a qualitative study of citizens' experience of participating in health counseling

Health and Disability

A qualitative study of citizens’ experience of participating

in health counseling

LOTTE NYGAARD ANDERSEN,1 STINNE SONNE ANDERSEN,1 BRITT MUURHOLM2 and KIRSTEN KAYA ROESSLER3

1University of Southern Denmark, Institute of Sport Science and Clinical Biomechanics, Odense M, Denmark2The Health Care Center, Sønderborg, Denmark3University of Southern Denmark, Institute of Psychology, Odense M, Denmark

Andersen, L. N., Andersen, S. S., Muurholm, B. & Roessler, K. K. (2014). A qualitative study of citizens’ experience of participating in healthcounseling. Scandinavian Journal of Psychology.

Individual health counseling is a form of intervention designed to minimize the effects of chronic health disease and to offer a path towards good healthpractices. The aim of the present study was to explore the experiences of those persons who participated in health counseling in order to assess the psy-chosocial significance of the counseling upon their health behavior. In addition the study was concerned with the factors which underlay peoples’ deci-sion to sign up for health counseling. The research involved 11 semi-structured interviews with individuals who had participated in a municipalitybased health counseling program. Data was analyzed using Malterud’s systemic text condensation and a theoretical framework around Bandura’s socialcognitive theory. Analysis revealed that an approach tailored to each individual with minor short-term goals accompanied by feeling supported by thecounselor produced the greatest impact on behavior. Receiving feedback from the counselor and feeling positive about the relationship were seen asessential. These aspects were also crucial in the decision to undertake health counseling. The study indicates that whether individual’s sign up on theirown initiative or conversely are invited to join the program has no influence upon their motivation to change their behavior. Overall the respondentsdemonstrated improvement in their behavior and attitudes towards their health. However, the study also indicates that this form of intervention is less oreven ineffective without the support of the individual’s immediate family.

Key words: Counseling, qualitative research, behavior change, health promotion, social cognitive theory.

Lotte Nygaard Andersen, University of Southern Denmark, Institute of Sport Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M,Denmark. Tel: +45 23 61 25 53; e-mail: [email protected]

INTRODUCTION

According to the World Health Organization, 36 million peopledied from chronic diseases such as cardiovascular diseases, can-cer, diabetes and chronic lung diseases in 2008 (Alwan, 2011).Unhealthy diet and physical inactivity are among the leadingcauses for chronic diseases (Waxman, 2004). In Denmark alone,the consequence of physical inactivity adds an additional annualcost of 2,883 billion DKK to the health care system (Juel,Sørensen & Brønnum-Hansen, 2006). Besides socioeconomicconsequences, chronic diseases affect the person and are associ-ated with reduced quality of life (Jia, Zack & Thompson, 2013;Rubin & Peyrot, 1999). Due to the extent of the problem, thereis much research in this area and several studies support theimpact of physical activity and dietary interventions in relationto minimizing chronic diseases and preventing the occurrenceof these (He, Nowson & MacGregor, 2006; Kesaniemi,Riddoch, Reeder, Blair & Sorensen, 2010; Ma, Zhou, Zhou &Huang, 2014; Waxman, 2004). In Denmark, the Health Lawstates that municipalities have the primary responsibility for cre-ating healthy environments and preventive services for their cit-izens (Hanak, Falk, Størup & Bruun, 2007). Individual healthcounseling is one of the ways in which the municipalities meettheir legal requirements. Motivational interviewing is a com-monly used technique in health counseling (Miller & Rollnick,2012; Noordman, de Vet, van der Weijden & van Dulmen,2013). The effect of motivational interviewing is found to begood and is supported by a meta-analysis, which concluded

on a significant and clinically relevant decrease in both bodymass index and systolic blood pressure for people who re-ceived motivational interviewing (Rubak, Sandbæk, Lauritzen &Christensen, 2005).A cross-sectional survey based on 7,947 Europeans, concluded

that 43% think that they have to improve their eating habits and48% think that they need to do more physical activity (Brotons,Drenthen, Durrer & Moral, 2012). Although the motivation tochange health behavior exists, changing lifestyle habits is often adifficult process involving both behavioral and cognitive change,and it is well known that it is difficult for people to maintainnew health habits (Hill, 2009; Roessler, 2011; Tuah, Amiel,Qureshi, Car, Kaur & Majeed, 2011). The Danish Health andMedicines Authority has produced material on the Small Stepsconcept, which is used in the municipalities. Small Steps recom-mend people to make small changes in their current behaviorthat can subsequently lead to a sustainable lifestyle change(Mikkelsen, Hejgaard & Dansgaard, 2012).Few studies have examined how people experience health

counseling (Chan, Fam & Ng, 2009; Dellasega, Anel-Tiangco &Gabbay, 2012; Hardcastle & Hagger, 2011; O’Sullivan, Fortier,Faubert et al., 2010; Walseth, Abildsnes & Schei, 2011), butnone of these focus on health counseling for the general popula-tion wanting to change health behavior. In order to investigatewhy people sign up for health counseling, and in order to gain adeeper understanding of which aspects of health counseling areof greatest importance to the health behavior of the person, morestudies are needed.

