Craig Allingham

All of them to a man until it hits them. Believe it happens to other men, So have this problem of invincibility. And then along comes Craig, who says you need to change what you're doing. And they look at me and think, go away.

Caroline Bills

Good morning, I'm Caroline Bills and I'm delighted to be here with Craig Allingham and Tahlia Alsop to kick off a fabulous discussion on behaviour change. But before we get started, let's welcome each other and acknowledge where we come from. I personally come from Boonwurrung country in down in Melbourne with the river people and I'd like to acknowledge that at the moment we're on Turrbal and Jagera people's land of Meanjin and they are the original owners and custodians of this land that we're meeting, working on and learning from. We'd all like to pay our respects to elders past, present and emerging. So let's kick off and find out a little bit about each other. I'll perhaps ask you Craig.

Craig 

Yes, Craig Allingham. I am a a physio from the Sunshine Coast which is the land of the Gubbi Gubbi. people and I have been involved with physio for oh. Some say too long but it's been quite awhile and my current interest is in older men and around prostate cancer journey and certainly behavioural change Yes.

Caroline 

Fantastic. And Tahlia.

Tahlia Alsop

Thanks Caroline. So my name’s Tahlia Alsop I'm a physio right here from the land of the Turrbal people in Brisbane. I'm a physio with a particular interest in neurological rehab, in particular in inpatient settings, and a PhD candidate at the University of Queensland, and my research in particular looks at behaviour change at a health professional level, an organisational level within inpatient rehab settings. We're looking forward to the conversation with you both today.

Caroline 

Great. And my background is certainly as a clinical physio, mainly in pain management and I still work clinically, but I branched off a number of years ago around in the early sort of 2000s into this area of behaviour change. And so now most of my work is actually around helping organisations and clinicians actually use a particular clinical practise methodology that embeds behaviour change in what we do.

So let's start by perhaps just thinking if can I get your opinions on where do you think the major issues are with behaviour change in you're either various areas and tell us a bit more about what you think the major challenges we have to face at the moment. Craig, can I start with you?

Craig 

Sure, yes. Well, so I work currently in a population of older men who generally over the age of 60, all of whom think disease and disability happen to other men. Although they I can make them aware of the the data of the incidents and likelihood of of prostate cancer or cardiovascular disease or diabetes in their age group. But all of them to a man until it hits them, believe it happens to other men. So have this problem of invincibility was not just a recent phenomenon when they turned 60. They developed it through their teens and have led their life accordingly. So firmly entrenched are their behaviours and have been reinforced by socialisation of gaining of masculinity, etcetera from the outset. And then along comes Craig who says you need to change what you're doing. And they look at me and think, go away. Yes, I don't want to do that. That's too difficult. Yeah. 

Caroline 

And particularly in the area of men's health, you're actually talking about fairly sensitive stuff.

Craig

Oh we are Yeah, we're and we're talking in some respects about some of the essence of masculinity. So it is quite close to home. But still they find it a journey that they're not willing to always under take. Not of course, that's a generalisation. Many of them are quite good at it and and are accepting and and I have the, the, the key discussion in that early contact point of asking them the question if they tell me they know they're what they're drinking habits are eating habits exercise habits and lifestyle things sports have done you know everything they've done and how how, what great warriors they are. I said, well, where is all that led you to now you've got prostate cancer.

Maybe it's time to reset a few things here. Use that trigger as reflect on what the outcome of this behaviour you're currently entrenched in.

Caroline 

Absolutely. And Tahlia, you're more in the sort of the acute, almost the diametric opposite area versus the prevention area and the challenges of trying to engage people when they don't really believe the problem is going to be relevant to them, to your area, which is perhaps people, you know, an acute setting.

Tahlia 

Yeah. And I think that was the challenge that we recognise when we first started looking at physical activity, specifically in the inpatient setting. We realised that there actually was a bit of a loss of autonomy from patients when they were in the inpatient setting and that they lost some of that personal sense of responsibility over their own activity in that setting. So we started to zoom out and look at, you know, how's the health professionals and the environment around them actually influencing their behaviour. So it was less so behaviour at the individual level and we saw it was more those multi level influences from how health professionals were promoting or not promoting and sometimes restricting physical activity in the inpatient setting. And then also how the hospitals that we build are quite often well equipped to keep people in in bed and restrict their physical activity.

Caroline

They're much easier to control patients when they're in bed.

Craig 

Not only control, but find yes, nothing worse than turning up for your inpatient rounds. And the patient isn't there, not in their bed immediately, The clock starts ticking, where we gonna find them? Where have they gone to, how long will they be, what else can I do till they get back. And so in terms of efficiency of service delivery from the practitioner point of view, and the higher you go up through the chain, the more expensive their time becomes that it suits the hospitals to have people nailed down.

