Helping People Make Healthy Decisions for Themselves, Animals, and Nature

Craig Stephen

Health promotion in a One Health world it is about empowering people, organizations, and governments to make decisions that promote reciprocal care of ourselves, animals, and ecosystems. Health promotion and harm reduction help people make choices and changes that increase their capacity to manage the complex of factors that influence health outcomes and create healthier environments. Health behaviour theories and theories of change can guide a systematic approach to promoting healthy change.

Our actions and choices determine if or how we translate the vision of reciprocal care into tangible change. Doing something about One Health problems, whether a zoonotic disease outbreak or food insecurity, will mean action, not only talk and research. There are often huge gaps between the available knowledge about healthy and sustainable living and actions towards it. Simply providing people with new knowledge is insufficient to promote action. Understanding the gaps between knowing and doing requires an understanding of what affects the choices people have, what enables or impedes their willingness or ability to act, and how well they can access and understand information available to them.

Change is hard. The outcomes of change are often less certain than the status quo. It can be threatening to confront uncertainty. People resist change if they believe they will lose something they value, or they won’t be able to adapt to the change. People quickly build psychological defences against change when uncertainty exists or if the suggestion of change implies they are aren’t acting in their own best interests or in the interests of others (Cohen and Sherman. 2014). Cultural entrenchment, dysfunctional management, and poor leadership can cause organizations to resist change (Hoag et al., 2002). Change requires patience, persistence, and a process. There are many models and theories of change. None are ideal and suited to all situations and context. Each is subject to limitations and questions. This chapter introduces some of the theories and frameworks that can guide strategies to help people, organizations, and communities make choices that lead to health-promoting actions for themselves, their communities, their animals, and Nature.

INDIVIDUAL CHANGE

Rarely is change a discrete or single event. It is a process. Not all people will be met at the same stage in the process of change (Bandura, 2004). Some people will have a high degree of motivation with a high sense of self-efficacy and positive expectations for a change. They can be induced or supported to change with minimal guidance. Other people will have self-doubts about their ability to change and the benefits of their efforts. They may start the process of change but can be quick to give up when they run into difficulties. They need interactive support and guidance to maintain their momentum to change. Still others will believe that the desired outcomes are beyond their control. They need a great deal of guidance in a structured program.

Theories can be useful in developing a systematic approach to helping people acquire the skills, capacities, and motivations to make decisions and take actions. Theories or models of change help us move beyond intuition to design and evaluate interventions based on understanding human behaviour (Box 9.1). Although there are differences among models and theories, they are complimentary with significant overlap. They all generally state that what people know and think affects how they act, but that knowledge is necessary, yet insufficient, to produce change. People’s perceptions, motivations, skills, and environments are key influences of change.

There are two broad aspects to change: thinking about it and doing it. Thinking about change is supported by helping people gain and understand information; becoming comfortable with the value, feasibility, and acceptability of change; and helping them believe they can change. Doing is supported by creating or finding opportunities to perform the new action, showing the value or benefits of those changes, and developing the social support to motivate maintaining the change.

BOX 9.1 CONSERVATION IS ABOUT INDIVIDUAL DECISIONS: A CASE STUDY OF FERAL CAT CONTROL

Major threats to biodiversity, such as habitat loss, overexploitation, climate change, and pollution, are the result of a cascade of earlier decisions that trace back to individual choices. The everyday decisions we make that influence these major threats are known as “target behaviours.” Each target behaviour will be driven by a set of motivations, attitudes, knowledge, values, and barriers that are specific to each target audience. McLeod et al. (2019) applied social and behavioural sciences to design equitable and ethically acceptable interventions for free-roaming cat management. They used four principles:

  • 1. Focus on human behaviour to understand how different stakeholders perceive and are affected by the problem, their priorities and interests, and potential conflicts with personal interests and what is collectively desirable.
  • 2. Know your audience by collecting target-specific information on the barriers that impede or enable their engagement in the desired behaviour as well as those factors that drive action.
  • 3. Link specific drivers and barriers to behaviour change techniques that are feasible and acceptable to the target audience.
  • 4. Use a science-based evaluation to determine w'hat w'orks and why.

McLeod et al. (2019) used these principles to work with land managers, cat owners, and the public to develop and adopt best practices for managing free-roaming cats.