© 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd

Scandinavian Journal of Psychology, 2014 DOI: 10.1111/sjop.12159

The aims of the present study are twofold: (1) to explore theexperiences of the persons who participated in health counseling,in order to assess psychosocial aspects of health counseling’ssignificance for citizens’ health behavior and (2) to understandthe decision making process that made the participating citizenssign up for health counseling. The findings of this study maysupport health professionals and municipal decision makers, intheir work to organize and regulate future health promotionactivities in their work against chronic diseases.

METHODS

Health Counseling

The individual health counseling examined throughout this study, is afree municipality-based service for all citizens and employees in amunicipality in Southern Denmark. Persons can be referred to healthcounseling by various entities in the municipality, by their general practi-tioner or they can sign up themselves after having been made aware ofhealth counseling by, for example, local newspapers or on the municipalwebsite. The health counseling is conducted by health professionalstrained in physiotherapy, occupational therapy or health and nutrition,and is based on motivational interviewing and the Small Steps concept.The goal of the service is to work towards a healthy and sustainable life-style and to provide behavioral change in diet, physical activity, smok-ing, alcohol and well-being. It takes place at the local health center andthe duration of the intervention and the frequency of counseling areagreed between the service-taker and the health supervisor.

Study design and theoretical framework

A qualitative approach using semi-structured interviews was chosen as themethod to obtain a complete and in-depth understanding of citizens’ experi-ences of health counseling. The framework of the study is phenomenologi-cal-hermeneutic and the method is based on a combination of descriptionand interpretation of informants’ experiences (Malterud, 2011).

Bandura’s (1997) social cognitive theory (SCT) was applied as a theo-retical framework to assess the psychosocial aspects of health counsel-ing’s significance for citizens’ health behavior. The theory describes theongoing dynamic relationship between behavior, environment and per-sonal factors, which include cognitive, affective and biological events.Self-efficacy refers to ones belief in ones capability to organize and exe-cute the courses of action required to produce a given task. The level ofself-efficacy is fundamental for human motivation and action in adoptingnew lifestyle habits or pursuing rehabilitative activities (Bandura, 1997).Self-efficacy interacts with goals, outcome expectations and perceivedimpediments (Bandura, 2004). According to Social cognitive theory,there are four sources that influence a person’s self–efficacy: Mastery

experiences, vicarious experiences, social persuasion and physiologicaland affective states (Bandura, 1997). A meta-analysis of physical activityinterventions concludes that feedback on previous performance orfeedback on others’ performance is associated with higher levels of self-efficacy (Ashford, Edmunds & French, 2010).

Based on the theoretical framework, it was hypothesized that the citi-zens would be motivated to change health behavior and that they wouldhave a certain degree of self-efficacy, because they have agreed to signup for the intervention. It was assumed that the concept of Small Steps,which include short goal setting, would promote the citizens’ masteryexperience and strengthen the citizens’ self-efficacy through successfulexperiences in achieving short term goals.

Interview guide

An interview guide containing relevant themes and related interviewquestions formulated in everyday-language was developed (Kvale &Brinkmann, 2009). To gain knowledge of the area, relevant literaturewas analyzed, observations were made at the local health center and anevaluation report of the specific health counseling was studied, beforethe interview guide was designed. The interview guide was inspired byBanduras theory and contained themes concerning motivation to sign upfor health counseling, outcome expectations and goal setting. It containedquestions such as Could you try to explain to me what health counselingis and how you experienced it? and What made you sign up for this par-ticular effort? Open-ended questions and reflexive listening was used togain in-depth and nuanced descriptions from the informants. The inter-view guide was continuously modified as new themes emerged fromobtained data. One example of this was increasingly detailed questionsabout Small Steps (see Appendix).

