Chapter 7 Theories of Behavior Change

Tips to avoid arguments and reducing client resistance

-Listen (what I hear is that your stressed and increasing exercise is not a priority right now), -make it hypothetical (suppose you made a change and are looking back on it now, how did it happen?), -acknowledge the resistance, don't steamroll, let clients clarify desires (sounds like you have doubts that this program will work for you) -emphasize personal choice and control (sounds like this is hard for you, what are your ideas on solving this or I was planning this but it sounds like you want to do this, what would be most helpful to focus on today) -emphasize success Always assist clients in seeing the positive, help increase their confidence and understand that they can succeed (inner motivation, you motivation is a 5 today, why not a 1 or a 2?) -Acknowledge ambivalence, validate feelings and show understanding (on one hand, you really value convenience and taste of fast food, but on the other your afraid if you don't stop it'll kill you") -Match the participants readiness, mismatching only fuels resistance. (action oriented solutions wont work with someone who is still contemplating change)

How many Americans are overweight or obese?

68%

Theory of Planned Behavior: implementation intention

Added component to the theory to account for the volitional component of behavior change, thought to increase the likelihood that intentions are acted upon. Skills include: -problem solving -goal setting -coping with challenges -recording progress Studies show this combination with the theory significantly increases behavior change way more than the theory used alone. Also shows that self-monitoring is important for implementing intention. Feedback could be used to set future goals and influenced implantation of intention. Social Cognitive Theory may also bridge the intention-behavior gap.

TTM's 10 processes of change

Cognitive strategies (precontemplation, contemplation, and preparation): Increasing knowledge, being aware of risks, caring about consequences for others, comprehending benefits, indentifying emotions related to behaviors. Behavioral strategies (preparation, action, and maintenance): substituting alternatives, enlisting social support, rewarding yourself, committing yourself, and reminding yourself.

SMALL goals reminder

S-self-selected- goals are your own, chosen to fit, your life and only changing behaviors willing to negotiate. M- measurable, concrete way to track goals. when will you now your goals are reached. A-action-oriented, the how, with realistic steps to achieving goal L- linked to your life, best achieved if they work within your life style and match your challenges and strengths, goals designed to fit your life. L- long-term, healthy for life, changes should be something you want to do for the rest of your life, create life-style goals that you feel confident you can maintain. Include detailed plans, more likely to be implemented, specificity results in target behaviors. use time frame. use clinical judgement and past experience to assist clients in setting realist goals.

Goal Setting Theory

Theory commonly accompanies many other theories, suggests 4 main goal-related mechanisms for behavior change: - Goals direct attention and energy toward desired behaviors -Goals lead to greater effort -Goals extend the time and energy devoted to a desired behavior -Goals increase the use of goal-relevant skills Success is moderated or affected by level of commitment to the change, importance of goal, self-efficacy, feedback on goal progress, and the attainment of the appropriate skill level to achieve the goal. The type of goal also affects success. Self-selected goals are more likely to be successful than those who have goals determined from outside source, intrinsic motivation may be lower if client doesn't have a say. Clients will be successful if they collaborate with you and work within their lifestyle when setting goals. Also specific goals are much more effective. Ambiguity leaves nothing to strive for and they don't perform as well. Encourage a way to track and measure specific behavior, along with specific feedback to guide the client's behavior. The more recorded and tracked the easier it is to pin point the barriers to behavior change more accurately.

Socioecological model

Theory or behavior change that takes into consideration the large social network and infrastructure of the client, because behaviors are shaped by interpersonal interactions, the surrounding environment, community, policy, and law. All these factors will impact behavior change and cause potential barriers. Creating an eco-map for your client may highlight some barriers and some supports. highlight positive and negative connections to their environment, may build rapport, increase awareness, plan for challenges, embrace support, promote self-reflection, and identify areas of improvement. Tool for clients to share their story, help them make changes that fit their life context. Let the client do the writing and designing give them feeling of control, but CPT may create a map key. Relationships are a two way street and need to remember what is helpful for one person may not be helpful for another. Structure supports are also important, is there a local gym nearby. Also ask, how can we change the map to help you receive the support you need to make your changes successful.

Limitations of HBM

While benefits and barrier to behavior change were predictors of intervention success, they were overall week predictors, but that study was not looking at specifically physical activity intervention.

