30 October 2013 1

 Define health behaviors.

 Examine the factors, that affect a person's behavior
change.
 Discuss the prevalence of health behaviors in
Pakistan.
 Understanding various behavior change techniques
with reference to Pakistani context.
 Apply behavior modification strategies in health care
settings.
 Evaluate health promotion programs in Pakistan in
light of behavior modification approaches.
 Conclude & summarize the presentation
30 October 2013 2
 100 Years Ago Versus Now

30 October 2013 3
 Health behaviours have being defined
by Matarazzo (1984) in terms of either:
 Health impairing habits, which he called
"behavioural pathogens" (for example
smoking, eating a high fat diet), or
 Health protective behaviours, which he
defined as "behavioural immunogens" (e.g.
attending a health checkups).
(Taylor, 1999)

30 October 2013 4
 Health behavior change is a complex set of
mechanisms and processes comprising of knowledge
and beliefs, self-regulation skills and abilities and
social facilitation.

 Health behavior change must occur to manage and

prevent the onset of chronic medical conditions
which result from an individual’s unhealthy
behavior.

 Health behavior changes occur on three different

levels. These are….
30 October 2013 (Catalbiano & Ricciardelli, 2013) 5
 Establish new Increasing existing Decreasing
healthy behaviors healthy behaviors unhealthy behaviors

• Scheduling more • Decreasing

• Taking Medication regular doctor
as prescribed. amount of salt and
appointments. sugar in diet.
• Participating in • Ensuring adequate
regular physical • Quitting smoking
amounts of sleep.
activity. • Reducing daily
• Increasing alcohol
• Consuming low fat consumption of
food products. consumption.
fibers, fruits and
vegetables.

(Catalbiano & Ricciardelli, 2013)

30 October 2013 6
 Alcoholism: According to WHO report 30% people in
Pakistan are involved in alcohol consumption.
(WHO, 2011)
 Smoking: In the year 2009, the prevalence of cigarette
smoking among females was 6.25% and among males was
34.47% in Pakistan.

 Condom use: 21.8% (46/211) in Lahore and 2.4% (5/24) in

Karachi.
(Saleem, Adrien & Razaque, 2013)
 HIV and homosexuality in Pakistan: According to National
Institute of Health, 2008 “Prevalence of HIV among
homosexual and bisexual Pakistani men is reaching alarming
proportions”
(Rajabali, Khan, Warraich, Khanani & Ali, 2008)
30 October 2013 7
 Poor Eating Habits And Lower Exercise Rate:
Obesity level is found to be 22 % in men and 37
% in women in urban area of Pakistan. Lifestyle
changes, high fat and carbohydrate rich diet and
lack of exercise are the prime factors.
(Ameen, 2011)
 Substance Abuse: An estimated 6.45 million, of
the population in Pakistan aged between 15 and
64 used drugs in the last 12 months..

(Ministry of narcotic control Pakistan, 2013)

30 October 2013 8
 BELIEFS ATTITUDES BEHAVIOR

30 October 2013
(Stuart, 2009; Taylor, 1999)9
 BIOLOGICAL FACTORS
• Genetics

SOCIO-CULTURAL FACTORS
• Peer pressure
• Social learning
• Impact of mass media
• Low socio-economic status

BEHAVIOURAL & PSYCHOLOGICAL

FACTORS
• Stress and coping
• Personality
30 October 2013 • Self-image & self esteem (Stuart, 2009; Taylor, 1999)10
 Conditioning

Modeling

Educational/Knowledge
Appeals

Fear Appeals

Cognitive Approaches

Readiness to change
Model/TTM

Persuasion
30 October 2013 11
 Conditioning and Modeling make up one
of the earliest principles of behavior
change, identified by various
researches.