Informants and data collection

During the period October 2012 to March 2013, 48 citizens had theirfinal health counseling session at the health center. During their finalhealth counseling session, all individuals aged 18 to 65 were asked bytheir health supervisor if they wanted to participate in the study. Writteninformation about the study was provided and the potential informantswere subsequently contacted by the researcher. Eleven citizens respondedpositively to the request for participating in the study. The reasons whycitizens refused to participate were lack of time and interest. With theaim to achieve maximum variation and thereby gain a broad understand-ing of the field, the researcher chose to include both genders, a wide agerange and informants with both short and long courses with healthcounseling.

The researcher conducted 11 semi structured face-to-face interviews(Duration: 38–87 min.). The interview took place in an undisturbed roomat the local health center. The sample comprised five females and sixmales (see Table 1). No reward was given for participation. Approval bythe Regional Ethic Committee was not required, but informed consent

Table 1. Demographic characteristics of informants

Informant Gender Age Duration of HC Frequency of HC Working status

1 Female 56 2 years 12 weeks Teacher2 Female 45 9 months 4–5 weeks Social worker3 Male 58 4 months 2 weeks Reported sick from flex job. Has a porter education4 Male 49 3–4 months 3–4 weeks Early retirement

Has worked in a brickyard5 Female 59 2.5 years 8–16 weeks Teacher and special advisor6 Male 44 2 years 4–12 weeks Self-employed handyman7 Male 51 1 years 4 weeks Special worker but long term unemployed8 Male 47 2 years 2–6 weeks Janitor9 Female 62 1 months 3 weeks Early retirement Social and health assistent10 Male 45 1 years 3–6 weeks Janitor11 Female 64 3 months 4 weeks Teacher


2 L. N. Andersen et al. Scand J Psychol (2014)

was obtained from all informants at the day of the interview. Confidenti-ality and anonymity was maintained throughout the research via the useof identification codes.

Data analysis

The audio-taped interviews were transcribed verbatim and the transcriptswere reviewed twice in order to check the accuracy of transcription. Alltranscripts were read carefully before analysis and the process and out-come of analysis were discussed and negotiated continuously among theauthors. The following steps were conducted: (1) total impression of thetranscripts to get a general sense of the whole statement; (2) identifyingand sorting meaning units, this coding process was supported by the soft-ware program NVivo 10 (QSR International, Burlington, MA); (3) con-densation of content and meaning; (4) synthesizing – from condensationto descriptions and concepts, and a coherent story grounded in empiricaldata about the phenomenon is told. Meaning the participants’ experienceswith and descriptions of health counseling. The final step included adiscussion of the results in relation to the theoretical framework (SCT)and to existing literature. This step produced an extended understandingand interpretation that went beyond the informants’ self-understanding(Malterud, 2012). Danish quotes were selected to validate the results andwere translated into English.

RESULTS

The data offered one understanding of how citizens experiencedhealth counseling. The analysis identified five main themes: (1) Iwish to change my life; (2) Getting my own tailored approach;(3) Small steps fit my life; (4) It’s all about getting a responseand (5) I try to treat my body properly.

I wish to change my life

The analysis shows three different ways in which citizens werereferred to health counseling. Two informants had heard abouthealth counseling at work, four informants had contacted healthcounseling after viewing an ad at the municipality’s website, inthe local newspaper or after having heard about it from friends.The remaining five informants had heard about health counsel-ing through their general practitioner or in connection withfollowing other courses at the health center. 10 out of 11 infor-mants described that they were motivated for the intervention.There was no tendency that informants who had signed upfor health counseling on their own initiative were moremotivated for making behavioral changes than those who hadbeen invited to health counseling, for example, through theirgeneral practitioner or through their workplace. For example, aman in his 40s who was referred to health counseling becausehis general practitioner thought it would improve his diabetes 2,was very motivated and experienced a weight loss of 16 kg in4 months.

But it is all about wanting it in order to. I had made up mymind, I wanted to lose weight (Male, 49).

One participant had joined the health counseling because shefelt a compulsion to attend when the municipality offered such acourse through her workplace. For her, the feeling of compulsionwas motivating. A man in his 50s signed up because of lack ofbetter health services. He was unemployed and the only thing hebelieved would help against his overweight was to get a job.

Well, I just said yes because I got the offer. I didn’t expectthat they would be able to help (Male, 51).

The reasons for signing up for health counseling varied amongthe informants, but they all wanted to change eating and physicalactivity behavior and they all had a goal containing a loss ofweight. Some informants had set a specific target for how muchweight they would like to lose, while others simply desired anon-specific loss of weight.The informants’ motivation for weight loss varied signifi-

cantly, but what was clear from most of their descriptions wasthat they wanted to improve the condition of an already diag-nosed lifestyle disease or wanted to prevent a lifestyle diseasefrom occurring. Diabetes, high blood sugar and high cholesterolwere mentioned by several informants.

