Behavior ChangeBehavior Change

Though there is strong Though there is strong evidence linking lifestyle abuse evidence linking lifestyle abuse and lack of well-being, many and lack of well-being, many people still smoke cigarettes, people still smoke cigarettes, drink excessive amounts of drink excessive amounts of alcohol and caffeine, never alcohol and caffeine, never exercise, burn out due to exercise, burn out due to stress, eat vast amounts of stress, eat vast amounts of high-fat foods, and refuse to high-fat foods, and refuse to fasten their seat belts.fasten their seat belts.

It is perplexing that knowledge It is perplexing that knowledge is not always linked to action. is not always linked to action.

Knowledge is not power; Knowledge is not power; rather, knowledge is only rather, knowledge is only potential power! Information is potential power! Information is necessary but not sufficient for necessary but not sufficient for creating meaningful change. creating meaningful change.

Fear of a heart attack or cancer has not kept many Fear of a heart attack or cancer has not kept many peoples involved in ongoing programs of exercise peoples involved in ongoing programs of exercise and dietary change. and dietary change.

Even when the information is positive or Even when the information is positive or inspirational, many still have difficulty making inspirational, many still have difficulty making lifestyle behavior changes. lifestyle behavior changes.

Our everyday behaviors are learned responses. Why Our everyday behaviors are learned responses. Why do some continue to smoke cigarettes, need alcohol do some continue to smoke cigarettes, need alcohol to have a good time, select fruit instead of cake for to have a good time, select fruit instead of cake for dessert, or automatically fasten their seat belt when dessert, or automatically fasten their seat belt when getting into a car? getting into a car?

These are learned behaviors. They occur as we These are learned behaviors. They occur as we respond to a variety of societal influences—parents, respond to a variety of societal influences—parents, friends, role models, advertising, and so on. Called friends, role models, advertising, and so on. Called habits, these learned behaviors can also be habits, these learned behaviors can also be unlearned. What is missing in the link between unlearned. What is missing in the link between knowledge and action is a systematic strategy or knowledge and action is a systematic strategy or plan.plan.

Change is difficultChange is difficult All of us who have tried to give up old habits and start All of us who have tried to give up old habits and start

new ones know how hard it is. new ones know how hard it is. Attempts to change can leave us feeling overwhelmed and Attempts to change can leave us feeling overwhelmed and

demoralized. We may want to give up, feeling it's easier to demoralized. We may want to give up, feeling it's easier to hang on to old habits. hang on to old habits.

Change can be especially difficult when someone else tells Change can be especially difficult when someone else tells us to do it—a physician, friend, parent, or spouse. For us to do it—a physician, friend, parent, or spouse. For many of us who face imposed change, the first reaction is many of us who face imposed change, the first reaction is to get angry and defensive. We do not like feeling forced to to get angry and defensive. We do not like feeling forced to do something even when the change may appear to be in do something even when the change may appear to be in our best interest. ("I'll change when I'm ready, thank you our best interest. ("I'll change when I'm ready, thank you very much!") very much!")

When we initiate change, we feel free. Psychologists use When we initiate change, we feel free. Psychologists use the term self-efficacy to describe people who believe that the term self-efficacy to describe people who believe that their own efforts can make a diference. You have a high their own efforts can make a diference. You have a high level of self-efficacy if you feel confidence in your ability to level of self-efficacy if you feel confidence in your ability to progress with a specific behavior change. progress with a specific behavior change.

Changing a behavior or Changing a behavior or breaking an unhealthy breaking an unhealthy habit involves learning habit involves learning new behavior. new behavior.

Just as in learning Just as in learning anything else, you must anything else, you must understand and practice understand and practice the basic skills and the basic skills and techniques of behavior techniques of behavior change. change.

Some people are already Some people are already excellent managers of excellent managers of their lives. They can their lives. They can study when they need study when they need to, exercise regularly, to, exercise regularly, turndown an offer of turndown an offer of chocolate creme pie, chocolate creme pie, and refuse a beer at a and refuse a beer at a party. party.

Behavior Change StrategiesBehavior Change Strategies

Once we have identified a behavior that should Once we have identified a behavior that should be changed, we must then choose a behavior be changed, we must then choose a behavior change technique. Following is a list of the change technique. Following is a list of the most commonly used techniques: most commonly used techniques:

SHAPING:SHAPING: A series a small steps are used to A series a small steps are used to gradually achieve a particular goal.gradually achieve a particular goal.

