Principles of behavioural change
By Kristina Orth-Gomér,
From a lecture at the European Heart House, Nice France, Febr 18 1999
Behavioural factors play a crucial role in prevention
Successful primary and secondary prevention depends on subjects´ and patients´ adherence to advice and prescriptions. If we cannot get patients to change behaviour, then unfortunately most of our efforts may be in vain. They are all dependent on whether patients/subjects do what we tell them to do.
Patients´ adherence to medical advice is generally said to be low. Compliance with drug prescriptions has been estimated to be as low as 50 per cent. Compliance with advice for lifestyle change is probably not any better, and may be poorer.
There are several barriers and obstracles to behavioural change. Behavioural medicine research has identified three areas of great importance of patient adherence, which need to be considered in any efforts to influence health behaviour.
I. Low socio-economic status (SES)
Coronary disease is more common in low than high social strata in all industrialised countries. Research has been intense in this area in Great Britain, Holland, and Sweden. In Sweden the overall incidence of coronary disease is decreasing as in most Western European countries.
However, in low SES sub-groups (both men and women) the incidence of myocardial infarction is increasing. The causes for social inequalities are examined in a recent doctorial dissertation from Karolinska Institutet (Sarah P Wamala: Socio-economic Status and Cardiuovascular Vulnerability in Women; psychosocial, behavioural and biological mediators. Doctoral Thesis, KI, Stockholm, 1999). Women with mandatory school education had twice the risk of coronary disease as compared to women with academic education. Poor lifestyle (smoking, sedentary life and poor diet) and psychosocial stress were equally strong factors contributing to the SES differentials in CHD risk.
Low SES groups should be targeted. Information and behavioural reinforcement techniques need to be tailored for the neeeds of these specific groups. Health information is often produced by the highly educated for the highly educated. Information, health knowledge and health behaviours need to be directed towards low SES groups. The high SES groups will get the message anywhy.
Kaplan GA, Keil, JE, Socioeconomic factors and cardiovascular disease. A review of literature. Ciculation 1993;8:1973-1998.
2. Depression, social isolation, lack of social and family support
Depression, social isolation, lack of social support have been found to be strong and independent predictors of mortality in general populations and in cardiac patenets.
Effects are partly explained by the role of social support to promote healthy behaviour and reinforce adherence to medical regimens. Direct neuroendocrine mechanisms of depressed mood have also been identified. In a five year follow-up of Swedish women with coronary disease thoso who were both socially isolated and depressed had a 33% recurrence rate as compared to 9% in women who were socially integrated and had a more optimistic mood (Orth-Gomér K, AM Heart Ass, Nov 1998 Dallas, USA, abstract no 973)
Socially isolated and depressed patients need to be identified and preventive efforts should be tageted for such patients. An ongoing US multicenter behavioural intervention (ENRICHD) will provide further knowledge on appropriate methods.
3. The five stages of behavioural change
Over 70% of the adult populations in most developed countries will see a physician each year for a check-up. Therefore the opportunity for the physician to initiate behavioural change such as smoking cessation is unique. The success of such efforts, however, is dependent on proper recognition of the patients´motivational stage. Five seperate stages have been identified;
a. Pre-contemplation Behavioural change has low priority for the patient, negative aspects do not outweight the positive rewards associate with behavioural, e.g. smoking. Advice and information will have little direct effect.
The patient begins to evaluate option to change behaviour. Pro´s and con´s are considered. This may be a crucual period for targeted information.
The patient is ready to change, but needs the tools to make it successful. Practical advice and arrangements to change behaviour will be helpful.
The patient makes active attemps to change behaviour. Tools and help to develop behavioural changes may be needed. Support from health professionals and family and network members is important.
Behaviour has changed but the risk of relapse is imminent. Tools to prevent relapse are needed. Social support is crucial.
Emperical evidence that tailoring of interventions according to these stages does increase adherence is beginning to appear. Experience from USA and Australia suggests that preventive efforts according to this model become more cost-effective.
Professor Kristina Orth-Gomér
Division of Preventive Medicine
Karolinska Institutet, Stockholm