The risk of Diabetes 2 and all the lifestyle diseases andknowing how obese persons die faster and, well, so manythings, you are not very mobile (Male, 45).

For about half of the informants, it had a great significancethat lifestyle changes could help influence their physical appear-ance positively. The desire for a better appearance was linked toboth a desire for greater self-fulfillment and to being easiersocially accepted as slim.

But to me it might have been just as much the visual andthe appearance going to stores and really fancy clothes,and I didn’t really think that any of it would fit me. And Iconstantly had to go one size up and one size up again andit didn’t really fit and then on (Female, 45).

Getting my own tailored approach

Several informants expressed the importance of health counsel-ing being specifically tailored to their everyday life. Theyexplained that they did not lack knowledge about health, ratherthey lacked the tools to make a healthier lifestyle fit into theirdaily lives. A woman in her 50s describes how the health super-visor helped her figure out how to practically implement the newhabits into her everyday life:

Here you have to say, OK what are you going to doinstead and where do you do something that comes easy,so it doesn’t turn into a huge change. For example, it’slike wanting to go for a walk, when do we do it then. Is itright after work. Is it before dinner, is it after dinner.How do we make it fit practically into our everyday life(Female, 59).

For seven of the informants, it had been a decisive factor thatthe health counseling was individual. They found the topic oftheir own health behavior personal and several informantsdescribe that they would not have liked to sit in a group and talkabout themselves. They describe that they would not have signedup if the intervention had been based on group sessions.The setting of health counseling was closely associated with

the tailored approach. The duration of the health counselingintervention varied a lot between the informants and theyexplained that it was an advantage that it was not a given course


Citizens experience of health counseling 3Scand J Psychol (2014)

they had to go through. Some informants preferred to have con-versations bi-weekly, while others found it appropriate withlonger intervals between the conversations. Some informantsfelt good about their health counseling process only lasting afew months, while others felt good about stretching the processacross years.

If it had been a course with a duration of three monthsthen it would have been a big change . . . Now the coursehas had a duration of two years . . . and because it has beenequalized over such a long period, I don’t think that it hasbeen a big change. You have learned and you have taken itin and you have seen it from a completely different pointof view and over time you have gotten rid of the old badhabits (Male, 44).

For three of the informants, the tailored approach throughhealth conversations was not sufficient and they decided to leavethe health counseling intervention because it did not live up totheir expectations. They would have preferred a health care ser-vice with, for example, fitness training, kitchen training and gro-cery shopping. Two of them expressed that it would have beenmotivating for them if the intervention had been based on groupsessions which would allowed for sharing of similar challengesand experiences.

The motivation becomes much larger if you are in a group.You talk to the others and you don’t think as much aboutit when others are also exercising, and you don’t think asmuch about the pain (Male, 51).

Small steps fit my life

The tailored approach was associated with learning how to makesmall changes fit into one’s everyday life. One informantdescribes how the most important thing she learned during theprocess was to think in short sequences.

It is the small steps. It is accepting that the small stepsmake a difference. I actually think that has been a crucialfactor. Of course you can make some large changes to yourlifestyle, but if you want it to last, then it cannot be too farfrom your everyday life (Female, 56).

One informant had set a target that he would lose 5 kg eachyear, until he at some point in the future would weigh 100 kg.He was disappointed with intensive diets that failed.Several informants described that despite the fact that the

changes were small, it required hard work to implement them ineveryday life and it was difficult to accept that changing lifestylewas a long lasting process. One informant explained that whenimplementing several changes into everyday life, it was impor-tant to build up slowly, otherwise he would simply forget theinitial changes. On the other hand, he describes that the smallsteps sometimes were too small. This made him ride 15 km onhis bike instead of the 5 km he had agreed with the healthsupervisor, which in turn resulted in decreased motivation.Another informant describes that when he experienced successwith smaller changes, he began to believe that he was also capa-ble of changing other things.

Well, now I have actually managed to get to where Iwanted to go, but then these last couple of weeks, I foundout that I actually want to go even further. It’s like a newbox opening up (Male, 47).

It’s all about getting a response

Most of the informants found that the health supervisor was ableto support them in their process towards a lifestyle change. Theyexplain that they had a feeling of being taken seriously and lis-tened to. The health supervisor was able to provide support byfollowing up on the points that had been discussed at previousconsultations and by giving the informants feedback on theiractions.

It was nice just to talk about it, I mean, constantly follow-ing up on where you stand, right, that she was followingme (Female, 59).

