The concordance conundrum: understanding the complexities of behaviour change

When we think about behaviour change we tend to do so mostly in terms of ‘why’ people change but not necessarily about ‘how’ they change. Much of the available literature focuses on theories of behaviour as opposed to behaviour change. It is a minefield.

Until the late 1970s, when leading US-based psychologists James Prochaska (Director of Cancer Prevention Research Center and Professor of Clinical and Health Psychology at the University of Rhode Island, USA) and Carlo DiClemente (Professor in the Department of Psychology at the University of Maryland, USA) started work on their Transtheoretical Model (TTM),¹ the field was fragmented with around 300 theories on behaviour change in existence.²

TTM is based on principles developed over 35 years. It is an integrative, biopsychosocial model that explores intentional behaviour change, integrating key constructs from 25 leading psychotherapy theories into a comprehensive model that can be applied to a variety of behaviours.

Stages of change

There are six stages to achieving change and people progress – not always sequentially – through each stage on their way to success. The model has been applied in many therapy areas including, eating disorders, medicines compliance and cancer screening, with the aim of understanding success factors that underpin behavioural change.

Six stages

1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
6. Termination

While the time that an individual may spend at each stage is variable, often depending on the behaviour that needs to be changed and the urgency surrounding it, the tasks required to move to the next stage are not. Certain techniques work best at each stage to reduce resistance, promote progress and prevent relapse. These principles include decisional balance, self-efficacy and the processes of change.

Less than 20% of the population who are at risk if they do not change their behaviour are willing to take action. As such, action-oriented guidance is unlikely to be effective in the early stages of change for around 80% of us. As a healthcare professional (HCP) actively looking to catalyse change in their patients, this is a challenge that needs to be overcome if concordance is to improve.

Here we take a look at the steps and the techniques that can be deployed to support patients are they move from one stage to another.

1. Precontemplation – not ready to change
   Individuals at this stage have no intention of changing in the near future (set at six months). For them it is very much ‘ignorance is bliss’.

   Techniques for moving to the next stage:

   • Validate lack of readiness/willingness to change
   • Encourage re-evaluation of current behaviour
   • Encourage self-exploration (as a means of moving towards contemplation and action)
   • Explain the risk to them of not making changes.
   
   Existing care plans may not meet the needs of these patients and more dialogue is needed to open their minds to the benefits of changing (Prochaska et al, 2015).
2. Contemplation – considering change
   People at this stage are ambivalent to change and in two minds about the benefits of investing time and energy into changing over the next six months. They may be more aware of the pros and cons of changing their behaviour but are not committed to action.

   Techniques for moving to the next stage:

   • Encourage evaluation of the pros and cons of behaviour change
   • Identify and promote new, positive, realistic expectations around change
   • Coach them towards taking action – but be weary not to push too hard.
   
   As people weigh up the pros and cons they can become stuck at this stage, a phenomenon coined as chronic contemplation or behavioural procrastination.²
3. Preparation – ready to change
   People here have some experience of change and are trying to make positive alterations e.g. talking to their HCP, downloading a self-help app or relying on self-change. They plan to act in the next month.

   Techniques for moving to the next stage:

   • Reinforce the need to evaluate the pros and cons of behaviour change
   • Work with them to identify and promote new, positive, realistic expectations around change
   • Encourage them to take small steps towards their goal
   • Encourage them to attend a group session, e.g. stop smoking clinic or a weight loss programme, explaining the benefits of group interaction.
4. Action – making change
   People at this stage have already made clear and specific modifications to their lifestyles over the past six months. They are focused on changing and have invested time and energy in doing so.

   Techniques for moving to the next stage:

   • Help patients restructure cues and build social support
   • Improve self-efficacy by preparing for bumps in the road
   • Give them the tools needed to cope with feelings of loss or frustration.
   
   The criteria for behaviour change is dependent upon the change itself. Action does not always signal behaviour change. For behaviours such a cancer prevention, the criterion for change could be attending a screening, for example, mammogram, or colonoscopy. Whereas for smoking cessation, the criterion would be total abstinence as the health benefits are recognised only when a person stops smoking.
5. Maintenance – sticking with it
   Having made demonstrable changes, people in this group are working to prevent relapse and consolidate the gains realised through action. They are increasingly confident they can maintain these new behaviours. Maintenance can last from six months to five years, depending on the behaviour being changed.

   Techniques for moving to the next stage:

   • Plan and develop support
   • Reinforce internal rewards
   • Discuss mechanisms for preventing relapse.
6. Termination – successful change
   People at this stage are not tempted to revert back to old ways irrespective of environmental factors. Their new behaviour has become automatic, as if they had never behaved any differently, for example, someone with hypertension who struggled to take his/her medication as directed now doesn’t think twice about taking it and rarely, if ever, forgets.

Relapse is also a consideration. Although it was not a stage discussed by Prochaska and DiClemente in the original article, it signals a return to old behaviours having made attempts to change. It is important for HCPs to explore the triggers for regression, re-assess motivations and barriers, and support the development of stronger coping mechanisms.

These six steps belie the complexities that underpin how, when, why and if we can make changes. It is all about timing and assessing accurately where in the cycle patients are, tailoring the conversation to the stage they are at currently. It is about knowing when to introduce the concept of an intervention and how to do so effectively. There are of course incidences when time is a luxury and for a variety of reasons immediate concordance with a treatment regimen is a must.

Find out more

Understanding behaviour change is one of a series of articles focused on how companies can make the most of these opportunities, exploring how communication between industry and HCPs, and between HCPs and their patients can be taken to the next level to improve  patient outcomes.

To find out more and to download other guides from the series, visit https://pageandpage.uk.com/media_lab