thousands of smokers in Australia have already stopped. You can too.

Identifying feelings & verbal persuasion


Tailoring information to stages of change Deciding to Quit

Getting Ready to Quit

Quitting

Staying a Non-smoker Coping with Setbacks Helping Others Quit

Pre-contemplation

Contemplation

Preparation

Action & maintenance


Contemplation: Deciding to QuitHere is how to get started with your quitting.You need to knowSmoking KillsCigarettes are full of poisonsSmoking causes diseaseSome benefits of quittingQuit and save a packetMore good reasons to quitDeciding to quit checklistThe internet & stopping smoking - research projectQuit Pack Order FormHow much do you spend on smoking?

http://www.quit.org.au/quit/display.cfm?Category=Deciding%20to%20Quit&ArticleID=1049&table=Quitting












Deciding to quit checklist I’ll reduce my risk of heart attack. I’ll reduce my risk of getting cancer. I’ll feel fitter and my skin will look younger. Within twelve hours, my body will be free of

nicotine. I’ll set a great example for the children around

me. My lungs will start to recover and be able to clean

themselves properly. I’ll have more money to spend any way I choose. I’ll give myself a confidence boost by quitting

cigarettesVerbal persuasion, raise awareness


Contemplation: Deciding to QuitTry this List all your reasons for quitting, and then number the three

reasons you think are important. Meaningful to the individual & promote

benefits

Try this From the following list, tick the things that you want to do

when you are a non-smoker. Add your own ideas in the space provided.

Having more energy to play sport or keep up with the kids. Knowing I'm back in control and no longer addicted. I'll be free from the hassle of always checking that I have

enough cigarettes. Reducing the risk of getting sick from cancer or heart

disease.Identifying feelings, promoting performance & promote benefits


Preparation: Getting ready to QuitSmokers who plan before they quit are more successful

than those who don't, and planning can be done quickly

Understand your nicotine addiction The Quit Book Know why you smoke Smoking Record Plan ways to deal with quitting Quit course Set a date to quit Some words about weight gain Getting ready to quit checklist

http://www.quit.org.au/quit/display.cfm?Category=Getting%20Ready%20to%20Quit&ArticleID=99&table=Quitting










Set a date to quit

Unless there is a very good reason, make the date within two weeks from now.

Choose an easy date to stop, one when you will not be under much pressure, but will have plenty to occupy yourself.

Practice Quitting Once you have picked a date to quit, stick to it. Before you quit, you might try a practice smokefree

day to see how you would go. Or you could experiment by not smoking at times

when you normally would; This will help you to work out how much you need

to prepare for these situations when you quit completely.

Goal setting/action planning


Action: QuittingNow's the time to put all

your work into practice and quit.

You are ready Understand withdrawal symptoms

Coping with cravings Excuses for not quitting –

myths and reality Quitting checklist

http://www.quit.org.au/quit/display.cfm?Category=Quitting&ArticleID=110&table=Quitting




Action: QuittingYou are ready You've made your decision to quit. You have any extra information or support you feel you

need. You've done your planning. You've set your quit date. Stick to your decision. You're doing the right thing.

Choose an approach that will work for you You could go cold turkey. For many people, this is a

successful method. You could cut down by reducing gradually If you choose to cut down make sure your quit date is set

for two weeks after you start reducing your smoking. On your quit date, cut out cigarettes altogether.


Quitting checklist I will choose whether to stop suddenly or gradually. Withdrawal symptoms are a good sign I can confront cravings by remembering the 4Ds:

Delay Deep breathe Drink water Do something else.

I will congratulate myself every time I resist the urge for a cigarette.

Reminding myself of my reasons to quit will make it easier to refuse cigarettes.

I have the right to refuse a cigarette and can do so without upsetting others

I can keep my hands busy Even if I decide to have alcohol, I’ll stick to my decision to

quit.


Maintenance:Staying a Non-smokerThe worst is over. You'll feel the urge to smoke less

and less, and soon you'll hardly think about cigarettes.

But the urge to smoke can return when you least expect it.

You can stay stopped, but you need to be prepared. There is always something better than a cigarette.

The new you

Find new ways to relax & other things to do

Staying a non-smoker checklist


Maintenance:Coping with setbacksQuitting can be hard. You might be going along OK, and suddenly you feel

like smoking again.Sometimes, as you gain confidence, you actually

start to think quitting is easy, so why not smoke again? Your resolve starts to weaken.

Try this

If you have a cigarette

If you go back to regular smoking


Method

Focus Group Individual Interviews

Content / Script Dev’t

Concept Testing

Product Testing

Final Product

Promotional Strategy

ProductDevelopment

ConceptDevelopment

Research &Development

Product Modification

Product Modification


Consumers have had a say !


Empowerment and self management principles HPs provide

Expertise Information Psychological support

Individual The daily decision making in the treatment of

their condition Adults more likely to make and maintain

change if they are personally meaningful and freely chosen Robert Anderson


Key concepts of self managementRecognition of problems as seen by

the person and encouraging them to identify solution “Identifying problems often means HP

needs to be silent!!” (Skinner)Discovery and enhancement of internal

reinforcement for behavior changeEncompasses social learning and

behavioral theories


How self management differs from patient education

Self-Management Patient Education

Purpose: To Manage Life With Disease

To Change Behaviors

To Increase Skills/Self-Confidence

To Increase Knowledge

To Problem Solve And Make Decisions

To Use Specific Tools

Kate Lorig

Self-Management PatientEducation

Purpose To manage life with disease

To changebehaviors

To increase skills/self confidence

To increaseknowledge

To problem solveand make decisions

To use specific tools

Kate Lorig


How self management differs from patient education

Self Management

Patient Education

NeedsAssessment

Patient problems

What patients need to know

Content Disease, role, & emotional management

Disease knowledge and behaviors

Leader Leader is guide Leader is expert

Kate Lorig


Evidence

Good evidence to support self management Improves quality of life Supports behavior change Decreases health care

utilisationwww.cfah.org.au Barlow. J et alWHO


References Robert Anderson et al “Using the empowerment

approach to help clients” Chapter 17 in “Practical psychology for diabetes Clinicians” Anderson, B and Rubin, R. Published ADA Alexandria Virginia 1996.

