Persuading patients to make health-related changes can be a difficult task requiring special behavioral interventions. These interventions can help the patients maintain these changes over time.

ADVICE AND INFORMATION ARE NOT ENOUGH

Giving the patients just advice and information is not enough to make them stick to the changes they need to incorporate into their daily routines. We need to address the barriers to adopting healthy behavioral changes to help them with their interests and goals related to their health.

These interventions may deem necessary for patients with difficulty sticking to the treatment plan. These patients usually follow a plan for a while and then stop, which results in the condition returning to where we started.

The patients interested in making changes related to their health need to be motivated. Without motivation, patients may find it hard to stick to a plan. So motivation comes first in making health-related changes.

WHY DO PEOPLE DO WHAT THEY DO?

To understand why people do what they do, we need to broaden our thinking about the origin of human behavior.

ORIGIN OF BEHAVIOR

Our brain is influenced by certain factors which give origin to our behaviors. These factors may include the following:

BIOLOGY/ EVOLUTION

The human brain has transformed and evolved over millions of years, adopting the behaviors essential for survival. These behaviors help us survive in our environment and be a part of a diverse and modern society. From a biological and evolutionary perspective, our brain has a desire or motivation for certain behaviors because these behaviors play an enormous role in our survival.
These behaviors may include the following:

• Eat as much as possible
• Rest when you can
• Remember and recognize problems
• Worry and avoid the risk
• Be liked by others

Our brain temps us to eat as much as possible when food is available, rest when we can, and remember and recognize problems. Our brain also makes us worry and avoid risk, a key factor not allowing us to stick to the change.

LIFE EXPERIENCES

Habits
Our life experiences significantly govern our behaviors. We develop different habits by doing the same thing under the same circumstances. These habits get incorporated into our behaviors and resist change.

Thoughts and beliefs
Over time, we develop different beliefs regarding different things. They make us stick to what we know and not adapt to change. For example, if a patient believes that doing exercise with low back pain can be dangerous, it will be difficult to persuade these patients to exercise when they have low back pain.

Values and identity
Over time, we develop values and build an identity that represents what we think of ourselves. So, if a person values rest over exercise, it may not be easy to convince them to exercise even when necessary.

ENVIRONMENT

The human environment also influences their behaviors. Our environment can either motivate or demotivate us to change our behavior. A comfortable and motivating environment can encourage people to engage and participate in different activities. Designing an environment according to patients’ needs can significantly change their behaviors and allow them to stick to the change.

There is always a reason behind patients not sticking to the change. We should be curious and find it out. It will allow us to utilize a targeted behavioral intervention to change patients' behaviors and make them stick to it.

PSYCHOLOGICAL SKILLS TO CHANGE THE BEHAVIORS

A few psychological skills that we can utilize to change patients’ behaviors and make them able to adapt to the change are as follows:

CONSCIOUS CHOICES

We need to replace automatic habits with conscious choices. Sticking to automatic habits will ultimately result in patients keep doing the same thing over and over again. So as a first step towards behavior change, we should encourage and motivate the patient to make conscious choices and stop being on autopilot mode.

The patients should switch themselves from automatic to choice mode. It means that the patients need to stop, think, and choose what is needed to be done in this situation rather than just following the habits and ending up with similar unwanted results.

TOOLS AND TECHNIQUES TO SWITCH FROM AUTOMATIC TO CONSCIOUS CHOICE MODE

Setting a goal for behavior change and monitoring the new behavior is effective in helping people initiate change and maintain it. During maintenance, the focus will change from future expectations to experiences with outcomes (1).

Different strategies to change health behavior are as follows (2):

• SMART (Specific, Measurable, Attainable, Relevant, Timely) goal setting
• Identify possible barriers and develop solutions
• Self-monitoring
• Setting realistic and small goals
• Make diaries
• Create routines

Several tools and techniques help us disrupt the automatic mode of making choices and move to conscious choice mode. These include the following techniques:

• Goal setting
• Planning
• Tracking and reflecting
• Support and accountability

Goal setting
We can classify the goals into what and why categories. 

Goal setting — The why
The why of the goal setting lies in making a clear distinction of what the barriers and hurdles are for the patients today and what they want their future to be. Their future aim will give a clear-cut answer to why they want to change their behavior.

Goal setting — The what
The 'what' of the goal setting will answer what the patients should do to achieve their desired future. After discussing why the patients want to change their behaviors and what kind of future they desire, we can set specific, measurable, and relevant goals for the patient to achieve the future they dream of. The goals should be specific and measurable to allow us to assess the progress and make changes when needed. Another important thing is to set realistic goals. Realistic goals mean achievable and few goals. Setting a bunch of perfect goals may discourage the patients if they fail to achieve these goals.

Planning
After specifying clear goals, the planning phase begins. We will identify when, where, and how to achieve the preset goals. We will lay out the task, time, and place where the task will occur. Adherence to the plan is key to reaching the desired goals regarding the behavior change.

