The person who is ill
4.3 Lifestyle choices and ‘changing behaviour’
I have, somewhat unusually, chosen a narrative of an acute illness (death from a bleeding colonic polyp, told from the perspective of a grieving father) as an example of how a literary perspective may add value in studying how people cope with illness in themselves and their relatives. More usually, it is chronic illness that is studied using the tools of narrative analysis. Cancer, for example, is often presented as a personal tragedy that throws a family into a reluctant but unstoppable drama. When a patient or carer tells the story of cancer, the various relatives, friends, nurses, doctors and informal carers inevitably become characters in the drama – such as heroes, villains, clowns or bystanders. Acts or omissions of individuals (or the system, or the gods) may be presented (implicitly or explicitly, and justifiably or otherwise) as having
‘caused’ a particular turn in the story. The person cannot change the situation, but at least he or she can account for what has happened and key individuals can be depicted as virtuous (brave, selfless, devoted) and as following the expected social norms and conventions (e.g. the doctor demonstrated skill and judgement; the family pulled together).
I have written a separate monograph on how narrative analysis can inform and enrich the practice of medicine.16My own interest in narrative lies mainly with the medical management of physical illness and the ill person’s use of nar- rative in coping with conditions such as cancer, diabetes, depression and other chronic conditions. Others, notably John Launer, have taken a more psychody- namic perspective on the application of narrative theory to illness – especially the use of narrative-based family therapy in the care of complex distress in primary care.17
Here’s an example: Wazim Maziak, writing in the British Medical Journal about the appallingly high prevalence of obesity (70%) and diabetes (24%) in the Arab world, says,
‘Solutions for such health problems cannot necessarily be imported. For example, advocating diet and physical activity to combat the epidemic of obesity among women in Arab societies may be na¨ıve. Overwhelmed by having to take care of large households, and deprived of basic knowledge and power to conceptualise life outside traditional frameworks, women may be unable to alter their lives’.18
I believe that the term ‘supporting positive lifestyle choices’ is generally preferable to ‘changing behaviour’, because it avoids victim blaming and also because it does not assume that the level of change has to be the individual (see Section 3.9). Providing women-only swimming sessions for Muslim (and other) women in local swimming pools, for example, is a different approach to supporting positive lifestyle choices. It does involve a change in the women’s behaviour (more of them may now go swimming), but the problem was not the women’s motivation or intention – it was the cultural appropriateness of the facilities available. Having voiced my reservations about targeting individual behaviour, let’s briefly consider the academic basis of some commonly used behaviour change strategies aimed at patients. Incidentally, taking note of the patients’ perspective set out in the first paragraph, I cover changing health professionals’ behaviour in Section 5.4.
Prochaska and DiClemente’s widely cited model of behaviour change19 is more popularly known as the ‘transtheoretical model’. I have placed the word ‘transtheoretical’ in quotation marks because it implies that the model transcends a number of different theoretical streams. In my own view, it can be explained largely in terms of mainstream cognitive theory (see Section 2.3).
The core concepts are motivation, behaviour change (the former being seen as the key to the latter) and the sequential transition between ‘stages’ of moti- vation. According to the model, an individual faced with a behaviour change moves back and forth between five stages (Table 4.3): (a) pre-contemplative (in which they are not even considering the change), (b) contemplative (in which they are considering the change but not attempting to change), (c) preparation (in which they are getting ready to make the change), (d) action (in which they are actively making the change) and (e) maintenance (in which they are attempting to maintain the change). The model suggests different approaches to influence and support the patient depending on the stage of change, and the approaches are oriented to shift the individuals from their current stage to a higher one.
The stages of change model is used extensively by clinicians and clinical researchers to try to influence patients’ success in changing their behaviour – most usually, in giving up unhealthy habits like smoking and excess drink- ing. The practical application of the model is that instead of giving the same health advice to everyone, this advice is tailored to the particular individ- ual’s stage of change. Thus, for example, a person who states that he or she
Table 4.3 The stages of change model and how to classify someone.