Caroline 

And this is one of the biggest problems that we, I think as recognising as a profession that the levels of behaviour change need to actually happen in a multifaceted way. We've got a reasonable complexity and a lot of us start with the journey into here thinking why aren't those clients doing what I want them to? Hmm.

Craig 

And Tahlia, is it also a safety issue in terms of people not being ready to move themselves and letting them because they need to do it? But still, we'll get a Porter for that. You could walk to radiology, but no, we'll get you a Porter.

Tahlia 

Absolutely. And a lot of that is well ingrained into policy as well. So it's not only that some health professionals don't feel comfortable assisting patients to be physically active in small ways, like walking to an appointment instead of getting a Porter to take them, but it's also that policies often restrict them. We've got policies in place that say that's how patients are to be transported or that patients are to stay in bed until they've had a physio review, for example. So it's very difficult for even when we know that a lot of health professionals and particularly physios value physical activity for their patients. We know that patients actually value physical activity in the inpatient setting but the structure and the policy around the inpatient setting tells us that no, people can't be physically active because they've gotta be safe. A risk averse approach to movements.

Caroline 

And it's the tension between the systems risk and the benefit to the patient of taking that risk. In terms of that's what we'd we'd often like the patient to take more risk but the system is saying no, no, no, we we'd prefer to minimise that risk.

Craig 

yes for financial exposure reasons as much as anything else. Yes.

Tahlia 

yeah. And also measures of productivity of the department and just in general, performance indicators of a department are often centred around falls. And so it looks good if we haven't had any falls and it's not actually measured if it's we haven't had any falls because no one gets out of bed. So they're very safe. But then what's the potential risk of these patients having such high sedentary time and extremely low physical activity?

Caroline 

Absolutely.

Craig 

Do they measure patients choking and so the ones they don't feed never choke. 

Tahlia 

It's interesting, isn't it? Cause that's exactly the approach.

Craig 

Exactly, yes.

Caroline 

Yeah. And Tahlia you in the research world that you're in, what would you say are the biggest challenges facing physios at the moment? 

Tahlia 

I think it is those organisational pressures is that when we talk to physios, physios do believe in my area of research promoting physical activity. They prioritise it on a personal level, but they don't feel that they're supported to be able to actually deliver that care in practise. 

Craig 

I beg to differ on the prioritising. This morning here in this conference centre we're in for the IGNITE conference. I observed the physios arriving at ground level and then going up to the mezzanine level to access the Great Hall. 10% took the stairs, at least 80 to 90% took the escalator. So I don't see them prioritising physical activity in their own lives at all, or even thinking about it was just follow the one in front, follow the one in front. Plenty of room on the steps.

Tahlia 

Yeah, and that's an excellent point because we, we do actually know that health professionals own physical activity influences how they deliver physical activity promotion in practise. So we don't always practise what we preach and I think we're also perhaps not aware of just how subject we are to our environment, whether that be the availability. I think that the escalator and the stairs are pretty well placed to choose either way here, but probably the social pressure that if the person in front of you looks the escalator, you'll probably tend to take the escalator as well.

Caroline 

There's also a lot of things that we don't know about people.

Craig 

Oh, there may be managing personal risks that I don't know about. I understand that, yes. So they could have had stents in place or new knees, who knows. But just as an observation. 

Caroline 

Yes And that's one of the things that I've observed over 15 years of standing in front of not only physios but all health professionals across multidisciplinary because health change methodology is a universal method of both training and implementation. And what I've observed is definitely clinicians absolutely come to this with good intent, knowing what they're wanting to try and achieve with their clients to get them to follow their advice and use the the research evidence. But the huge cry is been over the years, but it's so complex to actually integrate your engagement and skills to really get the person on board with your clinical skills.

And very much the message is also even when I know how to do that, there are so many other systems pressures that make it really difficult for me to do the work I want to do. So we've got two issues here of clinician skills to actually be able to effectively have conversations with clients and share information in a way that's likely to increase the uptake of advice. And so from your perspective, Craig, in the prevention area, we know that that group when they are not faced immediately with a problem, then it's much harder to engage them. But you at least now often have that opportunity. Do you want to comment on that?

Craig 

oh for hours? Yes. Yeah. This group I deal with older men there, there's a significant gap between stated intention and behaviour and not saying it's unique to that group, but that is the group I work with. And so getting them to, yes, you can give them the goal setting and and whatever. And and yeah, yeah, I got that, I got that. But they have this this system of filters. It's it's not something I've I've made up. It's it's come through the research that men when they're taking in health information from any source, whether it's from we as clinicians or whether it's from a public health campaign on whatever, they find new information disturbing to their male ego. It has to be reconciled with their systems of belief and understanding of how they function in society. So they filter information and the first filter it goes through is the filter of of severity.