Implementation intention
Implementation intention is an important technique that can be utilized in the planning phase to increase the patient’s adherence. The implementation intention means that the patient decides when, where, and how he wants to perform the task. The researches show that utilizing implementation intention can improve the chances of success (3). Implementation intention switches the mode from goal-directed behavior from hesitant to immediate, from effortful to efficient, and from a conscious intent to act to direct response elicitation by the situation.

Make it visual
Making the plan visual can help the patients adhere to the behavior change. Ask the patients to imagine what they will do throughout the process, like coming home, changing outfits, and exercising. This way, the patients can become aware of potential barriers to adopting the behavior. They can visualize and anticipate barriers and rectify them properly. They can accustom themselves to the task required to implement the plan.

Motivation and barriers
We should motivate the patient about the benefits of adhering to the change. We should ask the patients about potential barriers and decide how to resolve these barriers. We should discuss the advantages of sticking to the plan and see if anything other than the plan is worth being the barrier to the behavior change.

For example, if the patient plans to exercise and if he does not exercise and instead ends up resting on a couch, we should motivate him by telling him that exercising can help him with his problems than resting. This way, we can motivate the patient by laying out the potential benefits of adhering to change and avoiding barriers.

 
Implementing all these tools may be difficult, and we should utilize the most appropriate tool available and reflect and track the results.

Tracking and reflecting
Tracking the changes in their behavior can be a helpful tool to see if they are making any progress, and if yes, then how much progress. The patients can do it in many ways. They can tick the checkboxes on their calendar and see if they missed a session and how many sessions of exercise they have completed over the past month or week. It will help them reflect on their experience regarding behavior change. They can think of the barriers preventing them from adhering to change, and they can struggle to rectify them. They can praise themselves for the success they are making and be at their best in behavioral change therapy.

Monitoring goal progress is an effective self-regulation strategy. The interventions that increase the frequency of progress monitoring can promote behavior change (4). Monitoring behavior, results, and outcomes are more effective when in writing and shared with someone else.

Support and accountability
Support and accountability can significantly impact the outcome. The support can be from the therapist during the meetings with the patient on the success of the behavior change therapy. The patients can also seek support from another person or a support group. The support keeps the patients motivated and active throughout the process of change.

Social support
Social support can significantly affect adherence to behavior change. A study concluded that if the behavior change was supervised by a competent supervisor, the chances of success increased by 65%. And if the patients have social support from friends and family, the chances increase by 35% (5).

Several strategies, including motivational interviewing, long-term follow-up, skill training, social support, and self-monitoring, increase the long-term adherence to health behavior change (6).

KEEP GOING

We need to keep track of what is working for the patient and what progress we are making in the patient’s behavior change. It will keep us and the patient motivated. Noticing the benefits and progress is essential as it will help us plan the future behavioral therapy of the patient.

After goal setting and planning, the next thing is to keep the patient going with the change. Following strategies can help us in this regard:

NOTICE WHAT IS GOING WELL

Ask the patient to notice what is going well and the benefits of sticking to the change because it can motivate patients to be more engaged in the behavior change process. Look for the strategies that are working and helping the patient succeed. Create a self-praising attitude in the patient for doing well. Ask the patient what he likes the most in the new behavior and what he learns throughout the behavior change process that he considers useful in daily life.

DON’T GIVE UP

When we implement behavioral change therapy, the journey can be challenging, and there may be hurdles and setbacks. The goal here is to continue with the therapy even when the patients have a hard time sticking to the change due to several reasons like pain which will restrict their ability to exercise. In these cases, we should encourage the patients to keep going and not give up.

Some patients have a higher inner critique, and when they fail to practice behavior change, they blame themselves for not being good enough. This situation poses a challenge and may restrain the patient from sticking to change. The patients need a supportive guide to help them keep going and not give up. The patients should be aware of this self-critique and able to cope with it. The patient should learn self-care to minimize the effect of self-critique.

If you want to learn more about the tools, techniques, and interventions to change health behavior, watch the lecture on health behavior change by Andreas Lycke on TrustMe-Ed.

REFERENCES

1. Samdal GB, Eide GE, Barth T, Williams G, Meland E. Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses. Int J Behav Nutr Phys Act. 2017;14(1):42.
2. Hooker S, Punjabi A, Justesen K, Boyle L, Sherman MD. Encouraging Health Behavior Change: Eight Evidence-Based Strategies. Fam Pract Manag. 2018;25(2):31-6.
3. Gollwitzer PM, Sheeran P. Implementation Intentions and Goal Achievement: A Meta‐analysis of Effects and Processes.  Advances in Experimental Social Psychology. 38: Academic Press; 2006. p. 69-119.
4. Harkin B, Webb TL, Chang BP, Prestwich A, Conner M, Kellar I, et al. Does monitoring goal progress promote goal attainment? A meta-analysis of the experimental evidence. Psychol Bull. 2016;142(2):198-229.
5. Lemstra M, Bird Y, Nwankwo C, Rogers M, Moraros J. Weight loss intervention adherence and factors promoting adherence: a meta-analysis. Patient Prefer Adherence. 2016;10:1547-59.
6. Middleton KR, Anton SD, Perri MG. Long-Term Adherence to Health Behavior Change. Am J Lifestyle Med. 2013;7(6):395-404.