Behavior change.

1. Behaviour

2. Behavioural strategies
 Problem solving
 Self-monitoring
 Goal setting (Plan: what, how, when)
 Social support
 Self-rewards (reinforcement)
 Cognitive restructuring (CBT)

3. Behavioral definition
Behaviour- a set of actions; the ways
we conduct ourselves; the things that
we do.

4. Developing a successful
Intervention: key Components
 Identify and know your target
populations
 Identify the behavioral goals
 Identify the influencing factors
 Identifying the appropriate
strategy for affecting each
influencing factors.

5. Personal Influences that Impact
Behaviour
 Risk Appraisal: What are my chance of
becoming infected because of what I do?
 Self Perception: What do I do about my
ability to avoid risk?
 Emotions and Arousal: How my feelings
affect my behaviour?
 Relationship/Social Influence: What
people, places and things affect me?
 Environmental: How does society
influence my behaviour?

6. How do I Change my
Behaviour?
 Identify a behavior you changed or tried
to change.
 What was the impact of the behaviour
on your health?
 How much did the change affect your
life?
 Who/what were the obstacles to
changing?
 What was the reward for changing?
 Who/what were your helper for change?

7. Behaviour Change
List the important changes in the pictures ???

8. Behaviour Change
Quit smoking... Tar the roads... NOT your LUNGS!
Today its me,
because of u...
Tomorrow its u,
because of me...
Fully burnt Cigarette ASH Smokers Lung

9. Behaviour Change
 Increased interest of behaviour change in different fields
with the hope that understanding it will improve the
services offered
◦ Health
◦ Education
◦ Criminology
◦ Energy
◦ International development
 Behavioural change theories have gained recognition in
health for their possible effectiveness in explaining health-
related behaviours and providing insight into methods that
would encourage individuals to develop and maintain
healthy lifestyles

10. Behaviour Change
 Different terms used for behaviour
change
◦ Strategic Behavioral Communication (SBC)
◦ Information, Education, Communication
(IEC)
◦ Communication for Social Change (CSC)
◦ Behaviour change communication (BCC)

11. Behaviour Change
 Many theories exist for Behaviour
change, the most prevalent are
◦ Learning theories
◦ Social Cognitive Theory
◦ Theories of Reasoned
Action and Planned Behaviour
◦ Trans-theoretical Model
◦ Health Action Process Approach

12. Why Do People NOT Change
Behavior?
 People may not
◦ Understand the message
◦ See themselves as vulnerable
◦ Trust the bearers of the message
 People may
◦ Think the short-term benefits of current behaviors
outweigh the long-term risks
 Some “healthy choices” are costly
 Recommended behavior may conflict with
beliefs
 After all, people believe that malaria is a
common disease and is not so serious
Can you name more reasons?

13. Theory of Behaviour Change
 Pavlov’s Classical Conditioning
 Skinner’s Operant Behavioursim

14. Smoking
Alcohol
Dietary
Physical Activity
Non communicable
diseases such as
(NCDs)
• Diabetes
• Obesity
• Hypertension,
• Cancers, etc.
Sexual Activity
Substance abuse
HIV, STD, Hepatitis
Rash Driving Road Traffic Accidents
Mental Disorders
Healthy life
Health-compromising behaviors can be eliminated by self-
regulatory efforts, and by adopting health-enhancing behaviors
Fortunately, human beings have, in theory, control over their conduct
Behaviour Public Health

15. How to change behaviour ???
Five stages of behaviour change
Stage 1
Precontemplation
Stage 2
Contemplation
Stage 3
Preparation
Stage 4
Action
Stage 5
Maintenance

16. Stages of Behaviour change… Diabetes
Stage 1
Precontemplation
Stage 2
Contemplation
Stage 3
Preparation
Stage 4
Action
Stage 5
Maintenance
Why should
I change ????
• I want to LIVE...
I will save myself
• Prevention is
better then cure
• Learn regarding
healthy practices
• Filter facts from
Myths
• Doctor calling
• Dietary changes
• Physical activity
• Regular
medicines
• Positive re-
enforcement,
Negative re-
enforcement
and awarding
• Opinion leader
I don’t have
disease …..
I am no
more
Happy… I
am
worried… I
am having
Diabetes
I am ready to
change
I am doing… I will
continue to
do….

17. Behavior change is a continuous
process
 It involves strong community
participation
 Refutes myths and corrects
misunderstanding
 Social norms and public policies
influence behavior change. A strategic
shift must be also be attempted
simultaneously.
 BCC often complements and supports
other prevention strategies and

18. Stepped approach to
change
A journey of a thousand
miles begins with a single step

19. What influence Behaviour?
Human behaviour is influenced by a huge
range of factors. Why we do what we do
into some key factors and principles that
are important to consider when designing
communications aimed at influencing
behaviour change. ‘Individual behaviours
are deeply embedded in social and
institutional contexts. We are guided as
much by what others around us say and do,
and by the “rules of the game” as we are by
personal choice.’