Does this clinical possibility sound severe? Does the diagnosis, you know, look at the data whatever it is And so they look at rate, the severity. If it's severe, they'll keep saying, OK, yes, it's severe. Men die from this, is it severe to me, am I going to die from this? And they take on that personal reading of am I exposed personally Now once they're diagnosed with prostate cancer, yeah, that was an easy one. Yes, you've already got it. But for other things on you know arthritis and autoimmune diseases and some of the neurological conditions, they don't yet see it as being severe either because they don't know enough about it or they know too much about themselves. So if they get past the severity filter, it's not all done, done deal yet because they then look at the efficacy filter of is what the physio is telling me is what the clinicians are telling me doesn't make sense. Does it sound logical, does it sound like it will solve the problem and reduce my exposure to the severity that I've already accepted. So if that goes through and says yeah, tick that box. The last box, and this is where many fall over, is on self efficacy.

Am I prepared to exercise twice a day? Am I prepared to change what I eat? Am I prepared to give up bread, cheese and alcohol, which would solve most problems for men, But there you go. So that that last one, they just see they're nodding. Still, they're still agreeing without the clinicians recommending, but deep down in their sole they're saying this is never going to work for me. Exactly. Yeah. And they don't change their behaviours. 

Caroline 

No

Craig 

they withdraw from the system and we just say, Oh, well, they weren't ready or they didn't listen, but maybe we didn't pitch it right.

Caroline 

And you've absolutely beautifully encapsulated one of the tools that we use, which helps clinicians to actually follow that method of actually making sure that the client knows what the issue is and how big a problem it is and they know why it might be a problem for them is the first leg of the conversation. Because if you don't, as you say, each point they can fall over.

Craig 

They will stop listening.

Caroline 

And then they not only need to know what works over time briefly and as you're sharing that, they also might need to also know, well, why does that work, because that might not make sense, particularly in the realms of osteoarthritis or movement after initial surgery they go, but I've, I've got stitches, if I move I I'm gonna blow my stitches. So there's a lot of knowledge and belief barriers there. So they've got to know what to do briefly over time and also why doing it might benefit them. And that's on a macro level and that's exactly the first conversation that we need to have. But our normal training doesn't actually train us to have the conversation in that order which needs to happen to meet the patients decision making and knowledge needs before we waste 45 minutes finding out a whole lot of detail about them on areas that they're never going to change. 

Craig 

And do you know what this is mirrors sales.

Caroline 

Yes. 

Craig 

And marketing.

Caroline 

Well, that's right.

Craig 

If you go to buy a new car, don't just buy a new car. Listen to how it's sold to you and you'll become a better clinician.

Caroline 

They don't say, look, this car has a steering wheel and four wheels and takes you from home to work. They say if you buy a Jeep, you're going to have an adventurous life. How does this resonate with your research, Tahlia?

Tahlia 

Yeah, well, what I was just thinking about Craig that. I'm curious at what point that you see men in their journey and they've obviously at the point that you're seeing them, they must have had some intention or some. Drive to change at some point? Do you see that they do make any initial changes in that doesn't sustain that?

Craig 

That's a good question. Obviously as a clinician I see men once they're diagnosed or they have symptoms, you know, nobody comes in and says I'm coming to see the physio. I want to, I want you to look after me because I don't want to get crook. They come in with pain or they're coming with disability or they come in post op or whatever. So our contact point is I've sprained my ankle at football. My contact point is is is after something has happened.

So to some extent the filters started to open because they have something has gone awry. And I see that as a window of opportunity to keep their filters open as long as possible. And not only deal with their current problem for which they've sought my care, but how can we now ripple out from that and extend this to a health, to a holistic approach to if if there's something else I could do for you, would you like to know about it? Type approach? Yes.

Caroline 

And the timing of that conversation and the decision around when you broaden out and when you ask often very personal questions about how much alcohol do you drink, how much exercise you.

Craig 

And they lie. They always lie.

Caroline 

And that's a great design that for clinicians that if you get the feeling people aren't liking that question, you've possibly gone there too early and you need to stay with their problem that they're perceiving at the moment. And that doesn't mean that you have to do it all today because hopefully exactly. We know that physios are fantastic at developing, rapport and relationships, but everybody's understanding of how you do that is difficult and varied. And I think what we're struggling with now as a profession is we've now got all the elements that we need to put together. We know that clinicians need much broader skill set than perhaps we originally thought. Often the emphasis rightly is on clinical knowledge and that's critical, but we've got to actually really understand the weaving in of engagement and sharing information skills in a way that doesn't disengage people. And so that's a clinical unique skill set that's been actually well recognised now in the Adelphi studies and the research that we haven't possibly shifted to just yet. And then we need process, universal process skills that make it easiest for easier for us to work together and shift slowly some of those systems barriers.

