L03 Psychological Medicine Health Behaviour Change

Overview

The lecture defines health and health behaviour, then explains why knowing that a behaviour is harmful is rarely enough to change it. It sets out the internal and external barriers that stand in the way, the habit loop that keeps a behaviour running and the three points at which that loop can be targeted, the beliefs and thoughts that sit underneath a competing behaviour, and the Stages of Change model used to assess where a patient currently is. It closes on the doctor’s role in behaviour change and points to motivational interviewing as the technique taught elsewhere.

Learning objectives as stated:

1. Understand what health behaviour is.
2. Understand why people exhibit different health behaviours.
3. Understand how doctors play a role in changing people’s health behaviours.
4. Become familiar with the Stages of Change Model.

Health and health behaviour

• Health: the overall state of wellbeing, not just the absence of disease.
• Health behaviour: action taken to improve wellbeing and prevent illness.

Five healthy lifestyle practices that reduce chronic diseases:

1. Never smoking.
2. Healthy BMI / no obesity.
3. Moderate to vigorous exercise.
4. Healthy diet.
5. Moderate alcohol consumption.

Why knowledge alone does not change behaviour

The naive model presented is a single step: knowledge about adverse effects leads directly to healthy behaviour. The lecture then undercuts it, since desire and temptation compete with knowledge (illustrated by the angel and the slice of chocolate cake, and by the fast-food cartoon offering a token “healthy alternative” as an example of superficial, ineffective change). What actually stands between knowledge and behaviour is the set of barriers below, the habit loop, and the person’s underlying beliefs.

Barriers to change

The two categories are drawn as overlapping circles, so a given barrier can be both.

Internal barriers

• Lack of knowledge.
• Unhelpful beliefs, including low self-efficacy.
• Lack of motivation.
• Fear of change.
• Triggering situations.

External barriers

• Lack of support.
• Societal / cultural expectations.
• Geographical location.
• Accessibility / lack of resources.

A second barriers list is given in behavioural terms:

1. Enjoyment of competing poor health behaviours.
2. No immediate adverse effects of poor behaviours.
3. The amount of effort involved in changing health behaviours.
4. Triggering environments / social groups.

The habit loop

Triggering situations are explained through the habit loop, a cycle of three elements:

1. Cue: the trigger that starts the habit.
2. Routine: the action, that is, the habit itself.
3. Reward: the benefits gained through the habit.

The reward feeds back to the cue, closing the cycle.

Worked example, smoking:

• Cue (trigger for behaviour): seeing cigarettes, a social situation, or a stress situation.
• Routine (the behaviour): lighting up a cigarette, starting smoking.
• Reward (the result): status, satisfaction, comfort, looking cool.
• At the centre of the loop, craving for nicotine drives the cycle round.

Breaking the habit loop

Three points of the loop are marked as the places it can be targeted and broken: the cue, the routine, and the reward. The barriers above (internal and external) are then presented as what stands in the way of breaking the loop, so identifying the target point and the relevant barriers goes together. Further reading given: The Power of Habit: Why we do what we do and how to change, Charles Duhigg.

Beliefs, thoughts and responses

A cognitive model is applied to cake. The stimulus (the cake) prompts a thought, “one bite wouldn’t hurt”, and that thought produces three parallel outputs:

• Emotional response: “wow that feels good”.
• Body response: growling tummy, thirsty.
• Behavioural response: eat, and order a milkshake.

The thought is itself generated by underlying beliefs, and the two given are held at the same time: “eating too much cake is not good for me” and “cake makes me feel good”. The point is that the belief, not the knowledge, drives the thought that drives the behaviour.

Assessing readiness: the Stages of Change model

The Stages of Change model is drawn as a cycle running in this order:

1. Pre-contemplation.
2. Contemplation.
3. Preparation.
4. Action.
5. Maintenance.
6. Relapse (or lapse), which returns to pre-contemplation.

Warning

The slide gives the stage names and the cycle only. No definitions of the individual stages are given on the slide.

The doctor’s role

Behaviour change is presented as a two-step sequence: (1) it starts with the doctor, then (2) interaction with the patient, arriving at an idea or insight.