Transtheoretical Model

The Transtheoretical Model tells us that people w ill not change until they are ready to do so (Prochaska and Velicer, 1997), and that there are five stages of change: (i) precontemplation, (ii) contemplation, (iii) preparation, (iv) action, and (v) maintenance or termination. Interventions need to be customized to match the stage at which you find the people with w'hom you work (Table 9.1). This is reflected in the principle of “meeting people where they are” found in harm reduction thinking (see Chapter 6 for more on harm reduction). People may move back and forth between stages rather than follow an inevitable linear progression from inaction to a permanent change. Knowing where they are in the process will help you match your interventions to someone’s readiness for change.

The Transtheoretical Model has been used to influence human behaviours linked to chronic diseases such as smoking, bad diets, and inactivity. Lessons

TABLE 9.1

The Stages of Change According to the Transtheoretical Model

Stage

Defining Features

Precontemplation

People do not intend to change in the foreseeable future. They may not see the need for change or be aware that the current situation can lead to negative consequences. The pros of the current situation are perceived to outweigh the cons

Contemplation

People recognize the current situation may be problematic. They start to consider both the pros and the cons of change but still have mixed or contradictory' feelings about the need to change

Determination

People believe change is for the better and start making steps towards that change

Action

People have made the change and intend on maintaining the change for the foreseeable future

Maintenance

People are maintaining the actions needed to keep the change going. They work to prevent relapsing to the earlier state

Termination

People may not want to return to the old state, but they are sure the situation will not reoccur, so they stop the necessary' actions

learned from overcoming such behaviours have informed strategies to discourage destructive environmental behaviour and inspire people to engage in pro- environmental actions (Nisbet and Gick, 2008). The Theory of Routine Mode Choice Decisions (Schneider, 2013), for example, was developed to promote sustainable transportation choices and seems influenced by the Transtheoretical Model. The five steps of the Theory of Routine Mode Choice are (i) making people aware of options and making them available, (ii) apprising people of the safety of the more sustainable options, (iii) making the more sustainable options convenient and cost-effective, (iv) making the sustainable option enjoyable, and (v) helping people sustain their choices. The Transtheoretical Model has been used in veterinary medicine to understand the decisions of animal owners or managers. For example, it was used to identify determinants of dairy farmers’ biosecurity attitudes and behaviours in Great Britain (Richens et al„ 2018). That study found a clear dichotomy between “precontemplaters” and “maintainers,” with few farmers in the three other stages of change (Table 9.1). Many farmers saw the benefits of using biosecurity, so a lack of awareness seemed unlikely to be the reason behind lack of implementation. The investigators found farmer perceptions that diseases were inevitable and beyond their control to be an important deterrent to change. The use of a theory of change in this case helped the investigators understand how to guide precontemplative farmers towards change.

Health Belief Model

The Health Belief Model is widely used to guide human health promotion and disease prevention programs (Champion and Skinner, 2008). Table 9.2 presents some guiding question from this model to help in program design. The model

TABLE 9.2

Some Guiding Questions to Encourage Behaviour Change Derived from the Health Belief Model

From the Model

Guiding Questions

Perceptions of susceptibility, seriousness, benefits, and barriers

  • • Who/what is at risk?
  • • Does the population at risk (or those in a position to make decisions on behalf of animals or ecosystems at risk) have access to accurate, trustworthy information presented in a manner suited to their circumstances and characteristics?
  • • Have the benefits of the actions been explained in a manner relevant to those being asked to change?
  • • Why do the perceived risks of change outweigh perceived benefits?
  • • What is the nature of evidence upon which these perceptions are based?
  • • Can the barriers be feasibly overcome ?

Cues to action

  • • What is the best medium and method of providing cues to action to the target audience(s)?
  • • Who is a trusted voice that can provide cues?

Self-efficacy

  • • Have people been shown how to perform the desired behaviour, or trained or assisted in implementing the change?
  • • Is there a series of incremental steps that can encourage change?

argues that to change, people must first perceive that the problem they are trying to avoid is serious and that they are susceptible to the problem. They must believe that the proposed change can reduce risk and that the barriers to taking the action are outweighed by the benefits. These barriers can be logistic, financial, social, or others. This model recognizes that people need a cue to action before change will happen. These may be internal cues (e.g. pre-clinical symptoms of a diseases) or external cues (e.g. media messages or prompts from a health care professional). The last component of the model deals with self-efficacy: a persons’ confidence in his or her capacity to act and make the change. Perceptions and beliefs influencing the various stages of this model are impacted by modifying variables such as age, gender, personality, socio-economic status, and knowledge. Perceived barriers and perceived susceptibility can be the most powerful predictors of the likelihood that a person will adopt a health behaviour.