 Majority knowledge and skills for health

behavior change assessment and
interventions come from these
behavioral approaches.
30 October 2013
(Catalbiano & Ricciardelli, 2013) & (Taylor, 1999) 12
Unconditioned Unconditioned Conditioned Conditioned
stimulus stimulus stimulus stimulus

Unconditioned Unconditioned Unconditioned

response response response
(Nausea, gagging, (Nausea, gagging, (Nausea, gagging,
vomiting) vomiting) vomiting)

30 October 2013 13
 “Contingency Contracting’ is
an example of behavioral
change working on Skinner’s
principle of Operant
conditioning.

 It involves a formal contract

between the patient and the
therapist, defining what
behaviors are to be changed
and what privileges or
consequences follow the
performance of these
behaviors.
30 October 2013 14
 “Self-help Program” Operates on Bandura’s
concept of Modeling.

 Self help program includes a self help group in

which the client observes others who have
successfully stopped smoking, drinking or drug
use and he/she can also raise expectancies for
achieving the same goal.

(Stuart, 2009)
30 October 2013 15
 Educational appeals make the assumption
that people will change their health
habits if they have correct information.

 Unfortunately, it’s usually not enough to

make people act.

 Its affectivity is enhanced when

combined with other factors like
motivation, self-efficacy etc.
30 October 2013 (Taylor, 1999) 16
30 October 2013 17
 This approach assumes that if
people are fearful that a
particular habit is hurting their
health , they will change their
behavior to reduce their fear.

 However, research shows that

fear appeals have only a limited
value in modulating health
behavior change.

 Fear appeals are most likely to

be effective for individuals who
are in a precontemplation stage
because they are unfamiliar
with a given health risk.
30 October 2013 (Stroebe, 2011) 18
 Cognitive Self-
Visualization
Restructuring Observation

Thought Changing self- Self-

Stopping/Blocking talk Monitoring

30 October 2013 19
 Examine your current health habits by
conducting a self-assessment. Then analyze
and evaluate your life style.
Identify and choose a target behavior from the
several identified unhealthy behaviors. Start with
simple then move to more difficult behaviors
Obtaining information about your target behavior.
Including current and future benefits and risks of
your target behavior.

Find outside help if involved in complex behaviors. You

may need to seek professional guidance. Identify
various resources and develop a support network on
campus and
30 October 2013in the community. 20
30 October 2013 21
 ACTION

PREPARATION:

MAINTENANCE

CONTEMPLATION:

PRECONTEMPLATION

30 October 2013
Stages of Change Model by Prochaska & DiClemente 1986 22
“Persuasion is a health promotion strategy widely
used to influence individual health beliefs and
behavior. People are exposed to more or less complex
messages that reflect a position advocated by a
source and arguments designed to support that
position.”

A well-known influential tool used in various behavior

modification programs as it almost makes use of all
other strategies like knowledge and fear appeals etc.
(Stroebe, 2011)
30 October 2013 23
 SOURCE CREDIBILITY: The communicator
should be expert, prestigious, trustworthy, likable and
similar to the audience in some respect.

 The communicator appears to have nothing to gain if

the audience accepts the message.

 CONVERT COMMUNICATORS: Are those

people who have overcome their undesirable
behaviors. They can be very persuasive as they
demonstrate a sense of mastery and self-control over
their behaviors.

30 October 2013 (Baumeister & Bushman, 2011) 24

30 October 2013 25
30 October 2013 26
 The message appeals to emotions, particularly fear
and anxiety.

 The message also provides a course of action that

will if followed reduce fear or produce personally
desirable results.

 The message states clear-cut conclusions.

 The message is backed up by facts and statistics.

 The message is repeated as frequently as possible.

30 October 2013 (Coon & Mitterer, 2013) 27
AUDIENCE: If audience is receptive to
changing a health habit, then
communication should only include
favorable points, but if audience is not
inclined to accept the message, the
communication should discuss both sides of
the issue.

