1. 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

2. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Presentation purpose Target 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

3. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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

4. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Behavior change cycle Trigger Pre- contemplation contemplation Preparation Action & maintenance Awareness raising Promote benefits Identify obstacles Assessment Goal setting/action plans Promote self efficacy

5. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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

6. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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

7. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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

8. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Contemplation: Deciding to Quit Here is how to get started with your quitting. You need to know Smoking Kills Cigarettes are full of poisons Smoking causes disease Some benefits of quitting Quit and save a packet More good reasons to quit Deciding to quit checklist The internet & stopping smoking - research project Quit Pack Order Form How much do you spend on smoking?

9. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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 cigarettes Verbal persuasion, raise awareness

10. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Contemplation: Deciding to Quit Try 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

11. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Preparation: Getting ready to Quit Smokers 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

12. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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

13. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Action: Quitting Now's the time to put all your work into practice and quit. You are ready Understand withdrawal symptoms Understand withdrawal symptoms Coping with cravings Excuses for not quitting – myths and reality Excuses for not quitting – myths and reality Quitting checklist

14. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Action: Quitting You 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.

15. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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.

16. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Maintenance:Staying a Non-smoker The 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

17. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Maintenance:Coping with setbacks Quitting 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

18. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Method Focus GroupIndividual Interviews Content / Script Dev’t Concept Testing Product Testing Final Product Promotional Strategy Product Development Concept Development Research & Development Product Modification

19. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Consumers have had a say !

20. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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

21. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Key concepts of self management Recognition 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 change Encompasses social learning and behavioral theories

22. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 How self management differs from patient education Self-ManagementPatient 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

23. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 How self management differs from patient education Self Management Patient Education Needs Assessment Patient problems What patients need to know Content Disease, role, & emotional management Disease knowledge and behaviors Leader Leader is guideLeader is expert Kate Lorig

24. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Evidence Good evidence to support self management  Improves quality of life  Supports behavior change  Decreases health care utilisation www.cfah.org.au Barlow. J et al WHO

25. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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.auwww.cfah.org.au Adherence to long term therapies www.who.org go to publications linkwww.who.org

26. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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.

27. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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.

28. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Lois’s Story

29. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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

30. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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

31. DPMI Workforce Development – The Alfred Workforce Development Team June 2005

32. 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 al Medical Care 38, 2000

33. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Automated telephone disease management 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

34. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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 Lorig Stanford Patient Education Centre

35. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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

36. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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 implementation The Robert Wood Johnson Foundation The Centre for the Advancement of Health www.cfah.org

37. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Ray’s story

38. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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 Linder Latrobe university

39. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Assessment/Problem definition Aim To 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

40. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Assessment/Problem definition Interview questions 1. 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

41. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Assessment/Problem definition 4. 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

42. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Problem solving and decision making Identifying problems Set goals Helping find alternative ways of to accomplish goals Setting contracts with themselves Checking the results Making changes as needed

43. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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

44. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 SMART Specific Measurable Achievable Realistic Timely Flinders University

45. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Guidelines for helping with - Problem solving Identify the problem List ideas Select one Assess the results Substitute another idea (if first didn’t work) Accept that the problem may not be solvable Kate Lorig

46. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Behavior Change Prevention Chronic disease care Target Audience  Population  Individual  Group programs Information Case Management

47. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Implementing change Individual practice Program changes Organisational 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

48. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Our changing roles Patient: Manager Health 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

49. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 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.