What’s the secret of behaviour change?

Abstract

This editorial refers to ‘Poor adherence to lifestyle recommendations in patients with coronary heart disease: results from the EUROASPIRE surveys’ by D. De Bacquer et al., pp. 383–395. Alan, 58 years old when he suffered his MI, was offered a secondary prevention program, and described his personal reasons for accepting to participate: ‘If there is anything I can do to improve my life and be healthier, I will absolutely take the opportunity and use what has been suggested to me and put all my efforts into achieving it.’ ‘Adherence’ is defined as ‘the extent to which a person’s behaviour (in terms of taking medication, following a diet, exercising or making other lifestyle changes) coincides with medical or health advice’. The following text takes as a starting point the results from the EUROASPIRE surveys,1 which addresses the crucial question of how to achieve and maintain lifestyle changes in patients with coronary heart disease. The results show that adherence to lifestyle advice is disappointingly low. The EUROASPIRE authors present interesting and in-depth reflections on this highly clinically relevant subject. The EOROASPIRE indeed has demonstrated the lack of implementation of the ESC Guidelines for CVD Prevention.2 As providers of health information, many clinicians have experienced frustration when they see that patients do not adhere to rational, evidence-based, advice. Commercial marketing often seems much more effective in influencing people’s behaviours. Commercial marketing offers a new and pleasurable behaviour where the rewards are tangible and immediate. It presents (seemingly) simple solutions. Health messages in the context of disease prevention often aim at preventing a pleasurable behaviour and prescribe complex and painstaking solutions to complex problems. The reward is vague and delayed to sometime in the future. The prospect of a possible future outcome may be too weak to have an impact, particularly in competition with many urgent everyday situations and needs. The EUROASPIRE study presents numerous examples of this. In stress management programs for post-MI patients, I was often impressed by the determination and efforts many patients showed. In comparison, working with high-risk (metabolic syndrome, obese, and diabetic) patients was different. Although their risk of suffering an acute cardiac event may be just as great as recurrence risk post-MI, it seemed that this was not understood and accepted. The commitment to the lifestyle program did not seem strong, compared to post-MI patients, and the success rate overall was lower. Such clinical experiences relate well to the EUROASPIRE results showing that illness perceptions play a role in the behavioural change process, although in a complex way. If disease severity is perceived as too threatening, without perception of own control, those perceptions may become barriers. If perceived severity is coupled with a sense of control—that one can do something to reduce risk and improve well-being—perceptions can act to increase urgency and motivation for behaviour change. The above-mentioned lifestyle program for high-risk patients was focused on reducing and preventing behaviours. The rationale was to deal with difficulties and barriers, and maybe too much attention was paid to failures instead of successes. Unknowingly, many traditional programs by ignoring to reinforce even small steps of success may instead create distress and helplessness. Several behaviour theories and models have been formulated and tested in relation to health behaviour change and are described briefly below. Social learning theory (SLT) is the most widely used.3 Its main features are built on learning theory (operant and respondent conditioning) with the addition of cognitive mechanisms like observational learning, cognitive processing, and self-efficacy. Operant learning refers to intentional behaviours influenced by consequences. Respondent conditioning describes the mechanism by which emotions and similar ‘reflexive’ reactions by experiences can be attached to specific situations that will subsequently trigger those reactions. Observational learning means that people learn by vicarious experiences, by observing others or sharing their experiences. Cognitive processing entails the role of personal thoughts, attitudes, knowledge, emotions, preferences, etc., in behaviour change. Self-efficacy is a crucial concept in SLT and is defined as the person’s confidence in his/her ability to perform and change a particular behaviour. The transtheoretical model of behaviour change4,5 is a framework that focuses on behaviour change as a dynamic process occurring in stages: pre-contemplation, contemplation, preparation, action, and maintenance. It has been used to assess patients’ motivation and preparedness for change, thereby allowing interventions to be tailored to patients’ readiness. Self-determination theory6,7 is a broad framework for understanding factors that influence motivation, autonomy, and psychological wellness. The basic idea is that behaviour change is more effective and lasting when patients are autonomously motivated. A related concept is locus of control. The EUROASPIRE study presents numerous examples of barriers to