The need for monitoring and feedback was present, both forthose who experienced success with health counseling and forthose who did not reach their goals and fulfill their expectations.A man in his 40s explains how the monitoring motivated him:

Well, it is for example having someone that I have to goto and hand over this note and talk about what happenedduring the week, right (Male, 47).

Several informants had a sense of obligation towards thehealth supervisor. The obligation was a motivating element fortheir behavioral change. One informant asked his health supervi-sor to be strict with him at the bi-weekly counseling, in order tokeep him on track. Most of the other informants simply felt thatthey wanted to show their health supervisor that they had pro-gressed. They did not want to waste anyone’s time.

When there is another human being involved, you get thefeeling that it is not good enough to show up and tell thatyou haven’t done anything. In a way, that has also beenhelpful (Female, 59).

Two of the informants who did not feel that the health coun-seling had improved their lifestyle habits in the way they hadwished for, explained that they would have liked even more con-trol and kicks by the shins from the health supervisor.

I try to treat my body properly

Physical improvements described as weight loss, increased fit-ness and reduced joint pains were for many informants con-nected to increased mental strength, a better mood and a feelingof control of their own situation.

I believe that I have become a more positive and happy per-son after having been here. And I hope that everyone couldbecome so. Because all of a sudden you start telling yourselfthat you decide for yourself whether you want to live longer.I mean, by trying to treat your body properly (Male, 58).

Two informants described that their diabetes through lifestylechanges, had become much better and two informants who



tended to have high blood sugar, experienced that they were ableto control their blood sugar with their new lifestyle.

I was running the risk of getting diabetes and stuff likethat. And I ran my way out of that (Female, 56).

Five informants experienced less pain after their health coun-seling course. Their previous pains were generally related to thejoints in the lower limb. One informant describes how hebelieved that the pains were diminished because his body wasmore satisfied, when it did not have to carry around so muchweight. Another explained how participating in health counselinghad made him more aware of his body’s signals. Due to this, hewas able to sense when he pushed himself too hard.Several informants describe how the physical improvements

and a higher mental surplus made it easier to cope with workand daily activities such as climbing stairs, lacing shoes andgardening. For some informants, the increased mental strengthresulted in succeeding with more things.

You are stronger when you are in the middle of the choiceright. That you know that if you do something one daywhich is not the optimal solution, then there is no reasonto thump yourself in the forehead about it. Instead you justmake the right choice the following day, right. So there’s agreater confidence that you know what to do (Female, 56).

Several informants experienced health counseling as a processwith personal development, where underlying causes of the un-healthy lifestyle emerged. For example, an informant describedthat he had realized that his eating habits were connected withhim feeling sad. Informant 7 realized that he is the only onewho can help himself through the long process of losing weight,while informant 9 considered whether changing her lifestyle wasworth all the hard work if she could not be certain that therewould be a reward in the end.Most informants experienced positive reactions and interest

from family, friends and neighbors towards their lifestylechanges and weight loss. This support gave some informants thecourage to maintain the lifestyle change and they felt that thesupport enhanced their confidence.One informant explained that the positive reactions to his

weight loss, was not enough to motivate him to continue withthe changed lifestyle. He would have liked his family to be partof the project and involved in the health counseling in order tosupport him. Four informants explained that it was difficult tointroduce new eating habits because of lack of support from theirfamilies:

And at home I have put my foot down and told my hus-band, but every time we go grocery shopping, he lovesliver pat�e with red cabbage and he loves sausage and hecontinues to buy the same (Female, 62).

DISCUSSION

From the study, it is clear that wishes to changing one’s life var-ies a lot. According to Bandura (1997), peoples’ belief in theirability to motivate themselves and regulate their own behavior,has a great influence on whether they consider changing their