The Health Belief Model has been used most extensively to understand why people don’t adopt disease prevention strategies, undertake screening tests for early disease detection, or comply with treatment recommendations. The model has also been used as a framework to design animal health studies as well as to put the results of research into context. For example, investigators in Nigeria used the model to design questionnaires to identify social and cognitive factors predicting the practice used by meat handlers of eating parts of the lung from cattle visibly infected with bovine tuberculosis in order to convince customers to buy meat (Hambolu et al., 2013). The model has also been used to explore motivators or disincentives to adopt environmentally friendly practices such as recycling (Lindsay and Strathman, 1997) and well water conservation (Morowatisharifabad et al., 2012). Understanding perceptions, barriers, and self-efficacy is increasingly important when trying to promote actions to mitigate climate change (Gifford, 2011). There has been less uptake of this model in proactive conservation because it is concerned more with actions to avoid negative consequences than actions to promote healthy capacities and environments.

Integrated Behaviour Model

The Theory of Planned Behaviour and the Theory of Reasoned Action both assume the best predictor of a behaviour is an intention to act, which in turn is determined by attitudes towards the action, social norms, and perceived control over the action. An Integrated Behaviour Model draws on these two theories as well as well as others (Montano and Kasprzyk, 2008). This model, like others, recognizes that people must have the intention or motivation to change. They must feel positive about the change. A desire to comply with social pressures or norms that promote the change further motivates people to act. People must have the knowledge and skills to act and face few or no constraints to impede the action. The requested change must be pertinent or relevant to the person being asked to change. Finally, the change should be performed often enough that it becomes a habit and relies less on intentions in order to sustain the change.

Precaution Adoption Process Model

The Precaution Adoption Process Model lists seven distinct stages a person goes through from lack of awareness to adoption and/or maintenance of a behaviour (Weinstein and Sandman, 2002):

  • • Stage 1 - The person is unaware of the issue.
  • • Stage 2 - The person is aware of the issue but is unengaged by it.
  • • Stage 3 - The person faces a decision to act or not.
  • • Stage 4 - The decision to not act has been made.
  • • Stage 5 - The decision to act has been made.
  • • Stage 6 - This is the stage of action.
  • • Stage 7 - The action is maintained.

This model recognizes that people who are unaware of an issue, or are unengaged by it, face different barriers from those who have decided to act or not. People in stage 1 need basic information about the hazard and the recommended precaution. Moving from stage 1 to stage 2 will be influenced by a person’s access to information, whether formally or informally. Moving from stage 2 to stage 3 will be similarly influenced but may be prompted by something that makes the threat and action seem personally relevant. For example, a farmer may be more likely to decide about biosecurity measures when a neighbouring farm is affected by a disease. Or a person may be more likely to decide to do something if a friend or family member experiences the negative outcome he or she is trying to avoid. Becoming aware that others are making up their minds may also motivate a decision. Moving from stage 3 to stage 4 or stage 5 will be heavily influenced by a person’s beliefs about hazard likelihood and severity, personal susceptibility, effectiveness and difficulty of changing, social norms, and personal fears. People who have come to a definite position on an issue have different responses to new' information and are more resistant to persuasion than people wfho have not formed opinions. The implications of some people saying that they have decided not to act are not the same as saying it is “unlikely” they will act or that they "might” act. People in stage 4 can be quite well informed but will tend to dispute or ignore information that challenges their decision not to act. Moving people from stage 5 to stage 6 means closing the gap between an intention to act and acting. Whereas detailed information on "how'” to change may not be as important as “why” to change for people in earlier stages, information on how to change is essential for people at this stage. Understanding the time, skills, and effort needed to change; knowing how to find support for change; detailed “how'-to” information; and cues for action are needed. Finally, the transition from stage 6 to stage 7 needs ongoing support and re-enforcement of the value of action to habituate the change.

 
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