Transcript In Theory…It Makes Sense.

In Theory…It Makes Sense.
A Sample Overview of Behavior
Change Theories and Their
Practical Application
Beverly Barber, RN
Terry Stewart
Denver Public Health
www.denverhealth.org/dph
www.DenverPTC.org
People change (or don’t change) a behavior
for a variety of reasons!!
But how do we explain it?
Behavioral Science
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Seeks to understand how and why people do
what they do
Psychology
 Sociology
 Anthropology
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Behavioral Theory
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Can be used to help understand the behavioral
determinants of risk
Provides the basis for activities within a
behavioral intervention
Guides the evaluation of an intervention
The constructs of theory suggest what to
monitor and how to measure effectiveness
Behavior Change Theories & Models
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Health Belief Model
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Social Cognitive (Learning) Theory
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Albert Bandura
Theory of Reasoned Action
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Irwin M. Rosenstock
Martin Fishbein and Icek Ajzen
Transtheoretical Model/Stages of Change
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James O. Prochaska and Carlo C. DiClemente
Health Belief Model (HBM)
Premise: Health related behaviors depend on
four key beliefs; all of which must be operating
for a risk reducing / health promoting
behavior to occur.
 Key Components
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Threat / Risk
Perceived susceptibility
 Perceived severity
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Outcome Expectations
Perceived benefits of performing a behavior
 Perceived barriers of performing a behavior
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HBM – Threat
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Susceptibility
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The recognition that personal behavior places one at
risk for an infection/disease
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“I don’t use condoms, so I’m at risk for HIV or STIs.”
Severity
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The belief the infection/disease/condition will cause
serious harm
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“My father had a heart attack and he had to have triple bypass surgery.”
HBM – Outcome Expectations
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Decisional Balance
The belief that the benefits of performing the
behavior(s) need to outweigh the consequences of not
performing it before behavior change will occur.
“If I work out I will feel better.”
 “If I work out I won’t have time to watch American
Idol.”
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Social Cognitive (Learning)
Theory
Premise: Behavior is learned through direct experience or by
modeling others’ behaviors through observation.
Acquisition of a new skill is often required. The chances of
behavior being repeated depends on the person’s assessment
of its cost / benefits

Key Components
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Self-efficacy
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Can be increased through practice
Skill Acquisition
 Outcome expectations
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Positive or negative consequences
Reinforcement
Bend & Snap
Theory of Reasoned Action
Premise: In order for behavior change to occur,
one must have an intention to change.
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Intentions are influenced by two major
factors:
Attitudes: based on an individual’s beliefs about
the positive and negative consequences of
performing the behavior
 Subjective norms