behavior and participate in rehabilitative activities. The presentstudy indicates that even though the informants established con-tact with health counseling in different ways, 10 out of 11 infor-mants felt motivated and they all had clear objectives with thecourse. Only a few studies have examined why persons sign upfor health activities. However, the findings of the present studyare supported by a study examining patients’ experiences withself-referral for in-patient rehabilitation. A study by Andreassenand Wyller (2005) find that patients are motivated and have clearobjectives regardless of whether they have applied on their owninitiative. Furthermore, the feeling of being forced to sign upfor the health promotion efforts offered by society which wasdescribed by informant 1, is also found in a study of unem-ployed people by Romppainen, Salaniemi, J€ahi and Virtanen(2012). In contrast to the study by Romppainen et al., (2012),informant 1 found the feeling of compulsion motivating. It isimportant to note that the results of the present study regardingmotivation may be explained by the fact that participation inhealth counseling is voluntary. It is likely that those with nointerest in health counseling have simply declined the offer.There may be two possible reasons why people are motivatedfor health counseling regardless of how they have been referred.One possibility is that citizens are actually motivated for healthcounseling even before they hear about the offer. Meaning thatcitizens are on different stages of change and therefore also haveto go through different stages to change according to The Trans-theoretical Model of Health Behavior Change (Prochaska &Velicer, 1997). This is supported by Brotons et al. (2012) cross-sectional study which concludes that up to 48% of the respon-dents in a sample believe that they have to change eitherphysical activity or eating habits. The second possibility is thatthe citizens need an external motivation in order to sign up forhealth counseling. This is in line with the informants’ descrip-tions of needing to feel an obligation towards another person.The present study found that the motivation for changing

health behavior was associated with positive outcome expec-tations related to physical health improvement and changedappearance. The informants’ expectations of improving theirappearance were founded in both personal wishes of increasedself-satisfaction, but also in achieving wider social acceptance.According to Bandura (1997), positive outcome expectations areessential for making a behavioral change. This might explainwhy informant 7 who did not expect that health counselingwould help him, quit the intervention.A dominant theme that emerges from the analysis is the

importance of citizens getting their own tailored approach. Inprevious studies, the optimal amount of health counseling hasbeen discussed (Hardcastle & Hagger, 2011). The present studyshows that there were big differences in what persons consideredto be an appropriate frequency and duration of health counsel-ing. Except from informant 9, those who had a health counselingcourse of less than a year commonly have very clear goals forwhat they wanted to achieve through health counseling. Theywere also very clear on what role the health supervisor shouldfill in the process. On the other hand, those who had a healthcounseling course lasting two years or more, had a more generalobjective of improving their health behavior. They were,however, very aware of the importance of small steps and



emphasized that health counseling had been a process of per-sonal development. This indicates that those with an extensivecourse had low self-efficacy and that it was important for themto increase their feeling of control and self-efficacy through slowindividual guidance. This is consistent with Bandura’s Theory(Bandura, 1997).For seven informants, it was essential that the health counsel-

ing was individual. They explain that they needed the tailoredapproach in order to adapt the lifestyle changes to their specificeveryday lives. This finding is consistent with other studieswhich have shown that the tailored approach is more effectiveand that people prefer this to standardized messages (O’Sullivanet al., 2010; Skinner, Strecher & Hospers, 1994). To gain a dee-per understanding of why people want an individual course, twounderlying reasons were found; four informants had poor previ-ous experience with being in a group. This may have resulted inpoor mastery experience and thus a low degree of self-efficacyin group contexts. Three female informants found that theirhealth was a private matter in which they did not wish toinvolve others. Common to these three was that they were veryaware of how their being overweight affected their appearance.This may indicate that they feel embarrassed because of theiroverweight and that they do not want others to see them asvulnerable individuals.Three informants would have liked the health counseling to

be carried out in groups where practical activities such as cook-ing and exercising would have been possible. The commonalityis that they all articulate barriers associated with implementingnew healthy habits to their everyday family life. This indicates aneed for a community where citizens can mirror themselves inothers’ health behavior in order to achieve vicarious experiences.This is consistent with Bandura (1997) and Ashford et al.’s(2010) conclusions stating that vicarious experiences is animportant factor in increasing a person’s self-efficacy.Short- and long-term goal setting are important elements in

the process of adopting a new health behavior (Bandura, 1986).In this study, several informants praised the Small Step approachand they acknowledged that a successful lifestyle change isachieved through small changes in everyday life. Adopting theperspective of Bandura, this can be interpreted as the informantsachieving positive mastery experiences through small successeswhich then lead to increased self-efficacy. This is consistent witha review by Hill (2009), examining the effects of large versussmall changes in relation to physical activity and diet. He con-cludes that small steps can be a successful route to creating sus-tainable lifestyle changes and reducing obesity rates. On theother hand, study results show that citizens find it difficult toaccept small steps when you want significant results. Combinedwith citizens’ general need to feel obliged, this finding indicatesthat it is doubtful whether citizens can continue to implementsmall lifestyle changes after the end of their health counselingcourses.Getting a response was an important element in the infor-

mants’ process towards a healthier lifestyle. The importance ofbeing personally supported, listened to and taken seriously, issupported by Bandura’s (1997) theory which states that socialpersuasion strengthens the individual’s self-efficacy. It is tempt-ing to assume that the informants have signed up for health