Barlow J. et a “Self – management approaches for people with chronic conditions: a review” Patient Education and Counseling 48 (2002) 177-187

“Patients as effective collaborators in managing chronic conditions” www.cfah.org.au

Adherence to long term therapies www.who.org go to publications link

http://www.cfah.org.au/

http://www.who.org/


Diabetes self management education in Australia Norsworthy document reviewed

8 articles / 153 studies of the effectiveness of diabetes interventions.

Concluding the evidence presented provides

powerful arguments that diabetes self management education is: Able to influence behaviour change and improve

knowledge and skill for diabetes self management Can result in a reduction in secondary complication

rates Can reduce the person’s reliance on health services.


Diabetes self management education in Australia Access and equity issues

Rural areas Indigenous people CALD communities People of low socio-

economic status.

People in socially disadvantaged areas receive fewer long consultations than people in higher socio-economic areas.


Lois’s Story


Self management models Disease – related, education-

focus provision of information, skill development

Behaviour change focused Readiness to change Motivational interviewing Goal orientated programs

Psychosocial – focused support Support groups Social isolation Self efficacy


Delivery of self management programs Provided through a

variety of modalities Face to face Telephone Email Web based

Principles can be incorporated into group or individual counselling sessions



Automated telephone disease management RCT : People with diabetes Intervention:

Received weekly calls from automated telephone system

To discuss self-care activities and hear self-care tips Control: Normal office visits and information

FINDINGS: Intervention Group

Reported fewer depressive symptoms Higher self efficacy for self care Greater satisfaction with services received Improvement in health related quality of life

Petitte et alMedical Care 38, 2000


Automated telephone disease managementFINDINGS: Intervention Group

Reported fewer depressive symptoms Higher self efficacy for self care Greater satisfaction with services

received Improvement in health related quality of

life


Back pain email discussion group RCT 580 subjects Intervention:

Closed moderated email discussion group & back pain book and video tape

Controls: Non health magazine subscription of their choice

Findings at 1- year: Significant improvements in pain, disability, role

function and health distress Less physician visits and hospitalisation days

Kate LorigStanford Patient Education Centre


Behavioural weight loss program

Objective: Determine effectiveness of Internet behavioural weight loss program compared to weight loss education website

RCT 6 months, 91 subjects, 18-60yrs, 81 female, BMI 25-36

Control Group: web based information relating to weight loss

Intervention: as above plus weekly email messages, online submission of diaries, therapist feedback

FINDINGS Mean weight loss in intervention group at 6 months 4.1kg (4.5) Mean weight loss in control group at 6 months 1.6kg (3.3)Tate JAMA March 2001


Essential elements of self management interventions Disease, medication and health

management Role management Emotional management Support enhancement of self efficacy Problem solving training Follow up Tracking and ensuring implementationThe Robert Wood Johnson FoundationThe Centre for the Advancement of Healthwww.cfah.org


Ray’s story


Motivational interviewing Seeks to understand the persons

frame of reference – reflective listening

Expresses acceptance and affirmation

Elicits and selectively reinforces the patients own self motivational statement, expression of problem, concern, desire and intention and ability to change.

Helen LinderLatrobe university


Assessment/Problem definitionAimTo help clients realise they are

responsible for, and in charge of, their condition

Prioritise problems and identify situations they want to improve

Experience emotional and psychological commitment

Develop a plan of action


Assessment/Problem definitionInterview questions1. What part of living with your

condition is the most difficult or unsatisfying for you?

2. How does the situation make you feel?

3. How does this situation have to change for you to feel better about it?

Robert Anderson


Assessment/Problem definition4. Are you willing to take action to improve

the situation for yourself?

5. What are the steps that you can take to bring you closer to where you want to be?

6. Is there one thing that you will do when you leave here to improve things for yourself?

Robert Anderson


Problem solving and decision making Identifying problemsSet goals Helping find alternative ways of to

accomplish goalsSetting contracts with themselvesChecking the results Making changes as needed


Goal setting- Getting started

Choose long term goal Goals should be something you want to do

Identify steps needed to reach long term goal

Choose one of those steps to start working towards goal


SMART

SpecificMeasurableAchievableRealisticTimely

Flinders University


Guidelines for helping with - Problem solving

Identify the problemList ideas Select oneAssess the resultsSubstitute another idea (if first didn’t

work)Accept that the problem may not be

solvableKate Lorig


Behavior Change

Prevention

Chronic disease care

Target Audience Population Individual Group programs

Information

Case Management


Implementing change Individual practiceProgram changesOrganisational approach Small incremental changes can still have

an effect Can require philosophical shift Education process/skill development Reorganisation of services Systematic approach to assessment and care

planning using tools that support identification of problem & patient generated goals


Our changing roles Patient: ManagerHealth Professional: Assistant

Responsible to clients rather than for them

Sharing knowledge and expertise to help make informed decisions to about their care

Collaborative approach with client generated

solutions to problems as perceived by client


EDWARD DE BONO

It is better to have enough ideas for some of them to be wrong, than to be always right by having no ideas at all.