adherence, which are in line with reviews of success and obstacle factors. Lack of self-confidence, and not having participated in a cardiac rehabilitation program, was frequently reported as barriers to change. Other barriers were a lack of information and understanding of the characteristics of the disease. Some patients reported that they enjoyed their present lifestyle and saw any change as a less desirable way of living. Probably, social and cultural norms, which also vary across Europe, contributed to this finding. In EUROASPIRE, as in many adherence studies, the assessment relies on self-report, which may contribute to an underestimation of adherence. The problem thus may be even worse than reported. Reviews of adherence studies demonstrate that a few factors contribute positively to adherence.6 Prior success with health behaviour change increases the probability of adherence.8 Thus, participation in Cardiac rehabilitation programs is important, in line with the EUROASPIRE results. The opportunity to try new health behaviours and encounter progress, feedback, and social support, is of utmost importance.6,9 Another factor that has consistently been shown to enhance adherence is the quality of communication between the health professional/provider and the patient.10 To build a trusting relationship and a working alliance, where the patient is actively involved, and where his/her experiences, thoughts, emotions, priorities, and social situation, are taken into account in decisions about change, is of vital importance. Motivational Interviewing may be an effective way to build that alliance.11 Motivation in terms of readiness for change can be assessed. ‘Able, willing, and ready’ summarizes the patient’s self-rated importance for change, confidence in ability to perform, and preparedness to initiate behavioural change in the immediate future.12 Linking this clinical assessment to the idea of stages of change in the transtheoretical model can help patients and health professionals to understand which dimension of motivation that needs to be strengthened. Self-efficacy—the experience that one can perform a certain behaviour that is under one’s control, and positive outcome expectations—is highlighted in many studies as a success factor. Self-efficacy is a key concept in SLT, and it can be influenced by systematic efforts in treatment programs. Early success, observational learning, feedback, reinforcement of concrete effort, ability to perform, outcome expectancy, can be built into programs where patients are offered opportunities to practice new behavioural skills under supervision, instruction, and feedback. Progress and success will increase confidence in one’s ability. Realistic goal setting, small steps and gradual increase, and immediate reinforcement that bridge the gap between efforts and long-term effects, will maintain the effort. Social support, technical and biometric feedback, and professional feedback should be built into behavioural programs to obtain long-term maintenance.12 Reviews show that few studies report consistent use of a particular behavioural model in designing interventions. Reported results of efficacy and effects of theory-driven interventions for cardiac patients are few and with mixed results. The most consistent evidence is presented for the SLT model.9,13 Among methods that constitute applications of SLT are Motivational Interviewing and Cognitive Behaviour Therapy (CBT), which when applied in combination have demonstrated effects on health-related lifestyle change.14 The EUROASPIRE authors report adherence to lifestyle changes across several European countries. Cardiac rehabilitation programs vary widely between those countries, and multimodal, multi-professional, comprehensive programs in line with ESC Guidelines recommendations are not available everywhere. Systematic and evidence-based behavioural methods may be lacking in many hospital and health organizations. Thus, there is indeed room for improvement in terms of designing behaviour change intervention, applying, and evaluating them. Education and training of specialized personnel is a crucial key to success. Close monitoring and assessment of fidelity to treatment regimen and components is of vital importance—unfortunately often lacking in research on behavioural interventions. The strongest case when it comes to the application of behavioural theories in lifestyle change interventions is for SLT, as applied in CBT. A summary of evidence-based treatment components that have been demonstrated to increase the likelihood of health behaviour change and adherence is the following: Realistic context Small steps Flexibility Repeated practice Self-monitoring Feedback Long-term perspective Information and knowledge Social support Relapse prevention Support of self-efficacy Values, priorities, quality of life Long-term behavioural change programs can be strengthened by paying attention to the patients’ beliefs, attitudes, priorities, and core values of life. It is a bridge to support intrinsic motivation and long-term adherence and maintenance. Conflict of interest: none declared. The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Preventive Cardiology or of the European Society of Cardiology.

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