This article is the third in a series exploring the role of the nurse and other health professionals within public health and the Making Every Contact Count (MECC) approach (Craig and Senior, 2018; Senior and Craig, 2019). This article will explore use of behaviour change models in MECC.
The National Institute for Health and Care Excellence (NICE) (2014) states that the accumulation of small changes in individual lifestyle behaviours will create significant improvements in the health of the population. The NHS response—MECC—recognises that nurses and other health professionals have numerous opportunistic encounters with patients and their families to address lifestyle behaviours and support behaviour change (Lawrence et al, 2016).
Supporting behaviour change is not easy and requires thought, care and a deep understanding of what motivates people. If nurses understand the wide-ranging social and economic pressures that patients act under, they will be in a better position to support them to change (Kelly and Barker, 2016). MECC maximises the opportunity within routine health and care interactions for a brief discussion on health or wellbeing factors to take place (NICE, 2014).
As behaviours contribute to the cause of much current mortality and morbidity, interventions to change behaviour are essential in the prevention of or exacerbation of disease and/or long-term conditions (Michie and Johnston, 2012). Research in psychology has demonstrated that behaviour and behaviour change follow predictable patterns. In order to support patients in changing their behaviours, an understanding of behaviour change theory is required.
Behaviour is individual, based on how we see others behave and act, and it occurs in context.
Davis et al (2015) define behaviour as:
‘Anything a person does in response to internal or external events. Actions may be overt (motor or verbal) and directly measurable, or covert (activities not viewable but involving voluntary muscles) and indirectly measurable; behaviours are physical events that occur in the body and are controlled by the brain.’
NICE describes behaviour change intervention as:
‘Single or multiple sessions of motivational discussion focused on increasing the individual's insight and awareness regarding specific health behaviours and their motivation for change.’
Before any intervention takes place, NICE (2014) suggests that the nurse should use a recognised model of change. There are several theoretical models of change used within nursing practice. Before discussing goal setting and goal follow-up, it is crucial that the nurse is able to identify and understand at which stage their patient is in relation to making changes to their lifestyle that will improve their health.
The Transtheoretical Model
The Transtheoretical Model, sometimes referred to as the ‘stages of change’ or ‘spiral of change’ model, by Prochaska and DiClemente (1994), describes the different stages that individuals go through when changes to lifestyle are required (Royal College of Nursing (RCN), 2016). There is an assumption that behaviour change occurs in a linear fashion: a progression through a series of stages (see Figure 1):
‘Precontemplation’ can be seen when the patient is not thinking seriously or perhaps has not thought about making a change in health behaviour such as stopping smoking, reducing their alcohol intake or taking part in more physical activity. Addressing lifestyle behaviour at this stage may result in noncompliance or avoidance. It is critical not to push the desired behaviour change agenda at this stage and merely offer brief advice and the option to discuss in more depth if required.
At the ‘contemplation’ stage patients are beginning to consider their behaviour in relation to their health—this may be due to advice received, advertising or discussions with others. From the perspective of the nurse or other health professional, this stage is an ideal time to initiate discussions about desired changes.
The next stage sees the patient preparing to change their behaviour. The ‘preparation’ stage requires the nurse or other health professional to assist and advise about strategies or refer on to other accessible support to start the changes. Following this stage the patient has made all the necessary preparations and moves into the ‘action’ stage, and they begin to carry out steps to change their behaviours. Small achievable steps to start the process will give the patient confidence. They see the rewards of their behaviour change and continue. Over time their actions will increase until they achieve their ultimate goal of maintaining the desired change and sustain the new healthier behaviour.
However, for many patients, ‘maintenance’ is the most difficult part. Owing to several different reasons, relapses may occur and these can happen at any point in the continuum. The nurse's role is to help the patient recognise scenarios in which relapses may arise and negotiate strategies to manage them. It is crucial to support a patient so they do not feel that they have failed and assist them to keep moving towards their desired goal (RCN, 2017).
The Transtheoretical Model can be used in isolation or in conjunction with other models such as the COM-B Model (capability, opportunity, and motivation in order to change behaviour) (Michie et al, 2011) and the Health Belief Model (Becker, 1974). When used in conjunction with other models, the Transtheoretical Model is often used primarily to identify at what point the patient is in relation to the changes required. As alluded to earlier, should the patient present in the precontemplation stage, an in-depth assessment is not required.
COM-B Model
The COM-B Model is a theoretical model that aids understanding of the barriers to and facilitators of behaviour. It focuses on three conditions that are required—capability, opportunity and motivation—and their interactions in order to change behaviour (see Figure 2). This model recognises that behaviour is part of an interacting system involving all these components (Michie et al, 2011).
For any change in behaviour to occur, a person must:
If one or more of these factors are missing, then it is less likely that behaviour change will occur.
Health Belief Model
The Health Belief Model by Becker (1974) contains several primary components and constructs that predict why people will take action to prevent, to screen for, or to control illness/conditions. These include susceptibility, seriousness, benefits and barriers to a behaviour, cues to action and self-efficacy (see Figure 3).
By exploring these components and constructs of the model, an in-depth understanding of the economic, social, environmental and psychological factors that influence the patient is gained. Once insight into the prevailing factors is gained, the likelihood of a patient engaging in health-promoting behaviour can be determined. In addition, the model aids recognition of the inequalities in health and the impact of social factors faced by the patient as well as offering reasons why the health improvement or protection opportunities may not be taken.
Summary
It is well known that nurses are often the most suitably placed health professionals to assess whether patients have a desire to change their behaviour and support the steps required to change in order to improve their health and wellbeing. Three models of behaviour change have been highlighted, with the Transtheoretical Model recognised as a primary resource to identify a patient's stage of change. The adoption of the model as routine practice by all nurses and other health professionals would enable quick identification of those who require advice, assistance and onward referral.
The next article in this series will provide a summary of behaviour change tools that nurses can use when engaging with their patients and the general public in changing their behaviour.