Changing Behaviour in the context of EPODE-like programmes
Prof. Jan Vinck, member of the VIASANO expert committee, from the University of Hasselt, describes here some psychological approaches that are used in CBIs aimed at promoting long term healthier habits in the population. The focus is on the importance of changing the local living environment through a multistakeholder approach in order to reach a sustainable change in individual behaviours.
It is generally agreed that fighting obesity requires long term changes in eating behaviours and physical activity – short term changes being futile and sometimes even counterproductive.
Two large approaches to behaviour modification can be distinguished in health promotion. The first evolved from the “health education” tradition that, historically, was the first to be applied in health promotion. The second approach is firmly anchored in a long standing tradition of theorizing and research on habits and habit formation. In this tradition the environment is an important factor in shaping and maintaining behaviour.
A somewhat similar distinction between these two approaches to behaviour modification is the distinction between reflective and impulsive (Hoffmann, Friese et al. 2008) or automatic (Rothman, Sheeran et al. 2009) routes. In both cases the important difference between the two approaches is that the reflective approach assumes a (more or less deliberate and conscious) intention and decision from the person to change its own behaviour, whereas the second approach is not dependent upon such decision and assumes that behaviour will more or less automatically adapt to the environment.
In practice, the impulsive/automatic approach is, until recently, relatively underused, while it has stronger long term effects.
Recently, elements of both approaches have been incorporated in social marketing strategies (Donovan and Henley 2003;) in a primarily pragmatic way.
The health education or reflective approach assumes that giving the necessary information (about “healthy” behaviour and/or about the risks of “unhealthy” behaviour) will result in the formation of an intention to change behaviour and to subsequent behavioural adaptation. Gradually it became clear that this “rational” approach is conceptually weak (Ogden 2003) and less effective than one could have hoped (Crossley 2001), especially when fear arousal is used (Ruiter, Abraham et al. 2001). This relative weakness led to several adaptations of the model, trying to close the gap between intentions and behaviour and to reformulate it as a model of self-regulation (Hall and Fong 2007). Important among these adaptations are the extension to a preparation phase including implementation intentions (Schwarzer 1992; Brandstätter, Lengfelder et al. 2001), the right formulation of behavioural goals according to e.g. the SMART criteria, tailoring interventions to the characteristics of the person and its position in the stages of motivation process (Prochaska and DiClemente 1986), and relapse prevention (Marlatt and Gordon 1985).
However, several reasons to consider additional possibilities for behaviour modification remain:
- large portions of the population ignore health education efforts, and do not invest in changing health behaviour. These are also usually the most vulnerable groups.
- maintaining deliberate behavioural changes remains difficult, so that drop outs are frequent.
The “impulsive” or “automatic” approach focuses on the modification of habits. A habit is, per definition, a behavioural pattern that is relatively stable over time. And of course it are these stable behaviours that are interesting. Only long term unhealthy behaviour will have adverse effects on health, and, only stable healthy behaviour will benefit health. So the question is: “what makes unhealthy habits so stable, and, therefore, difficult to change?” and “how can we create new, more healthy habits?”
Behaviour is not produced in a vacuum; behaviour is a response to a given situation. And while living situations have always some stable characteristics, behavioural patterns will develop that are adapted to these environmental characteristics. The relevant situational features may be physical (e.g. the availability of a pleasant walking path; the availability of fast food), social (e.g. social models; social norm; social pressure), motivational (e.g. the taste of food; the cost of physical activity in terms of effort and time) or cultural (e.g. tradition of a family meal; of spending leisure time watching TV; acceptability of breast feeding).
It has now been convincingly demonstrated that we live in an “obesogenic” environment (Horgen and Brownell 2002, WCRC 2009). An obesogenic environment is typically eliciting the consumption of too much energy and discouraging physical activity. So the message is simple: as long as we don’t change this environment, healthy behaviour will remain “unadapted” and therefore difficult to maintain in the long run because the environment is “pushing” unhealthy behaviours. That is what we see in traditional prevention efforts whereinitial changesrapidly return to earlier behavioural patterns. So, we have to change the environment to make healthy behaviours the most natural, the most easy and rewarding response. However, how do we change the physical environment (e.g. the attractiveness of park areas), how do we change the cost and benefit of behaviour (e.g. the price of food), how do we change the social norm of being physically active? To achieve most of these changes, it is necessary to collaborate with institutions or actors that have control over these environmental factors (WCRF 2009).And that is exactly one of the fundamental pillars of Epode-like projects: to help local political authorities to bring together the people that are responsible for crucial aspects of the environment (food industry and distribution, media, urbanists, clubs for youth and seniors, catering industry, school and health care systems etc.) , in order to permanently change the local living environment of the population.
Epode-like programmes combine methods of health communication and social marketing techniques with a community oriented approach to change the local living situation of the participants. And it is interesting to see that the addition of the latter approach coincides with demonstrable downward trends in the weight of children in the FLVS study (Romon, Lommez et al. 2008). This is clearly a stimulus to continue along the same lines.
A number of challenges remain:
- the role of emotions should be explored; e.g. depression is as often preceding as following obesity (Rooke and Thorsteinsson 2008)
- evaluation of projects is to be further developed.
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 We restrict this discussion to the domain of primary prevention/health promotion; so we do not consider behaviour modification techniques in e.g. treatment or clinical practice.