T H E C A R R O T O R T H E S T I C K ? E X P L O R I N G M O T - - PowerPoint PPT Presentation

T H E C A R R O T O R T H E S T I C K ? E X P L O R I N G M O T I V A T I O N A N D B E H A V I O U R A L C H A N G E

J A S D E E P D H I R , C L I N I C A L S P E C I A L I S T M S K B S C ( P T ) , T D P T, M C L S C ( M T ) F C A M P T -

S P E C I A L T H A N K S T O D R . D A V E W A L T O N A N D J I M M I L L A R D F O R T H E I R P E R M I S S I O N S T O U S E J O I N T M A T E R I A L

OBJECTIVES OF THE WORKSHOP

• Introduce the evidence and theories of behavioural change models
• Discuss the main underpinnings behind behavioural change models
• Discuss the application of behavioural change models as it pertains

to to intervention and adherence

• Demonstrate how these concepts can be threaded in teaching
• Outline and apply Motivational Interviewing (MI) techniques

WHY DO PEOPLE CHANGE BEHAVIOURS?

WHY DO WE USE THESE NOW?

10 billion trips have been completed worldwide (July 2018).This figure is climbing rapidly, with 14 million Uber trips completed each day.

• In early 2018, Uber

launched Express POOL. Similar to uberPOOL, Express POOL involves sharing a ride with other riders who are headed in the same

• direction. Longer wait time and

had to walk a distance to a meeting point

• Uber realized there were

increased cancellations happening.

• “In this case, we dove into the behavioral

science literature to gather insights about people’s perceptions of time and waiting.”

• The Problem
• People dread idleness
• Operational transparency,
• People want to feel like they are advancing well

towards their objective.

• A Solution
• highlighting progress during wait times by

explaining each step going on behind the scenes, like identifying other riders traveling the same way and finding a car for the trip, explaining the arrival time estimate calculation—could be provided by clicking an info icon.

• The Express POOL team tested these ideas in an

A/B experiment and observed an 11 percent reduction in the post-request cancellation rate.

MOTIVES FOR USING AIRBNB IN METROPOLITAN TOURISM – WHY DO PEOPLE SLEEP IN THE BED OF A STRANGER? Natalie Stors & Andreas Kagermeier

W H AT P E R C E N TA G E O F P E O P L E A C T U A L LY S T I C K TO T H E I R N E W Y E A R ’ S R E S O L U T I O N ?

8%

UNDERSTANDING BEHAVIOUR CHANGE

WHAT IF THE GOVERNMENT OF CANADA ISSUED THE FOLLOWING PUBLIC HEATH ADVISORY

• It has been discovered that cell phone use poses a major health concern.

The present information states that using your cell phone (1) produces brain damage; (2) is unpredictable; (3) is cumulative based on continued exposure; and (4 ) we have no way

• f knowing how much exposure is too much, nor what will happen to people at their

present level of exposure. However, for those who have not suffered any side effects to date, should stop using their cell phone until we have more information.

• How many of you

would …..

• 1. NOT SEE IT AS A

PROBLEM

• 2. THINK ABOUT IT

BUT NOT MAKE ANY CHANGE

• 3. CONSIDERING IT

STRONGLY

• 4. WILL DO IT NOW

WHY …...?

• What made you choose your stance?
• What would you need to help you make a different choice?

WHAT IF…..?

• You just heard that there is a case of brain damage in your

city. –Who would this make you change your mind and to where?

• You just heard that a relative of yours just got brain damage

from cell phone use. –Who would move their section now and to where?

W H A T D I D Y O U C O N S I D E R W H E N M A K I N G Y O U R D E C I S I O N ?

• T H E I M P O R TA N C E O F Y O U R C E L L P H O N E

I N Y O U R L I F E .

• T H E A M O U N T Y O U U S E Y O U R C E L L P H O N E
• W H AT A C T I V I T I E S Y O U U S E Y O U R C E L L

P H O N E F O R A N D W H AT N E E D S A R E F I L L E D I . E . W O R K , C O N N E C T I N G W I T H F A M I LY / F R I E N D S , B R A N D I N G , R E S E A R C H , E N T E R TA I N M E N T … .

• C O U L D Y O U G E T T H E S E N E E D S M E T I N

OT H E R W AY S ?