counseling because of a doubt in their own ability to carry outthe actions that will lead to a changed health behavior. Theoreti-cally, this is linked to Bandura’s statement that people who haveself-doubt about personal efficacy, need additional support andguidance (Bandura, 2004). Two of the informants who were notsatisfied with health counseling, explained that they needed evenmore control and obligation towards the health supervisor. Thismay be interpreted as searching for external motivation becauseof self-doubt about personal efficacy. Also when linked to theconcept of empowerment it may be interpreted that differentinformants have different needs. From this perspective the infor-mants’ power to change life style can be seen as linked to infor-mants’ actual life style and to the method used for enhancingempowerment (Smith, Tang & Nutbeam, 2006) and this mayindicate that not necessarily all citizens are obvious choices forhealth counseling.The informants articulate the importance of receiving continu-

ous feedback and being monitored continuously. This is consis-tent with a systematic review with meta-analysis examiningwhether increased self-efficacy results in increased physicalactivity, which concludes that feedback on previous performanceincreases self-efficacy (Ashford et al., 2010).The feeling of being obliged to comply with an agreement is

also seen in a study by Walseth et al. (2011) dealing with life-style counseling in general practice. Walseth’s study found thatfeeling an obligation to follow the advice of doctors played amajor role for patients. The importance of feeling responsible tosomeone when changing health behavior is also found in a studyof health counseling for obese people by Hardcastle and Hagger(2011). The feeling of obligation and the desire to show thehealth supervisor that you are actively pursuing your goal can befurther illuminated with the theory of gift giving by Mauss(2001). Mauss’s theory states that the fundamental and universalrule in social interaction is to give, receive and re-give. Viewedin this perspective, the fact that the citizens receive guidance andsupport provides them with a natural desire to deliver satisfac-tory results back to the health supervisor.The informant’s perceived impact of health counseling had

great influence on their motivation for changing health behavior.The informants describe how changing their health behaviorresulted in different reactions from their respective environments.As mentioned, perceived impediments and facilitators in theenvironment are important factors in the regulation of humanbehavior and motivation (Bandura, 2004). Some of the infor-mants in the present study experienced difficulties in implement-ing new eating habits if their families did not support theproject. This finding is supported by a qualitative study byHardcastle & Hagger (2011), which shows that a lack of socialsupport by partners presented a great barrier to the weight lossefforts of obese people. Furthermore, it is well demonstrated thatfamily support is a key element for promoting and sustaininghealth behavior changes (Gruber & Haldeman, 2009). Accordingto social cognitive theory, personal factors will influence humanmotivation, action and thought. In the present study, severalinformants experienced physical and mental improvementsthrough the process of health counseling and regarded them asimportant motivators for adopting new health behavior. Theseexperiences resulted in the informants becoming aware of their



body’s signals and gave the informants a feeling of controlling,for example, pain, blood glucose and mood. This perceived con-trol can be viewed as an increased belief in personal self-efficacyand a belief that the process of changing lifestyle can succeed. Inaddition, the informants experienced praise and positive feedbackfrom their environment, which further increased the motivationof health change. Two of the three informants who were not sat-isfied with health counseling, felt that their efforts generated noresults. This was discouraging to them and they did not get afeeling of self-control. The third informant, who was not satis-fied, described that neither physical improvement nor positivefeedback from the environment affected his motivation. From apsychosocial perspective, the lack of positive personal factorsand the feeling of barriers in the environment had a negativeimpact on the self-efficacy of the three. This has a negative effecton their motivation and thoughts about a new health behavior.

Methodological considerations

A critical review of the methods used in the present study indi-cates some limitations of the study. Forty eight citizens com-pleted during the period, all were asked to participate in thestudy. Eleven wanted to participate in the study and it is reason-able to believe that those who were interviewed have had eithera more positive or negative perception of the intervention thanthose who rejected. The number of interviews is quite small forquantitative research but relevant in this qualitative study aimingat understanding the processes operating in relation to our studyaims. It is, however, assessed that the informants included in thestudy provided nuanced descriptions of their experience withparticipating in health guidance. The data collection and analysiswas conducted by one researcher only, but an interrater reliabil-ity was guaranteed by feedback from other authors. The feed-back was provided based on listening to one of the interviewsand discussing the artificial quotes, which were created in theanalysis process. In addition, the researcher was given completeknowledge of the material, which formed the basis for in-depthanalysis and interpretation. In order to validate the results, thetranscriptions were read and listened to several times. In betweenthe interviews, the researcher had time to reflect on interviewtechniques and to discover new ways of understanding the sub-ject. This improved the quality of the latter interviews. In orderto ensure the internal validity, the researcher summarized theinformants’ statements and asked clarifying questions during theinterview sessions.