(Stroebe, 2011)
30 October 2013 28
 Research has demonstrated that excessively using persuasion can
render the client a passive recipient to expert knowledge combined
with advise giving can reduce client autonomy and generate
resistance.
 Persuasion doesn't ensure health behavior change in a long run i.e. no
guarantee of maintenance of the change.
 Many times, persuasive health campaigns do not cater the
discrepancy between individual and population perspectives of health
risk.
 Persuasive technologies may violate ethical grounds due to
manipulation with audience for reasons other than promoting health
change.
 Persuasion is found to be ineffective in reaching individuals of lower
socioeconomic status.

30 October 2013 (Chaterjee, Price & Meng, 2008) 29

 In this high-tech world, the real challenge for HCPs is to
better understand the health behaviors of humans and
develop innovative methods to help people overcome their
unhealthy behaviors and replace them with healthier
ones.

 MOTIVATIONAL INTERVIEWING, defined as “A

patient-centered, directive method for enhancing
intrinsic motivation to change”, is the solution to these
problems.

 MI brings about behavior change with the goal that the

patient, not the practitioner, expresses concerns about
the current behavior and presents arguments for change.
30 October 2013 30
 Exchanging Exploring Exploring
information Ambivalence readiness

Using
Increasing Interpersonal
Talk about skills like
Listen Reflect
change Empathizing

30 October 2013 31
 Health Promotion Means Changing Behavior at
Multiple Levels. These are:
 Individual: knowledge, attitudes, beliefs, personality.
Example: Readiness to change Model, cognitive
restructuring.
 Interpersonal: family, friends, peers. Example: Self-
Help Program, behavior contract etc.
 Community: social networks, standards, norms.
Example: Applying persuasion in Mass Media
Campaigns
 Public Policy: local policies related to healthy
practices. Example: Health promotion Programs like
OBSI, EPI, NACP etc.
30 October 2013 32
 Health communication and mobilization are two core concepts in
Health promotion theories.

 “ Health communication, like health education, is an approach

which attempts to change a set of behaviors in a large-scale
target audience regarding a specific problem in a predefined
period of time.”

 Community mobilization (CM) brings together community

members, leaders and institutions at various levels to work
together to identify and solve problems.

 Although public health sector is not so active in Pakistan, yet, we

have managed to have a health education wing at the federal
ministry
30 October 2013 of health comprising of only a health education
(Qazilbash,advisor.
2006) 33
 Malaria control program and Small pox eradication program
were the first that had public health messages.

 Optimal Birth Spacing Initiative (OBSI 2004) is a public

health promotional program found to have a strong
communication component with an aim highlighting the most
sensitive issue of family planning.

 Second is the Women Health Project, an initiative of the

Ministry of Health, aims to improve women's health by
addressing women issues at all levels through health
promotion, community mobilization, advocacy and capacity
building.

30 October 2013 (Qazilbash, 2006) 34

 The National AIDS Control Program
(NACP)2002 also comes under this category.
However, it couldn’t address the issue that in
a country like Pakistan, where HIV-AIDS has a
very low prevalence, what really was the
problem behavior that NACP thought to
change?

 According to literature, Pakistan is one of the

top three countries that have the highest
prevalence of unsafe injections in the world
(Simonsen et al 1999); a risk factor for spread
of HIV-AIDS, yet this issue does not come as
part of the problem any where.
30 October 2013 (Qazilbash, 2006) 35
 Making a helping or therapeutic relationship is the
first step in helping clients recognize their
undesirable behaviors.
 Nurses, themselves are seen as role models by
patients and their traits and characters are being
followed too. Therefore,a nurse should be self
aware of his/her own beliefs and attitudes that
shape health behaviors.
 Using a non-judgmental and empathetic behavior
also facilitates change in behavior.
 Nurses, as a CHN or PHN, should design coaching
modules, educational campaigns and self help
pamphlets to influence individual health beliefs and
behavior regarding smoking, drugs and alcohol use
etc.
30 October 2013 (Qazilbash, 2006) 36
 All HCPs, especially nurses should realize that the
existence of close family ties and extended family
structure in Pakistani culture implies that we conduct
culturally appropriate behavioral reforms with patients.

 Another underlying principle in health behavior change is

the joint decision-making by the family sometimes involving
the entire community in health care-seeking behavior.