• W H O I S P R O V I D I N G T H E I N F O R M AT I O N -

R E L I A B L E S O U R C E ?

• W H AT I S T H E S E V E R I T Y O F T H E B R A I N

D A M A G E

TRANS- THEORETICAL MODEL OF CHANGE

Pre- Contemplation Contemplation Preparation Action Maintenance Relapse

P R E - C O N T E M P L AT I O N

• Pre-contemplation-People in

this stage are not thinking about changing their behaviour and are not aware of their problem. They have no consideration for change.

C O N T E M P L AT I O N

• Contemplation-People in this

stage have thought about their problem and have devoted some thought to changing. They have not taken action to change however, they may be beginning to consider

• ptions for change.

P R E PA R AT I O N

• Preparation-People in this stage

have begun the process of change by examining possibilities and

• ptions.

AC T I O N

• Action-People in this stage have

taken steps to modifying their behaviour, experiences, or environment in order to

• vercome their problem. Action

involves the most overt behavioural changes and requires a commitment of time and energy.

M A I N T E N A N C E

• Maintenance-People in this stage

consolidate the gains attained as a result of initial action through sustained involvement in the new behaviour, Adoption of the new behaviour usually requires a period of many weeks to months.

TRANSTHEORETICAL MODEL OF CHANGE- STAGES

• Relapse- Inability to maintain the desired behaviour

WHAT MAKES PEOPLE MOVE FROM STAGE TO STAGE?

H T T P : / / T H E H U B E D U - P R O D U C T I O N . S 3 . A M A Z O N A W S . C O M / U P L O A D S / 3 / 1 8 7 2 2 9 7 3 - F 8 0 F - 4 B 5 5 - 8 F F E - FA FA 4 4 C 2 1 9 7 9 / H E A LT H _ E D U C AT I O N . P D F # PA G E = 1 3 5

TRANSTHEORETICAL MODEL OF CHANGE- STAGES

• Moving through the Stages of Change model is a process

that requires both cognitive and behavioural changes

• changes in attitude and awareness of one’s circumstances

(cognitive—the way one thinks)

• changes in actions to decrease the occurrence of undesirable

activities, and actions to engage in new, desirable activities (behaviour—the way one acts)

UNDERPINNINGS OF CHANGE

• Motivation- is a state of readiness or eagerness to change, which

may fluctuate from one time or situation to another.

• Is strongly influenced by internal and external factors.
• Self-efficacy/ Ability- can be defined as the likelihood to see
• neself as competent to cope with life’s challenges and to be

deserving of happiness.

• T
• improve self-efficacy, a person must experience success relative

to expectations. Specifically, the more realistic the expectation or goal is, the higher the degree of success will be.

• Deci and Ryan’s Self Determination Theory
• Becker’s Health Beliefs Model
• Ajzen’s Theory of Planned Behaviour

EXPLORING OTHER BEHAVIOUR CHANGE MODELS

file:///Users/admin/Downloads/SDTandintmotive%20(1).pdf

SELF-DETERMINATION THEORY

• According to SDT humans have basic psychological needs for autonomy

(feeling fully volitional or free to engage in a behavior), perceived competence (feeling effective in one’s actions), and relatedness (feeling safe and cared for in

• ne’s interpersonal relationships).
• When these needs are supported, patients’ participation in treatment will be

more autonomous and less controlled.

• Autonomous motivation is characterized by perceptions of valued benefits and

a willingness to participate.

• In contrast, controlled motivation in the healthcare domain typically involves

patient engagement in treatment due to external pressure, coercion, or feelings

• f guilt.
• more autonomously motivated behaviors leads to greater psychological well-

being and long-term behavioral persistence.

BECKER’S HEALTH BELIEFS MODEL

HEALTH BELIEFS MODEL

• The model suggests that decision-makers make a mental calculus about

whether the benefits of a promoted behavior change outweigh its practical and psychological costs or obstacles.

• Individuals conduct an internal assessment of the net benefits of changing their

behavior, and decide whether or not to act.

• The model identifies four aspects of this assessment: perceived susceptibility to

ill-health (risk perception), perceived severity of ill-health, perceived benefits of behavior change, and perceived barriers to taking action.