Why is theory important?

a frame-work that describes how and why behavior changes for a given population in a particular setting. Easy to discern what components contribute to the change because it provides a foundation of understanding how individual factors within an intervention influence the behavior. Allow for replication, sustainability, and generalizability. May be so successful that others want to utilize it. May serve as a guide in it's application. More effective inteventions than those that are not theory based. High-fidelity do 2x better than low-fidelity, greater satisfaction, achieved goals more often, and more positive expectations. Using and implementing plans that are theory based have more effective results than pure education. They also define what is known and what is yet to be learned in a field of study.

The Health Belief Model

a widely used theoretical approach developed in the 1950s, used to increase health screening behaviors and it suggests that the main predictor of behavior change are -(a) there perceived seriousness of a potential health problem (ex hypokinetic disease) related to the behavior (ex. physical activity) -(b) one's susceptibility to potential health consequences -(c) the belief that making the suggested behavior changes will result in decreased risk of consequences Clients must believe any perceived barriers are outweigh by benefits and must have the confidence in their ability to perform an action. The cost should be relevant and work the risk reduction offers. Studies show that understanding health risks and the benefits of exercise leads to move physical activity and vis versa. This theory has also been shown to be effective in intervention studies. Clients should be allowed to explore their own beliefs about the implications of their weight status, life style and risk of disease while being offered education about them and being informed of how physical activity can reduce risk of injury and disease. Also external cues to remind client of the risks and benefits, helping clients cop with negative feelings and teaching cognitive behavioral techniques may help change their perspective on physical activity. Easier for clients with identifiable health risks with high intentions and motivations to change.

systematic testing o ftheory

allows for identification of new behavior-change constructs and replacement of element of an intervention that are not as effective. theories are made to evolve and constantly improved.

Changing behavior

challenging because so many factors play an important role: readiness for change, motivation, ability, perceived self-efficacy, and even situational factors such as scheduling or peer influence. And other behaviors have been maintained over a life-time, meaning they have reinforced and maintained by one's environment.

TTM maintenance stage

client has been actively maintaining the changes made during the action stage, the new behaviors have been established for 6 months or more and the client is now working to prevent relapse. -continue behaviors -create plans to avoid relapse -continue to help reinforce and problem solve

TTM preparation stage

client has developed a plan of action towards behavior change nd will be making changes in the immediate future. -decided that it is work making the change -preparing to make change -may need help planning

TTM Action stage

client is actively making behavior changes (regularly active for less than 6 months) -actively creating change -may need assistance problem-solving -reinforce positive behavior

TTM contemplation stage

client is considering the negative consequences of their behavior and is considering changes within the next 6 months. -awareness of needs to change -open to discussion about change -still undecided -motivation and encouragement may be needed

TTM Precontemplation stage

client is not intending to take action toward change and is not considering benefits of change at this time -unaware of needs to change -resistant to change -raising awareness and education

TTM decision balance tool

clients weight pros and cons of behavior change and work through any ambiguity. Designed to reinforce the reasons why change is important while recognizing, appreciating and ultimately working through challenges. Important to give adequate time and respect to the challenges or cons of behavior change, after all increasing physical activity is difficult. This recognition by CPT rather than downplaying or ignoring these challenges wont help the client move through the core of their unhealthy behavior. It's important to come to their own conclusions about behavior change and take ownership of their goals, rather than being forced into them by a trainer.

Theory of Planned Behavior

developed from the Theory of Reasoned Action, has been used extensively in advertising, public relations campaigns, and more recently in health behavior change efforts. Intervention to engage will ultimately result in that behavior and a clients level of intent is shaped by their: - attitudes ( how helpul or enjoyable the behavior is perceived to be). -subjective norms (social pressure) -perceived control (self-efficacy and controllability) ex) Jamie likes physical activity (attitude), friends still play softball (subjective social pressure), and she think activity will help with her BP (perceived control) Client will require encouragement to remember past success and record current success to increase self-efficacy, have fun alternative activities catering towards their attitude, and great group based intervention to increase positive social pressures. This theory has been very successful with modifying behaviors such as smoking, alcohol abuse, and eating habits.