Stage Descriptor Defining question
Pre-contemplative Not even thinking about changing
Have you thought about change at all in the last 6 months? [Answer: no]
Contemplative Thinking about changing Have you planned to change between 31 days ago and 6 months ago? [Answer: yes]
Preparation Making plans to change Have you planned to change in the past 30 days? [Answer: yes]
Action Actively trying to change Have you actually changed (even for a short time) in the past 6 months? [Answer: yes]
Maintenance Having achieved the change, is trying to maintain it
Have you maintained the change for the past 6 months? [Answer: yes]
Summarised from Prochaska.20
has no intention of giving up smoking is simply informed of the dangers of smoking and told that more help is available if they change their mind;
someone who admits to trying to give up is offered information on the differ- ent methods of achieving this and offered counselling, pharmacotherapy and so on.20
A systematic review of smoking cessation trials, which was helpfully sum- marised in the British Medical Journal,21showed that such tailored approaches work better than ‘one size fits all’ interventions. The stages of change model helps us understand why a tailored approach might be more successful, and it also guides the design of new interventions. But the model is not without controversy. Indeed, critics have described it as a fundamentally flawed model whose popularity far outweighs its credibility.22For one thing, claims West, the stages proposed are entirely arbitrary (‘lines in the sand’) which do not have a firm basis in cognitive psychology. For another, the theory behind the model assumes that individuals typically make coherent and stable plans – and thus, at any point in time a person can be confidently classified, for example, as being in the ‘contemplative’stage as opposed to the ‘action’stage. Empirical research, claims West, suggests the opposite – that most people’s plans to quit smoking are unstable and may change on a daily basis. Finally, the stages of change model focuses on conscious, rational decision making whereas smoking (and other addictive behaviour) is often justified by recourse to non-rational expla- nations and hence may be relatively resistant to a rational treatment model.23 Nevertheless, Prochaska and DiClemente’s model is one of the most widely used in empirical research on patient behaviour change, so it’s certainly worth knowing about.
The stages of change model was recently tested against conventional ad- vice in a clinical trial.24 We all know that eating several portions a day of fresh fruit and vegetables improves long-term health. But as clinicians we often feel that eating fresh food is a ‘lifestyle’ that some people (especially those from low-income families) choose not to follow. Clinicians are rightly cynical about dishing out lifestyle advice since it is increasingly evident that patients do not ‘obey’ the doctor, nurse or pharmacist – they make their own choices that may or may not be influenced by what the professionals say.
This trial was a randomised design in which people from low-income groups were randomised to receive behavioural counselling based on the stages of change model or standard nutritional advice. Although both groups improved their intake of fruit and vegetables, the ‘stages of change’ group improved significantly more than the control group – a finding which suggests that the model has practical value, even though purists can find fault with its theoretical basis.
Another theory that primary care researchers increasingly draw upon in relation to behaviour change is the theory of reasoned action. Developed in the 1970s by Ajzen and Fishbein,25this theory has a number of core concepts:
norms, attitudes, values and intention. The theory states that a particular be- haviour is determined most immediately by the person’s intention to behave in that way. Intention to behave is in turn determined by (a) subjective norms (beliefs about what behaviour is expected by significant others, and motivation to comply with these expectations); (b) attitudes towards the behaviour (based on beliefs about, and evaluation of, the likely consequences of that behaviour) and (c) the relative importance to the individual of norms versus attitudes.
The theory of reasoned action was later extended to include non-voluntary behaviour (i.e. behaviour over which the individuals do not have complete control), and renamed the theory of planned behaviour.26
An example of how the theory of planned behaviour helps explain patients’
health choices and inform primary care interventions is a study by Conner et al. on why women use dietary supplements.27Users of such supplements were significantly more likely to have positive attitudes about supplements, and to believe that the supplements would keep them healthy and stop them from getting ill. Takers of the supplements also believed that this behaviour was a norm (i.e. an expected and accepted behaviour) within their own social group. The implication of this theory in relation to reducing unnecessary (and potentially harmful) supplement use in certain groups includes the possibility of developing interventions to change attitudes towards as well as simply knowledge about such supplements, and of challenging prevailing norms in certain subgroups. Again, the theory is useful only to the extent that it explains the findings of research and helps us in developing new hypotheses to test. The theory of reasoned action has been used to develop targeted, theory-driven interventions aimed at reducing marijuana smoking28and increasing positive behaviours such as brushing teeth,29 the use of condoms by high-risk drug
addicts in sexual encounters30 and patients’ compliance with prescribed medication.31
Ogden has offered an incisive critique of the theory of reasoned action (and other theories in what is known as the ‘social cognition’ school).32First, such theories do not enable the generation of hypotheses because their constructs are not sufficiently specific to allow them to be tested. Second, their central tenet is often a near-circular argument (the fact that a person who intends to smoke is more likely to smoke than someone who doesn’t intend to may be true – but it is true by definition, so it’s not saying much!). Finally, ques- tionnaires and other instruments designed to assess what people plan to do may influence those plans rather than being an unbiased measure of them.
If you feel swayed by these arguments, you should also look up Ajzen and Fishbein’s spirited response.33As with all theories, this one is useful for il- luminating reality, but it is not a short cut to any simple truths. The quote from Maziak, earlier in this chapter, reminds us that there are other levels of intervention, and other theories about how interventions work, that may prove more fit for purpose in promoting behaviour change for positive health outcomes.