Ability

Yes Yes No No

Unlikely to change May change with cognitive reframing May change if perceived barriers can be overcome Most likely to change

Motivated

MOTIVATION AND ABILITY

• MOTIVATION
• Decisional Balance
• Weighing the push/pull-what

would happen if I engaged in the behaviour? and what would happen if I did not?

• Determine a level of

importance to make the identified change

• ABILITY
• Determining self efficacy
• Even if I wanted to change

(motivated) do I have the means to do so

MOTIVATION-THE CARROT OR THE STICK?

Moving Towards and outcome Trying to avoid an outcome

WHAT ARE THE CONTRIBUTING FACTORS FOR MOTIVATION AND ABILITY THAT CAN BE MODIFIED?

• Personal (Motivational Interview)
• Social
• Physical/ Structural

SOCIAL

• Explore the power of community- can improve self efficacy.. ‘if
• thers can do it, so can I’
• ‘6 people in your corner’- Joseph Grenny
• Social norms will influence behaviour as people want to conform

and feel a part of something/ relatedness

WHICH ADVERTISING CAMPAIGN IS MORE SUCCESSFUL?

The Carrot The Stick

A COMMUNITY-INSPIRED HEALTH CARE EXPERIENCE…

A faith-based initiative that helped The Saddleback Church collectively lose 250,000 pounds.

PHYSICAL/ STRUCTURAL

• Assessing the barriers
• Do they have the space?
• Do they have the physical capacity?
• Do they have the equipment?
• Are they able to observe a change? (Feedback)
• Are there physical/structural reminders to reinforce? (i.e posters/

pictures)

FEEDBACK (MOTIVATION AND ABILTY)

• In an attempt to capitalize on the immense popularity of the 1964 T
• kyo

Olympics, the company Yamasa designed the world's first wearable step- counter, a device called a manpo-kei, which translates as “10,000-step meter”

FEEDBACK (MOTIVATION AND ABILTY)

FEEDBACK (MOTIVATION AND ABILTY)

THE EVIDENCE….

THE EVIDENCE….

APPLICATIONS TO INTERVENTION

TRANS- THEORETICAL MODEL OF CHANGE

Pre- Contemplation Contemplation Preparation Action Maintenance Relapse

H T T P S : / / W W W. S C I E N C E D I R E C T. C O M / T O P I C S / N U R S I N G - A N D - H E A LT H - P R O F E S S I O N S / T R A N S T H E O R E T I C A L - M O D E L

APPLICATION TO INTERVENTION

• PRECONTEMPLATION
• Raise doubt about resistance

to activity.

• patient needs to understand

the real risks of the current behaviours- The Stick

• Cast doubt on the lack-of-time
• r barriers to engagement (i.e

finances)

• Tolerance and patience are

needed when resistance to change is high.

• CONTEMPLATION
• Provide additional reasons to

change, i.e not just going on vacation or running a marathon

• Discover reasons for

ambivalence to change.

• Weigh the pros and cons/

Decisional Balance

• Pay attention for signs of

‘Change Talk”

APPLICATION TO INTERVENTION

• PREPARATION
• Assist in selecting the best options. A

realistic action plan.

• Goal setting should not simply based
• n outcomes. Establish process or

performance goals as well.

• Anticipate deviations In plans and set

up contingency plans

• ACTION
• Support decisions, eliminate doubt
• Give means to provide feedback on

how something is working.

• Self-monitoring is often a key to

success.

• Set up accountability frameworks
• Use prompts to initiate a behaviour

change(e.g.,put up signs or posters at home as reminders to exercise).

• Find a way to incorporate family/

friends

• Positive Reinforcement- The Carrot

APPLICATION TO INTERVENTION

• MAINTENACE
• Support new behaviours.
• Remind people of the benefits/pros
• Continue to provide accountability frameworks.
• Feedback
• Realistically examine the outcome goals

APPLICATION TO INTERVENTION

“Valuable behaviour change strategies are verbal feedback,

reinforcement, exercise testing, decision balance sheets, self-regulation, relapse prevention, progressed graded activities and booster sessions and action and coping plans.”

THE MOTIVATIONAL INTERVIEW (MI)

• MI facilitates identifying and building motivation/ ability
• “The premise behind Motivational Interviewing is that if you can get a patient

to argue in favour of behaviour change, then that change is much more likely to

• ccur” (Walton)
• Need to identify the patient’s perspective on the Importance of the behaviour

as well as the confidence that the patient has with respect to engaging in it.