20. Some factors that influence
behavioral change
 Physical stimuli
 Rational stimuli
 Skills
 Knowledge
 Social cultural factors
 Demographic-age, sex, etc
 Previous experiences
 Attitudes

21. Steps to Behavior Change
Knowledge
1. Recalls family planning messages.
2. Understands what family planning means.
3. Can name family planning method(s) and/or source of supply.
Approval
4. Responds favorably to family planning messages.
5. Discusses family planning with personal networks (family, friends)
6. Thinks family, friends, and community approve of family planning.
7. Approves of family planning.
Intention
8. Recognizes that family planning can meet a personal need.
9. Intends to consult a provider.
10. Intends to practice family planning at some time.
Practice
11. Goes to a provider of information/supplies/services.
12. Chooses a method and begins family planning use.
13. Continues family planning use.
Advocacy
14. Experiences and acknowledges personal benefits of family planning.
15. Advocates practice to others.
16. Supports programs in the community.

22. Standard for Behaviour
Change

23. Steps to Behavior Change
These are the ideal steps one follows towards behavior
change. They may apply to health workers or community
members
Knowledge:
• One first learns about a new behavior (injection safety
practices)
• Recalls messages on Injection Safety and understands
meaning of the messages
• Can name Injection safety strategies and practices
Approval:
• One then approves of the new behavior (Injection safety
Strategies)
• Responds favorably to injection safety messages
• Discusses injection safety with personal network
(professional, colleagues, family and friends)
• Thinks professional colleagues, family, friends and

24. Steps to Behavior Change cont.
Intention:
• One then believes this behavior is beneficial to them
and intends to adopt it.
• Recognizes that Injection safety strategies can meet
a personal need
• Intends to adopt injection safety practices
Practice:
• One then attempts new behavior and continues to
practice. (Practices proposed under each strategy in
injection safety)
Advocacy
• One can then promote the new behavior through
their social or professional networks as a satisfied
practitioner.
• Experiences and acknowledges personal benefits of

25. Specific Determinants of Behavior
What are some of the specific determinants of behavior we can examine?
This is another useful checklist that helps to reinforce and reiterate some of
the concepts previously covered. If you consider the range of items that
determine behavior, it is useful to ask the following questions when designing
a social marketing campaign:
•Do I know the knowledge and skill levels of my target audience?
•Do I understand how they view risk?
•What do they see as the perceived risk to themselves and to others for the
suggested behavior?
•What are their attitudes and beliefs?
•What consequences do they perceive?
•Do they feel a sense of self-efficacy whatever their social norms, intentions or
demographics?
•Finally, what are any other relevant or pertinent characteristics we need to
know?

26. Variables Underlying Behavioral
Performance
“Generally speaking it appears that in order for a person to
perform a given behavior one or more of the following must
be true:
1. The person must have formed a strong positive intention
(or made a commitment) to perform the behavior;
2. There are no environmental constraints that make it
impossible to perform the behavior;
3. The person has the skills necessary to perform that
behavior;
4. The person believes that the advantages (benefits,
anticipated positive outcomes) of performing the behavior
outweigh the disadvantages (costs, anticipated negative
outcomes);

27. Variables Underlying Behavioral
Performance
5. The person perceives more social (normative) pressure to
perform the behavior than to not perform the behavior;
6. The person perceives that performance of the behavior is
more consistent than inconsistent with his or her self image,
or that it’s performance does not violate personal standards
that activate negative self-actions;
7. The persons emotional reaction to performing the behavior
is more positive than negative;
8. The person perceives that he or she has the capabilities to
perform the behavior under a number of different
circumstances…”

28. Which Determines Behavior:
 Knowledge and skills?
 Perceived risk?
 Attitudes / Beliefs?
 Perceived consequences?
 Self-efficacy?
 Other relevant characteristics?

29. 1. Knowledge and Skills
Very briefly, the first thing to look at is the
knowledge and skills of our audience
 What do people know about the program?
 Do they know how to do the target
behavior?
 Can they access the program or service?
 What do we need to do to ensure they
receive needed information?

30. 2. Perceived Risk
 Does the target audience believe they are
personally susceptible or vulnerableto the
kinds of problems or health issues that may
incur if they do or do not perform certain
behaviors?
 How severe do they perceive the condition to
be?
 While we do not want to frighten people or
use their appeals in a non-judicious way,
sometimes we need to point out the kinds of
risk people face to motivate them to think
about behavioral changes.

31. 3. Attitudes
 What are the attitudes of the target
audience?
 How do they feel about the program,
service, or target behavior and the
behavior we are offering?
 Are there rumors in the community
which would affect their attitude?