The transtheoretical model (TTM) with motivational interviewing

first a smoking cessation model developed from Social Cognitive Theory and Social Learning Theory. Pertains to clients readiness to change which predicts ability to change (precontemplation, contemplation, preparation, action, maintenance). Once a stage is identified then CPT can help move client to more advanced stages of change. there are 10 processes of change (cognitive or behavioral). Cognitive being the precontemplation, contemplation, and preparation include increasing awareness about the problem of sedentary behabior and assessing how activity affects a person's life. Behavioral component includes action and maintenance stages, includes removing sedentary cues from behavior (stimulus control), and finding support for active behaviors (helping relationship) and reinforcing positive behavior (reinforcement management). As a client moves through the stages of change they develop different perspective on behavior, they build change-related skills and experiences and their self-efficacy increases. Leads to increased confidence, belief in change, and more engagement in successful behaviors. Uses a decision balance tool. Accepting that increasing physical activity and challenges are hard for a client. It's important for clients to come to their own conclusions about behavior change and take ownership of their goals. Unsolicieted advice from a CPT can make clients defensive and increase resistance, and they may argue why they should not change. Help incrase clients commitment to change by utilizing consciousness raising, dramatic relief, and self re-evaluation. Volitional strategies can help develop a clients concrete plan and problem solving skills to make their goals attainable.

RApport

fundamental component of successful interventions. Refers to a sense of trust, respect, or confidence, which a client holds for their trainer. Its the first step to adherence, and often the first task of a trainer, preceding other interventions. Initial respect may be due to tital but other respect and confidence are earned based on skill and prescribed intervention. Best ideas on how to build it: -be sure to display/communicate credentials -confirm your professionalism by dressing and acting -highlight things that you have in common: likes, dislikes, experiences (show who you two relate) -affirm cleints strengths that they have noted -empathize with their struggles/feelings -self-disclosure: share relevant struggles from past, take sincere interest in client -nonverbal cues: good eye contact, open posture, appropriate facial expressions -remaint nonjudgemental and open-minded -be a good listener -offer explanations for the components of intervention.

Goal setting

important component of successful physical activity intervention and behavior setting. A tool to promote increased and maintained activity. Can be used for short term to initiate change and long term to plan ahead for obstacles and realistic outcomes. Studies show it improves performance (2): -increases effort, persistence, attention, and motivation -facilitates progress towards longer term More effective if they are client selected, they take more ownership, feel mor committed, more accepted and embraced thus more likely to change behavior. You can teach them components of effective goals and help mold the goals to be more effective. Use SMART goals (specific, measurable, achievable, realistic, and time-oriented.

self-monitoring drawbacks

it's often subjective, self-reporting is a clients "best guess". the client may not intentionally misrepresent their behavior but there are many reasons for misreports, intentional or not. inaccurate recall, overestimate of amount of time or distance, emotional response due to being overweight, desire to impress or please trainer. A pedometer can be a non-subjective solution. It can also be perceived as a burden or just forgotten. Client wont benefit unless they use it. Studies show compliance was associated with achieving physical activity guidelines.

self-monitoring with a pedometer

less subjective form or behavior reporting, however clients need to wear them regularly.

Rival theories

may provide evidence for alternatives approaches that may lead to more significant behavior change.

Social Cognitive Theory

most commonly used theory in behavior change, and based on the HBM (Health Behavior Model), however it does not emphasize perceived susceptibility, and adds several important components. It most important factors are (2): -outcome expectations (what you think will happen as a result of new behavior) -self-efficacy (situation specific self confidence) further divided: -environment (both physical and social) -one's skills and abilities -opportunities to watch ans learn -self-control -reinforcement and incentives -coping skills -past experiences that may shape expectations. Places greater emphasis on clients thoughts and feelings, believing that clients actively shape their lives by thinking, feeling, reflecting, and observing themselves. Ex. continuous self doubt will lead to thoughts of failure and negative attitude towards self and exercise. Unrealistic thought are also not helpful. And CPT are there to help clients identify these thoughts and feelings and steer them towards success and self-confidence, and replacing thoughts with realistic ideals to improve clients self-efficacy and outcome expectation. Also surrounding clients with cues, social support, and education can enrich their environment and also promote further behavior change. Self-maintenance techniques (self-monitoring and planning, highlighting success) goes along with coping and problem-solving while increasing self-efficacy. Studies showed improvement in physical activity, and related self-efficacy and self-regulation. Social support, self-efficacy, outcome expectations, and self-regulation led to better success.

