While multiple behaviour change interventions are recognised for their potential to modify multiple behaviours and hence dramatically lower an individual’s risk of chronic disease, attempts are still being made to identify how various intervention components can be ordered to encourage behaviour change effectively. One criticism of previous multi-component studies has been that participants were not offered the opportunity to choose an approach to multiple behaviour change but in this study participants were able to attempt behaviour change in a manner they perceived as being feasible in the context of their own lives [44
Our findings showed that whilst sequential behaviour change was the preferred approach among a quarter of interviewed participants (most of whom were controls), almost half of interviewed participants opted to simultaneously change their smoking, diet and physical activity patterns. Furthermore, participants who attempted behaviour change concurrently were more successful at quitting smoking and more successful at both behaviour changes as compared to those who attempted changes sequentially. This is supported by Hyman et al. who found that simultaneous attempts at behaviour change were more effective than sequential attempts. As in our study Hyman et al. noted that following sequential interventions, for most participants, success was likely to be restricted to a single behaviour change [26
]. It should also be noted that a simultaneous multi-behaviour change study by Johnson et al. revealed that weight loss was achieved only after 24
months and was the outcome of changes to several behaviours [16
]. This indicates that while concurrent approaches may initially appear to produce changes in a single behaviour, small changes in other behaviours may cumulatively produce beneficial outcomes over a longer period. Thus, participants in this study who were attempting to limit weight gain to ≤3% while quitting smoking may require a longer period to achieve weight stability as compared to individuals solely attempting to limit weight gain [39
In contrast to our findings, Spring et al. identified sequential approaches to multiple behaviour changes as being superior to concurrent approaches [35
]. This may have been because unlike other studies, intervention participants were offered intensive support including pre-packaged meals for 16
weeks which may have contributed to these results. However, it is worth noting that of those who opted for a sequential approach in our study more than half were successful at smoking cessation. This indicates that participants’ readiness to attempt behaviour change either sequentially or simultaneously may be a crucial factor in the behaviour change process.
Multiple behaviour change interventions modelled on TTM assess participants’ readiness to change and accordingly provide stage-matched advice which has been found to aid significant behaviour change. Our findings point to the need for also assessing participants’ readiness to attempt multiple behaviour changes either sequentially or simultaneously. Such an approach would take into consideration the contextual variations between individuals and allow them to engage in multiple behaviour change in an order that they perceive as making multiple behaviour change attainable. It is theoretically plausible that interventions which are tailored to individuals’ ‘readiness to change’ and ‘preferred approach to behaviour change’ may be more effective in aiding transition to action/maintenance stage across multiple behaviours [37
]. Furthermore such interventions may be particularly effective in engaging hard-to-reach groups who may otherwise find multiple behaviour change untenable within the context of their lives [45
Our findings also revealed that some mechanisms influenced multiple behaviour change regardless of whether participants adopted simultaneous or sequential approaches. For example some participants described their concern on realising that they were replacing cigarettes with food. However, for most participants this compensatory behaviour did not adversely affect their quit attempt. It is likely that for these participants, their desire to quit smoking and to avoid excessive weight gain despite food cravings may have been sufficient incentive to motivate them to make other positive changes to their diet and physical activity even though most did not limit weight gain to ≤3%. This is consistent with Nigg et al’s suggestion that certain individuals view multiple behaviour change through a hierarchical lens which determines the order and the extent to which they change behaviour at a given time and in response to specific incentives [37
Other mechanisms that were identified as encouraging multiple behaviour change were psychological and physiological mechanisms. Psychological mechanisms such as improved confidence and increased self-efficacy following one behaviour change and physiological mechanisms such as improved taste sensation, ease of breathing and feeling ‘healthier’ were described as motivating participants to make further changes. These findings are consistent with those of other studies which indicate that one positive behaviour change can trigger physiological and psychological mechanisms that in turn encourage other behaviour changes [46
The interplay of these mechanisms on multiple behaviours was evident in participants’ descriptions of how perceived success or failure in one behaviour change triggered vicious or virtuous circles of behaviour change. This highlights the need for identifying promising mechanisms that may trigger virtuous circles of behaviour change as well as the importance of understanding how vicious circles of behaviour change are triggered so as to design interventions that can effectively mediate these and thereby encourage multiple behaviour change [46
This study offers a unique insight into the perceptions of participants’ attempting changes to their diet and physical activity alongside smoking cessation; to our knowledge no other study has explicitly explored this outwith the context of cardiac rehabilitation. It is worth mentioning that participants in this study were not informed that successful weight management was defined as limiting weight gain to ≤3%. As a result their goals and views of successful weight management may have been influenced by their body image, social norms, perceptions and experiences of weight gain and dieting during prior quit attempts. However, by not placing a target weight range, participants may have felt less pressured and more able to make changes to their diet and physical activity and maintain smoking abstinence despite post-cessation weight gain.
A limitation of this study was that the data revealed the perceptions and experiences of smokers in Glasgow who were attempting multiple behaviour change but it could not include the perceptions of those who dropped out of the study. It is important to explore the perceptions of this sub-group of the population in future studies as they are harder to engage in preventive services and may perceive multiple behaviour change differently. A second limitation is that, whilst the intervention took place in areas of multiple deprivation, data on the socio-economic status of participants were not collected and so we cannot determine the impacts of individual levels of poverty on participation in the study, outcomes achieved or perceptions of change. This is important because of the structural determinants of lifestyle behaviours, health outcomes and health inequalites.