32. 4. Perceived Consequences
 What does the target audience believe
they will gain if they adopt the target
behavior?
 What does the target audience believe
they will lose if they adopt the
behavior?
 How can we address this situation?

33. 5. Self-efficacy
 Defined: Self-efficacy is An individual’s
belief that he/she can do a desired
behavior
 Do consumers believe they can adopt
the target behavior the types of
behaviors we are asking them to do?
 Do they feel they would be successfully?
 We need to make sure everyone has the
sense they can succeed and find out
what problems would prevent them from
succeeding.

34. 6. Social Norms
 Defined: Social norms are the standards of
behavior for attitude accepted as usual practice
by groups of people.
 What do consumers perceive the norms to be?
 People do not like to act counter to social norms,
because they feel a sense of approval and
reinforcement through the people around them.
Going against social norms may be too steep of
price to pay, so we need to know what those
norms are before advocating certain kinds of
change.

35. 7. Intentions
 Intentions ask What does the audience
already plan to do about the new behavior?
 How ready are they to change?
 We know if people have strong intentions,
that means they are fairly ready to change
behavior. This predicts behavior far better
than we once thought. Therefore, intentions
are our important motivator for helping
people move to activation.

36. 8. Demographics
 Race / Ethnicity
 Where they live
 Age / Gender
 Education
 Religion
 Marital status
 Income
 Sexual orientation
 Occupation

37. 9. Other Social-Psychological
Determinants
 Self concept / Self esteem
- hopes, fears, aspirations
 Occupational stress
 Religiosity
 Recreation and leisure
 Social support networks
 Media habits
- what they watch, listen, read
- how often? where? when?

38. Some Behavior Change Tools
• Education
Effective when goals of society align with those
of target audience Benefits are attractive,
immediate, obvious, low costs, skills/resources
to change are available
Law/policy development
Effective when citizens are unlikely to change on
their own, and society is unwilling to pay the
costs associated with risky/unhealthy behavior
Marketing
Effective when goals of society and those of the
citizens are not entirely consistent, but citizens
can be influenced to change

39. Changing behaviors: A Practical
Framework
◦ The person has formed a strong positive
intention (or made a commitment) to perform
the behaviour.
◦ There are no environmental constraints that
make it impossible for the behaviour to
occur.
◦ The person has the skills necessary to
perform the behaviour.
◦ The person believes the advantages
(benefits, anticipated positive outcomes) of
performing the behaviour outweigh the
disadvantages (costs, anticipated negative

40. Changing behaviors: A Practical
Framework
◦ The person perceives more social pressure to
perform the behaviour than to not perform the
behaviour.
◦ The person perceives that the behaviour is
consistent with their self-image and does not
violate their personal standards.
◦ The person’s emotional reaction to
performing behaviour is more positive than
negative.
◦ The person believes (has confidence) that
they can execute the behaviour under a
number of different circumstances (i.e., the
person has the perceived self-efficacy to

41. The Behaviour Change Wheel: hub

42. Intervention
Intervention
:
Activities
designed to
change
behaviors

43. The behaviour Change Wheel: inner ring

44. Behaviour Change Wheel:
complete
Policies:
decisions
made by
authorities
concerning
intervention
s

45. Theories and Models of Behaviour Change
There are four categories of theories of
behaviour change:
• Focus on Individuals
• Social Theories and Models
• Structural and Environmental
• Constructs alone and Trans-theoretical
Models
These theories should be viewed as a continuum
of models moving from the strictly individually-
centered to the macro-level of structural and
environmentally focused.

46. The Behavior Change Spiral
Pre-contemplation
Contemplation
Preparation
Precontemplation: changing a behavior has not been considered;
person might not realize that change is possible or that it might be of
interest to them
Contemplation: something happens to prompt the person to start
thinking about change - perhaps hearing that someone has made changes -
or something else has changed - resulting in the need for further change
Preparation: person prepares to undertake the desired change – requires
gathering information, finding out how to achieve the change, ascertaining
skills necessary, deciding when change should take place - may include
talking with others to see how they feel about the likely change, considering
impact change will have and who will be affected
Action: people make changes, acting on previous decisions, experience,
information, new skills, and motivations for making the change
Maintenance: practice required for the new behavior to be consistently
maintained, incorporated into the repertoire of behaviors available to a
person at any one time

47. The Behavior Change Spiral in the
context of the Enabling Environment
Social features
eg nature of personal
relationships; expectations
of class, position, age,
gender; access to
knowledge,
information.
Cultural features
- the behaviors and
attitudes
considered acceptable in
given contexts - eg relating
to sex, gender, drugs,
leisure,
participation
Ethical and spiritual
features - influence of
personal and shared
values
and discussion about
moral
systems from which those
are derived - can include
rituals, religion and rights
of passage
Legal Features - laws
determining what people can
do and activities to
encourage
observance of those laws
Political features -
systems
of governance in which
change will have to take
place - can, for example,
limit access to information
and involvement in social
action
Resource features - affect
what is required to make
things happen - covers
human, financial and material
resources; community
knowledge and skills; and
items for exchange
6FeaturesoftheEnablingEnvironment