 In near future, nurses also need to tackle the challenges of

weak capacity, scarcity, in availability and inaccessibility of
social media resources, minimal involvement of target
audience etc. prevailing in our country.
30 October 2013 (Shaikh & Hatcher, 2007) 37
 I quit smoking because I know it will damage my lung
parenchyma cells. Knowledge appeal
 In psychiatric ward, nurses provide extra time to watch TV to
patients who have successfully lessen cigarette smoking and
limit the timing of watching TV for those patients who have not
successfully limit their smoking habit. Operant Conditioning
 Mr. X verbalized that “I started wearing condoms during sexual
intercourse when I watched Junaid Jhamshad on commercial of
reducing STI’s” Persuasion: source credibility
 Mr. Y opt for nicotine patches to reduce his alcohol
consumption when he analyzed that his friend has successfully
withdrawn from alcohol by using this technique Modeling
30 October 2013 38
 “Yet People change if
“Bad habits are they come to believe
like a comfortable it is both of value and
bed, easy to get achievable, so HCPs
into, but hard to should keep
get out of.”-Anon encouraging and
motivating their
clients.”

30 October 2013 39
 TAKE HOME MESSAGE
I promise to work on these behaviors:
 I will avoid high fat diet
 I will have 8 hours sleep at night
 I will avoid procrastination
Reward for meeting these expectations:
 (list down your own rewards)
Consequences for not meeting these expectation:
 (list down your own consequences)
 Ameen, Y. (2011). Obesity increasing at alarming rate in Pakistan. The News
Tribe. Retrieved from:
http://www.thenewstribe.com/2011/11/05/obesity-increasing-at-
alarming-rate-in-Pakistan/
 Baumeister, R. F., & Bushman, B. J. (2011). Social psychology and human
nature (2nd ed.). Wadsworth, Cengage Learning.
 Catalbiano, M. L., & Ricciardelli, L. A. (2013). Applied topics in health
psychology (1st ed.). Wiley-Blackwell Publishers
 Chaterjee, S., Price, A., & Meng, E. (2008). Healthy living with persuasive
technologies: Framework, issues, and challenges. Journal of the
American Medical Informatics Association, 16(2), 171- 178.
 Coon, D., & Mitterer, J. O. (2013). Introduction to psychology: Gateways to
mind and behaviour (13th ed.). Wadsworth, Cengage Learning.
 Ministry of narcotic control Pakistan. (2013). Drug use in Pakistan
2013: technical report summary. Retrieved from:
http://www.unodc.org/documents/pakistan/2013.03.01ab_Sum
mary_Report_Drug_Use_in_Pakistan_SvdV_v1.pdf
30 October 2013 41
 Rajabali A., Khan S., Warraich H. J., Khanani M. R., & Ali S. H. (2008).
HIV and homosexuality in Pakistan. Lancet Infect Diseses,8(8), 511-
515.
 Saleem, N. H., Adrien, A., & Razaque, A. (2013). Risky sexual behavior,
knowledge of sexually transmitted infections and treatment
utilization among a vulnerable population in Rawalpindi, Pakistan.
Journal of Pakistan Medical Association, 63(1), 1-5.
 Shaikh, B. T., & Hatcher, J. (2007). Health seeking behaviour and health
services utilization trends in National Health Survey of Pakistan: what
needs to be done? Pak J Med Association, 57(8), 411-414.
 Stroebe, W. (2011). Social psychology and health (3rd ed.). New York, NY:
McGraw-Hill
 Stuart, G. W. (2009). Principles and practice of psychiatric nursing. (9th ed.).
St. Louis: Mosby.
 Taylor, E. S. (1999). Health psychology. (4th ed.). New York, NY:
McGraw-Hill
 World Health Organization. (2011). Global status report on alcohol
and health. Retrieved from
http://www.who.int/substance_abuse/publications/global_alcoh
ol_report/msbgsruprofiles.pdf
30 October 2013 42