• The Therapist should not influence the Patient’s responses – the idea behind

the MI is for the patient to identify the behaviours independently as the Therapist acts as a passive- supportive guide to the patient’s self discovery process

• Therapeutic Alliance needs to be strong ad established for the MI to take place

OARS

• Open Ended Questions
• Affirmation
• Reflective Listening
• Summaries

OARS- AFFIRMATIONS

• Affirmations give the patient the message that “I see you and hear

you, and validate what you are saying”

• May be a statement of appreciation, encouragement to continue to

share

• signal of understanding through nods, sounds
• Voice tone, non forceful-eye contact and body language, posturing,

mirroring

7% 38% 55%

• Prof. Albert Mehrabian- Elements of Personal

Communication

Spoken Words Voice, Tone Body Language

OARS- AFFIRMATIONS

*Always consider context- this is not a blanket formula*

OARS- REFLECTIONS

• Reflective listening helps make sure that you understand what the

patient is telling you

• Note patient’s response to reflections: opens a possibility for the

patient to speaker may correct, clarify, verify, add

• Use a reflection after the patient answers a question. (Can repeat

words you have heard)

OARS- SUMMARIES

• Is a form of reflective listening - paraphrasing
• Can be used throughout an interaction
• Can be used at the end of an interaction to review what was

discussed

• Provides an invitation for patient to respond, clarify and add

CHANGE TALK

“I guess I could exercise if I decided to” “I don’t know what to do but something has to change” “I think this has been affecting me more than I realized”

• Partner 1: Think of a behaviour you would like to do more of, or

something you would like to change in your life.

• Sit facing away from the screen.

• Partner 2: Ask your partner to describe the behaviour they would

like to change/do more of.

• Partner 2: Ask your partner to rate how important making that

behaviour change is to them, on a scale from 0 (not at all important) to 10 (critically important)

• Partner 2: Ask ‘why did you not give it a lower number?’

• Partner 2: After your partner argues in favour of making the

behaviour change, now ask:

• What is the likelihood that you will make this behaviour change in

the next (reasonable amount of time)? 0 = not at all likely, 10 = extremely likely.

• Partner 2: Now ask “what would it take to raise that number by x

points (eg 1 or 2)”,

• or ask “What is preventing you from doing [behaviour]?”
• or “What barriers do you expect when trying to make that change?

• Partner 2: Think of a behaviour you would like to do more of, or

something you would like to change in your life.

• Sit facing away from the screen.

• Partner 1: Ask your partner to describe the behaviour they would

like to change/do more of.

• Partner 1: Ask your partner to rate how important making that

behaviour change is to them, on a scale from 0 (not at all important) to 10 (critically important)

• Partner 1: Ask ‘why did you not give it a lower number?’

• Partner 1: After your partner argues in favour of making the

behaviour change, now ask:

• What is the likelihood that you will make this behaviour change in

the next (reasonable amount of time)? 0 = not at all likely, 10 = extremely likely.

• Partner 1: Now ask “what would it take to raise that number by x

points (eg 1 or 2)”,

• or ask “What is preventing you from doing [behaviour]?”
• or “What barriers do you expect when trying to make that change?

“the review showed that motivational interventions can increase adherence to exercise, have a positive effect on long-term physical activity behaviour, improve self- efficacy and reduce levels of activity limitation. “

READING LIBRARY/ REFERENCE

• Walton D. Et al. Facilitating Behaviour change in Physiotherapy Practice: The Role of

Motivational Interviewing. School of Physical Therapy, The University of Western Ontario

• Miller, W.R., Rollnick, S. Motivational Interviewing: Preparing People for Change, 2nd Edition.

New York: The Guilford Press, 2002 and PPGNW’s Planned Parenthood University, Patient Education Series.

• Bassett SF (2015) Bridging the intention-behaviour gap with behaviour change strategies for

physiotherapy rehabilitation non-adherence. New Zealand Journal of Physiotherapy 43(3): 105-

• 111. doi 10.15619/NZJP/43.3.05
• http://www.businessofapps.com/data/uber-statistics/#1