48. Audiences along a Behavior Change Continuum:
Possible Communication Strategies
Unaware
Aware, concerned,
knowledgeable
Motivated to Change
Tries New Behavior
Sustains New Behavior
• Raise awareness
• Recommend a solution
• Identify perceived barriers and benefits
to behavior change
• Provide logistical information
• Use community groups to counsel and motivate
• Provide information on correct use
• Encourage continued use by emphasising benefits
• Reduce barriers through problem solving
• Build skills through behavioral trials
• Social support
• Remind them of benefits of new behavior
• Assure them of their ability to sustain new behavior
• Social support

49. Theory of Subjective Culture and
Interpersonal Relations
“…the likelihood of performing a given behavior is
determined by intentions, habits and facilitating
factors.
Intentions are, in turn, viewed as a function of:
- perceived consequences of performing the
behavior (outcome expectancies)
- social influences (including norms, roles and the
self concept) and
- emotions

50. Community-level Structural Models
“Suggests that environmental forces beyond the control of the
individual constrain or help the knowledge-behavior link:[for
example]
•Presence or absence of legal restrictions - eg availability of
condoms
•Wage scales - which define what proportion of people will have
the resources to purchase STD medication
•Access - to clinics capable of diagnosing and treating STDs
Each of these would make it either harder or easier for an
individual who learned about a practice to realize it.
Programming Implication
Also suggests that while individual education may be one strategy
for achieving behavior change, change in societal level structures
may be a more effective starting point - eg availability of
condoms”

51. Social Expectation Models
“Suggests that behavior which appears to be individual may be
viewed as a social behavior.. Individual practices are substantially the
result of conformity to the expectations of others.
Two paths through which private acts may be socially influenced:
• Direct Experience - the social network communicates the private
experience - for example expected and acceptable sexual practices
through sexual experience with particular partners
• Outside of Direct Experience - for example through conversation
amongst those in asocial network, mass media, books, observation of
others, all may provide as to what is expected or acceptable
May be that people are unable to articulate, or example, why they use
condoms, they just do it. Their conformity reflects the demands of their
social network without any reflective process producing awareness of
those demands.
Need to ask the question - ‘how do groups change their behavior?’
rather than ‘how do individuals change their behavior?’

52. Health Communication

53. Client Expectations
To be heard and understood
The opportunity to tell their story
To gain information
To feel able to cope
Failure to meet expectations leads to frustration

54. Empathy
“The ability to empathise is key.
Those with empathy have the ability
to put themselves in others shoes, to
see things from others perspectives
and to gauge the likely impact of their
behaviour.”
“Empathy is not just nice to have –
it’s a crucial and sophisticated skill.
Without it we diminish our ability to
influence; we create needless conflict
and resistance”

55. Key Skills
 Active Listening Skills
 Greeting/opening the interview
 Non-verbal communication
 Reflection (min. encouragers,
paraphrasing, reflecting feelings,
summarising)
 Ending the interview

56. The Evidence
The single most important factor for an
effective helping relationship is the
practitioners possession of strong
interpersonal skills
There is good evidence that a client centred
approach:
• Improves clinical outcomes
• Increases client satisfaction
• Improves compliance
• Reduces patients concerns

57. The Evidence
‘Good Communication is Good
Evidence-Based Medicine’
‘The therapists style can and
does influence motivation and
change’

58. But I have no time….
The use of good listening skills
can be very effective – even in a
short space of time.

59. Understanding motivation
 Brain processes that energise and
direct behaviour
 Not limited to choice and goal pursuit
 Needs to include
◦ drive
◦ habit
◦ desire
◦ instinct
◦ self-regulation
◦ etc.
59

60. Motivation
 Motivation is not something you can do to
people
 It has to come from within
 It is not an ‘all or nothing’ state
 It is influenced by the helping style of the
health practitioner

61. Motivating Change
The goal of motivational
interviewing is that the patient,
not the practitioner, expresses
concerns about the current
behaviour and presents arguments
for change.

62. Specific Motivational Strategies
• Exchanging information
• Explore current behaviours
• Explore Ambivalence
• Explore motivation/readiness

63. Exploring Motivation/Readiness
• Importance
– Reasons
• Confidence
– Obstacles

64. Motivation: reflective and automatic
64
Beliefs about what is good and bad,
conscious intentions, decisions and
plans
Emotional responses, desires and
habits resulting from associative
learning and physiological states
Automatic
Reflective

65. PRIME Theory: the structure of human
motivation
65