Tahlia 

Yeah, I think that in the UK they’ve got this concept of every contact counts, in particular when they're talking about physical activity promotion. And I think that that makes sense, particularly given a lot of the time health professionals delivering any type of health promotion behaviour change support complain that it takes too much time. But we actually do know from the literature that it's more frequent smaller contacts like starting a conversation and then maybe picking that up in the next appointment. And it might be something, you know, as physios, it's not our job to necessarily treat alcoholism for example. But if we notice that that's an issue in a patient, it is an opportunity for us to start a conversation because it is a relevant health behaviour and then consider referral on and things like that. But those initial brief contacts over a period of time, rather than thinking we have to dedicate an entire 45 minutes to sit down with the client and talk through behaviour change with them.

Craig 

Well, you're you're exactly right. And in your acute setting there's not a lot of time for that. 

Tahlia 

No, still, there are opportunities,

Craig 

definitely opportunities. I get that. But again, getting back to the cohort I'm with, there's plenty of evidence that if the recipient of the information feels that the deliverer has more insight in terms of similar life experiences, the message sticks better.

Caroline 

Yep. And we also know, just even from the research, that if the physio believes ardently in the delivery of whatever therapeutic intervention they're delivering, it will have a better effect than than at any intervention. That is delivered with less confidence.

Craig 

It can outweigh the evidence base.

Caroline 

Well, we know that In fact it.

Craig 

Because it is an evidence based,

Caroline 

yeah. And we know that in fact the interventions we actually have actually as an impact on behaviour change. The highest predictor of behaviour change is the therapeutic alliance and that relationship. So as I said, one of the issues though that we have to grapple with in training and in systems is to help clinicians know how to do that more effectively on the ground. Which is why, yes, you can have fantastic training courses. But unless you actually start a systematic way of discussing the nitty gritty of those varied conversations, because they're all going to be different on the ground with the team, you're you're missing that snowball opportunity to really share the great skills that many of the clinicians and the team have and enable others. Teach it quickly to other people so that we're not waiting for everyone to go. Ohhh yeah, I wish I'd known that 10 years ago in my practise and to develop a iteratively. So where would you, if you had your magic wand of where you want to see things go? Tahlia, where would you say you'd like things to go or or the things that you can offer messages for clinicians?

Tahlia 

How long have you got?

All

(Laughing)

Tahlia 

I think the the message that I love to send to clinicians is that we don't need to change attitudes to change behaviour. And we've got a whole toolkit of behaviour change principles that we can use to support people, to change their behaviour without necessarily trying to make people believe that in love, you know, for example, physical activity. We don't need to make, you know, change their attitudes towards that necessarily. There's a lot that we can do to support them to increase their physical activity without changing those attitudes.

Craig 

That's interesting. I keep going back to this. I haven't walked, worked in acute hospital situation for a long time. But I wish having heard and read some of your work that I could go back and do it properly. Because yeah, it was very much a matter of you walk into the room, you tell them what to do, you walk out, you come back later in the day, you do the same thing again and you work on, you're working on a patient, never with a patient. And to give them some empowerment to say what would you like to achieve today, I'd like to get out of bed. Let's work on that. This is what we're going to do. And so just getting that conversation to they choose the the goal the at least sometimes even the pathway. 

You know far wiser clinicians than than us have said in the past that if you listen to your your client long enough, they will tell you what's wrong with them and if you keep listening they'll tell you how to fix it. So we could just shut up a little bit and listen more. We will find little gaps in their armour, their defences to make the right pitch at the right time. And I think that's what you were talking about, Carol, with that. That if you go too far, too quickly, you need to know that your trust was too early, step back a little bit and gain some deeper rapport, find out why they found that uncomfortable before you move there again.

Caroline 

Yep. No, I concur. And that's where the missing link, I think, is of us all really getting a better understanding of the order to have those conversations, to help us use our skills effectively and understand and recognise when people are. We have a, you know, a thing called the decision line when people are less ready or less motivated to really know what not to do, which is don't say, oh, would you like to set a goal? Because the answer will be no. You know, it's that skill set. And that's really the area that I work in. Well, thanks for coming today. It's been a great discussion and lovely to hear your perspectives.

Craig and Tahlia 

Thank you.