Warning

[flag: the slide gives no text explaining what step 1 or step 2 involves, and the lightbulb endpoint is unlabelled; meaning beyond the sequence itself is not stated on the slide]

Motivational interviewing is named as the technique for this, covered in its own lecture and in tutorials rather than here.

Key take-home points

1. Health behaviour = action taken to improve wellbeing and prevent illness.
2. Different health behaviours may stem from various factors, including personality traits, situation and environment.
3. Understanding the patient’s concerns, situation, barriers, stage of change and underlying beliefs is what matters in changing behaviour.

Related teaching

ELM 2 Psych Med Block Module lectures on personality and health behaviour, Motivational Interviewing, health treatment adherence, and behavioural addictions; ELM 2 Case 2 (Health); ELM 3 Case 19 (weight gain and insulin resistance); ELM 3 Psychological Medicine Vertical Module lecture on obesity, psychological dimensions.

Self-test

1. Define health and health behaviour as given in this lecture.
2. List the five healthy lifestyle practices said to reduce chronic diseases.
3. Explain why the one-step model “knowledge about adverse effects produces healthy behaviour” is inadequate.
4. List the internal barriers to change, and state the example given of an unhelpful belief.
5. List the external barriers to change.
6. Describe the three elements of the habit loop in order and define each.
7. Apply the habit loop to smoking: give the cue, the routine and the reward, and say what sits at the centre driving the cycle.
8. Which three points of the habit loop are identified as targets for breaking it?
9. List the four barriers given in behavioural terms (the enjoyment / effort list).
10. In the cake model, describe how belief, thought and response are related, and name the three types of response produced.
11. Name the stages of the Stages of Change model in order, and say what follows relapse.
12. What does the lecture say a doctor must understand in order to change a patient’s behaviour, and which named technique is taught for doing it?
13. Integrative: a patient who smokes says they know it is harmful but has not thought about stopping. Identify their stage of change, describe how you could target the habit loop, and name one internal and one external barrier that could be standing in the way.

Answers

Reveal answers

1. Health is the overall state of wellbeing, not just the absence of disease. Health behaviour is action taken to improve wellbeing and prevent illness.
2. Never smoking; healthy BMI / no obesity; moderate to vigorous exercise; healthy diet; moderate alcohol consumption.
3. Because desire and temptation compete with knowledge, and because barriers, the habit loop and underlying beliefs sit between knowing and doing. People can hold the knowledge (“eating too much cake is not good for me”) and still act on the competing belief and reward.
4. Lack of knowledge; unhelpful beliefs; lack of motivation; fear of change; triggering situations. The unhelpful belief given as an example is low self-efficacy.
5. Lack of support; societal / cultural expectations; geographical location; accessibility / lack of resources.
6. Cue, the trigger that starts the habit; routine, the action or habit itself; reward, the benefits gained through the habit. The reward feeds back to the cue.
7. Cue: seeing cigarettes, a social situation, or a stress situation. Routine: lighting up a cigarette, starting smoking. Reward: status, satisfaction, comfort, looking cool. Craving for nicotine sits at the centre and drives the cycle.
8. The cue, the routine and the reward.
9. Enjoyment of competing poor health behaviours; no immediate adverse effects of poor behaviours; the amount of effort involved in changing health behaviours; triggering environments / social groups.
10. Underlying beliefs (“eating too much cake is not good for me” and “cake makes me feel good”) generate the thought “one bite wouldn’t hurt”, and that thought produces emotional responses (“wow that feels good”), body responses (growling tummy, thirsty) and behavioural responses (eat, order a milkshake).
11. Pre-contemplation, contemplation, preparation, action, maintenance, relapse (or lapse). Relapse returns to pre-contemplation.
12. The patient’s concerns, situation, barriers, stage of change and underlying beliefs. The named technique is motivational interviewing.
13. Stage: pre-contemplation. The loop can be targeted at the cue (seeing cigarettes, social or stress situations), the routine (lighting up) or the reward (status, satisfaction, comfort, looking cool). Internal barrier, for example lack of motivation or low self-efficacy; external barrier, for example lack of support or societal / cultural expectations.