CONCLUSION

This study provides knowledge about citizen’s experienceswith participating in municipality-based health counseling.Based on the results of the study, we conclude that healthcounseling has the ability to promote self-efficacy in relationto health behavior. Informants who gave a positive evaluationof health counseling showed a clear tendency to change theirlife style. It is assessed that psychosocial aspects such asobtaining positive mastery experiences through having anindividual tailored approach had a big significance for thecitizens’ health behavior. The same is true, for the attempt to

treat one’s body ‘properly’, including increased self-controlover body and mind. In addition feedback and feeling obligedtowards the health supervisor shows to be essential aspects forcitizens’ desire to change health behavior. The above aspectswere also mentioned as crucial factors in signing up for healthcounseling. All informants who found health counseling insuf-ficient, lacked support from immediate family in relation toimplementing new healthy habits. They expressed a need forpractical activities in groups and therefore individual healthcounseling might not be preferable for this group. A surpris-ing finding is that the informants felt motivated and had clearobjectives for health counseling, regardless of how they ini-tially had been introduced to sign up for health counseling.This finding indicates that it may not be essential whether theinitiative to a health effort stems directly from the citizen orfrom an externality.

The authors declare that they have no competing interests.

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Received 3 March 2014, accepted 3 July 2014

APPENDIX : INTERVIEW GUIDE

Research question Themes Interview questionThe project’s research questions What do I seek knowledge about? Interview question in everyday-language

Demographic information AgeEducationWorkSocial statusPractical information regardingstart and stop with HC

• How old are you?• Do you have any education? Which?• Do you work?• Do you have a family?• When did you start with HC?• How often did you attend HC?• How did you find a suitable frequency for the HCsessions?

Which factors made the citizen sign up for HC? Motivation to sign up for HC • Could you try to explain to me what HC is and howyou experienced it?

• Where did you first hear about HC?• What made you sign up for this particular effort?• Can you describe how your environment (family,friends, colleagues) reacted when you decided to startwith HC?

How did the citizen experience that HC affectedhis/her ability and inclination to change healthbehavior (self efficacy)?

Previous experiences with lifestylechanges (Mastery experiences,outcome expectations)

• What were your expectations to HC?• How did your health behavior change during theperiod with HC?

• Do you have previous experience with changinghealth behavior?And how did it go?

Goal setting and small steps • What was your objective with HC?



Research question Themes Interview questionThe project’s research questions What do I seek knowledge about? Interview question in everyday-language

• Did you create a health plan with goals andstrategies?And what did this health plan mean to you?

• Did you revise your health appointments fromsession to session?

• Have you and your health supervisor discussedSmall Steps?

• Could you describe one of your small steps to me?What did you do before and what do you do now?

An individual effort(vacarious experiences)

• What did it mean to you that HC was based onindividual sessions?

Recognition and support(social persuasion)

• How did you experience the role of the healthsupervisor?

• Was it your experience that the health supervisorwas able to support you (in relation to previouslymentioned items)?

Perceived impact(physiological andaffective changes)

• Could you try to explain what you found difficultabout changing health behavior?

• Did you experience any physical and mentaldifferences during your HC course? If yes, how didit affect your will to keep making lifestyle changes?

• Has the HC course provided you with any tools thatyou can make use of in the future?

• Has the HC course made you think of somethingelse?

Did the citizen experience a reductionin pain during the HC course?

If the informants mentioned the topicpain during the interview, theinterviewer asked further intothis topic.

Pain • Do you experience pain in your everyday life?• Could you try to describe how you experience thepain?

• How does the pain influence your everyday life(work, spare time, sport, social life, sleep, mood)?

• How did you experience the pain earlier? Beforeyou started with HC?

Debriefing

• Is there anything I have forgotten to ask you about? Is thereanything you would like to say or ask before we stop theinterview?

• How did you experience participating in the interview?

The interview guide has developed over time. For example,the interview guide initially contained more questions aboutpain. The reason why the questions regarding pain were brought

in was that Kommunernes Landsforening has created an evalua-tion report of the health guidance project in Sønderborg. In thisreport, a questionnaire pointed towards that the citizens hadexperienced an improvement in their pain-levels during the HCcourse.On the other hand, the number of questions regarding Small

Steps and the obligation towards the health supervisorincreased. This was a natural development, as it turned outthat these themes were of great importance to several of thecitizens.



a qualitative study of citizens' experience of participating in health counseling

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