Small Changes Model

new model, using several elements from other theories, has been successful in nutrition-based and physical activity-based interventions. Clients goals are relative to baseline activity in order to help make them realistic and attainable changes. ex. client who exercises once a month, switching to exercising everyday may be too much, therefore client would be introduced slowly toa level that is realistic and maintainable as a lifestyle change. It allows small behavioral changes, based ont he idea that the small the change the more easily and willing the client is to continue behaviors and build upon them over time. Studies showed that gradual weight loss resulted in a continuation to occur up to 9 months after treatment, where as, more traditional programs often regained weight within that time frame. Goals are also client selected, taking ownership, increasing self-efficacy. Asked to self-monitor their behavior towards goal-setting, problem-solving, feedback, and self-reward. Emphasizes thoughts about behavior, helps them with feelings and behaviors related to their goals. Baseline is of current unchanged behavior. Client helps come up with ways to work in physical activity and nutrient intake that works for them and reflects their selected goals, the CPT guides them. Some individuals may need more guidance and strategizing to create and reach their goals, making sure they are realistic and the client can reach success. Plans always need to be unique to the client and require tailoring and interventions to fit needs.

Limitations of SCM

not much is known on longer-term potential behavior change regarding weight management. Little is known about high-risk medical conditions or individuals with less developed abilities (ex. young children). Even the vest interventions can be thwarted or supported by environmental factors.

Limitations of Planned Behavior Theory

not sure if it increases physical activity on it's own, however, it does increase an individuals intentions, it does not translate into actual behavior change. Maybe due to its focus on purposeful, structured activity and not on dialy lifestyle activity increases. Studies show that intention may not be in line with actual behaviors (intention-behavior gap), maybe due to the behavior change being both motivational and volitional.

Customizing to a population

physical activity interventions are tailored towards various populations: children, elderly, physical limited (arthritis, cultural reasons). Its still very important to remember that each client has unique needs based on any combination of factors: age, physical ability, gender, culture, or other individual factors.

self-efficacy

refers to a client's belief in their ability to succeed and is important component of behavioral change success, promotes further progression and change. Increasing levels result in greater confidence, and believe in change, and more likely to engage in successful behavior.

Mixed results of using TTM

some research may not utilize the complete theoretical model of change. Many only use part of the theory or only site the state of change. using only part of it can create short-term success. And long-term don't always yield consistencies. Therefore it is suggested to use all available theories in combination to create a more powerful behavior change plan

behavioral change

the key to longer term success of clients. Interventions vary by modality (in person, on the phone, internet), setting (workplace, physician, church), format (individual, group), and regimen (recommended dietary restriction, and energy expenditure). Short term are generally successful, resulting in a loss of 10% initial bw. Long-term will gain 2/3rds of the weight back within the first year following completion and almost all of the weight within 5 years, fining that individuals are unable to maintain changes after intervention.

Theoretical fidelity

the level of precision in replicating theory-based recommendations.

self-monitoring

the practice of tracking one's own behavior for the dual purpose of increasing awareness and monitoring progress. monitoring can include writing down exercises, getting on a scale weekly, recording food intake, or wearing an accelerometer. Its the most influential predictor of successful behavior change for physical activity. This along with intervention and one other technique (intention formation, goal setting, feedback, review of goals) were more effective than those that did not. Its an important tool in increasing physical activity because its use increases client awareness of behavior, offers accountability, and given trainer information of client's behaviors outside of meetings, allows for goal setting and progress tracking, opportunity for feedback, skill that a client can use on their own. However, clients need much guidance. More does not always mean better, discussions should be about food, behavior, and patters that are helpful, also discuss barriers that will effect the monitoring and brainstorm ways to overcome them using problem-solving strategies.

Building theory into intervention

there is no guaranteed prescription that would help a client achieve and maintain physically active behavior, using theory based intervention has been showed to be more successful. What works for one client may not work for others, everyone is unique. Its important to keep a flexible and open-mind and be willing to tail interventions to clients needs. Different ways to set goals, work on strategies, giving feedback, and build rapport with each client.

Feedback

two-way communication between tow or more parties. Keep in mind that CPT do not impose their views without taking into consideration the clients vies. goal setting allows for this in the same way self-monitoring allows for goal setting. Goals also help keep track of what, when and how of exercise making it much easier to provide information regarding progress in a physical record and proximity to achieving set goals. Needs to be true for effective intervention. Both telephone and printed form increase likelihood of continued physical activity. Also used as a follow-up to keep clients on track in the long run. Varies by individual based on goals, progress, and other factors, thus need for tailoring, this increases motivation with increased long-term adherence to behavioral change. Intervention needs to meet client at their level.