What significant others think or feel about behavior
 Motivation to change behavior based on subjective
norms
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Subjective Norms
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“None of my friends smoke, so I feel like I
should quit.”
or
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“Seems like all my friends smoke, so I think
I’ll try it.”
Behavioral Determinants
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Perception of Personal Risk
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Susceptibility
Severity
Knowledge
Attitudes & Beliefs
Intentions
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Self-Efficacy
Skills
Perceived Norms
Social Norms
Social Support
Transtheoretical Model
aka, Stages of Change
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Precontemplative
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Contemplative
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Short-term planning for change and initial attempts at the new behavior
Action
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Thinking about change
Preparation / Ready for Action
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No recognition of need to change
Consistently do the new behavior for less than 6 months
Maintenance
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Performing the new behavior for more than 6 months
Denver Health
Cardiovascular Disease
Prevention
A partnership between
Denver Public Health and Denver
Community Health Services
2006-2009
Background
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CVD is the leading cause of mortality in Colorado,
particularly in the Latino population
INTERHEART study (2004) demonstrated that
90% of population attributable risk is due to
modifiable risk factors:
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Smoking, dyslipidemia, HTN, DM, obesity, diet, exercise,
psychosocial factors
In the general population, many have at least one
risk factor; >90% of CVD events occur in persons
with at least one risk factor
Intervention
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Potential activities available for participants
 Self-help tools, healthy nutrition and exercise activities,
community-based exercise programs, and referrals to the
Colorado QuitLine
 Navigator will facilitate client’s transition to communitybased programs
Navigator will follow-up with a client at 1-4 weeks and 6-10
weeks after enrollment to assist/encourage client in
participating in selected programs
Additional follow-up will be performed as needed
Physical Activity
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The Challenge
Despite the benefits of engaging in regular
physical activity such as: reduction of
cardiovascular disease and prevention of bone
loss associated with aging, more than 60% of
the adult population and more than half of the
young people (aged 2-21) do not exercise
regularly.15
Exercise: Benefits
Cardiovascular Risk Factors
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Increase in exercise tolerance - CVD risk factor
improved muscle function and aerobic capacity
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Reduction in body weight - CVD risk factor
Reduction in blood pressure - CVD risk factor
Reduction in bad (LDL) cholesterol - CVD risk factor
Increase in good (HDL) cholesterol - improves CVD risk
factor
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Increase in insulin sensitivity - CVD risk factor
Recreation Centers
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Clients eligible to receive 3-month passes to Denver Park and
Recreation centers
Participating centers: Barnum, Azatlan, and Rude
Able to participate in all activities offered at the centers
Exercise classes appropriate for beginners:
 Water aerobics, walking clubs, stretch and tone, yoga, Tai Chi,
introduction to weights, etc
 Access to VOA/Arthritis Foundation Gentle Exercises with
the Healthy Aging Program
Nutrition Programs
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A series of 6 interactive classes
 Nutrition
 Food shopping
 Food safety
 Physical activity
 Disease prevention
 Cooking demonstration
Classes offered at the local recreation centers
Adult Cessation
Promote Colorado Quitline & QuitNet
The 5 A’s
Address Agenda
Attend to the patient’s agenda
• Explain that you would like to talk about some healthy
choices for them to consider
The 5 A’s
Ask
• What does the patient know about the connection between his or
her
behavior and the possibility for disease?
• How does the patient feel about the behavior?
• Is the patient interested in changing the behavior?
• What are the patient’s fears about change?
• Has the patient tried to change the behavior before? What did and
didn’t
work?
• It is important to spend adequate time in this stage. Patient
counseling is more effective when patients know that the
physician/provider understands their perspective.
The 5 A’s
If you have limited time, spend most of it on assessment
and then incorporate what you learn into a few words
of advice.
Advise
• Tell the patient that you strongly advise behavior
change
• Personalize reasons for change (e.g., “By quitting
smoking you will help your
daughter have fewer asthma attacks.”)
• Discuss the immediate and long-term benefits of
change
The 5 A’s
Assist
• Provide accurate, complete information about risk and
give the patient written materials to take home
• Address the patient’s feelings and provide support
• Address barriers to change
• Discuss steps toward behavior change
• Get attending physicians, residents or preceptors
involved for additional
support, more extensive advice and referrals
The 5 A’s
Arrange Follow-up
• Reaffirm the plan
• Schedule follow-up appointment or phone call
Counseling tips
Suggestions for Counseling:
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Precontemplation to Contemplation: Demonstrate
unconditional acceptance of the person. Give information with
low pressure.
Contemplation to Preparation: Address the discomforts
associated with change. Suggest small changes in thinking to get
big changes in action.
Preparation to Action: Set a date for action and maintain
realistic expectations. Suggest action-oriented programs.
Expect 3 or 4 cycles of success and failure.
Action to Maintenance: Suggest strategies to prevent relapses.
Anchor benefits to long term repetition of behavior.
Planning for nutrition changes
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Making a Plan
What goal's can you set for yourself now?
Before my next visit, I am going to:
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Eat fried foods less often
Aim to eat 5 or more fruits and vegetables per day
Eat smaller portions and less fatty foods
Instead of regular soda and sweet teas, drink water, 100%
juice mixed with sparkling water, or skim milk
Make time for regular meals
Exercise regularly (try for 5 times a week)
Keep healthy snacks around
Make an appointment with a dietitian
Planning for Activity
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Making a Plan
What goals) can you set for yourself now?
Before my next visit, I am going to:
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Walk a little bit every day (with friends, kids, dog)
Exercise regularly (try for 5 times a week)
Join a local sports team, gym, or exercise class
Walk, bike, or take the bus instead of driving
Take the stairs and park farther away
Make an appointment with a personal trainer
Watch less TV
Other:____________________________________________
Client Centered Approach
References
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12. Kottke TE, Battista RN, DeFriese GH, et al. Attributes of
successful smoking cessation interventions in clinical practice: a
meta-analysis of 42 controlled trials. JAMA 1988;259: 2882-9.
15. U.S. Department of Health and Human Services. Physical
Activity and Health: A Report of the Surgeon General. Atlanta, GA:
Centers for Disease Control and Prevention, National Center for
Chronic Disease Prevention and Health Promotion, 1996.
Thank You!

Beverly Barber, RN
Denver Public Health
Cardiovascular Disease Prevention
[email protected]
303-436-7246

Terry Stewart
Denver Public Health
Denver STD/HIV Prevention Training Center
[email protected]
303-436-7267