The steps involve: The steps involve: a. Starting slowlya. Starting slowly b. Keeping the steps small and achievableb. Keeping the steps small and achievable c. Being flexible and ready to change if c. Being flexible and ready to change if

necessarynecessary d. Refusing to skip steps or move to the next d. Refusing to skip steps or move to the next

step until the previous step has been step until the previous step has been mastered.mastered.

Stages to changeStages to change

Behavior Change StrategiesBehavior Change Strategies

VISUALIZATION: VISUALIZATION: Imagined rehearsal Imagined rehearsal is used to mentally practice the is used to mentally practice the planned action ahead of time. planned action ahead of time.

MODELING:MODELING: Specific Specific behaviors are behaviors are learned by watching others perform learned by watching others perform them.them.

SITUATIONALSITUATIONAL INDUCEMENTINDUCEMENT: : Situations and occasions are structured Situations and occasions are structured to exert control over the behavior.to exert control over the behavior.

Behavior Change StrategiesBehavior Change Strategies POSITIVE REINFORCEMENTPOSITIVE REINFORCEMENT: This : This

technique is used to increase the likelihood technique is used to increase the likelihood that a positive behavior will occur. The that a positive behavior will occur. The following are positive reinforcers: following are positive reinforcers:

a. Consumable reinforcers: candy, gourmet a. Consumable reinforcers: candy, gourmet meals meals

b. Activity reinforcers: movies, vacationsb. Activity reinforcers: movies, vacations c. Manipulative reinforcers: Incentives: c. Manipulative reinforcers: Incentives:

Extra credit, time offExtra credit, time off d. Possessional reinforcers: tangible d. Possessional reinforcers: tangible

rewards: T-shirt, new TVrewards: T-shirt, new TV e. Social reinforcers: loving looks, e. Social reinforcers: loving looks,

affectionate hugs, and praiseaffectionate hugs, and praise

Behavior Change StrategiesBehavior Change Strategies MODIFYING SELF-TALKMODIFYING SELF-TALK: This technique involves : This technique involves

talking to oneself in a positive fashion. The way in talking to oneself in a positive fashion. The way in which we think and talk to ourselves can be beneficial which we think and talk to ourselves can be beneficial to behavior change. By changing irrational self-talk into to behavior change. By changing irrational self-talk into rational and positive statements about reality, positive rational and positive statements about reality, positive behaviors are more likely to occur. behaviors are more likely to occur.

Deciding which of these behavior-changing strategies to Deciding which of these behavior-changing strategies to choose is dependent upon many factors, not the least of choose is dependent upon many factors, not the least of which are the characters and the situations of the which are the characters and the situations of the individuals involved. individuals involved.

Successful behavioral change frequently involves using Successful behavioral change frequently involves using multiple strategies. multiple strategies.

Many people benefit from consulting with others, such Many people benefit from consulting with others, such as excigarette smokers, who have successfully made as excigarette smokers, who have successfully made positive behavioral changes or by joining support positive behavioral changes or by joining support groups (e.g., Alcoholic Anonymous, Overeaters groups (e.g., Alcoholic Anonymous, Overeaters Anonymous, etc). Anonymous, etc).

The behavior needing to be The behavior needing to be changed is nested within changed is nested within

specific events:specific events: ANTECEDENTS aANTECEDENTS are the events that “set re the events that “set

up” the behavior, provoking a person to up” the behavior, provoking a person to act in certain ways. It is surrounding a act in certain ways. It is surrounding a specific undesirable behavior must be specific undesirable behavior must be understood and somehow dealt with understood and somehow dealt with before a behavior can be changed. For before a behavior can be changed. For example, if a person is an alcoholic, a example, if a person is an alcoholic, a likely antecedent to that behavior is going likely antecedent to that behavior is going to a bar every night. This antecedent likely to a bar every night. This antecedent likely will have to be removed from his/her will have to be removed from his/her sphere of activity to avoid consumption of sphere of activity to avoid consumption of alcohol. alcohol.

CONSEQUENCESCONSEQUENCES are the results of the behavior and, often times, affect are the results of the behavior and, often times, affect

whether the behavior will be repeated. Careful whether the behavior will be repeated. Careful consideration of consequences can be a powerful consideration of consequences can be a powerful motivator to change a behavior. Recognizing that failure motivator to change a behavior. Recognizing that failure to consider the consequences during the triggering to consider the consequences during the triggering situation helps to lead to an undesirable behavior, and situation helps to lead to an undesirable behavior, and developing the habit of considering these consequences developing the habit of considering these consequences can be important steps toward behavioral change. can be important steps toward behavioral change.

Successful behavior change requires careful assessment Successful behavior change requires careful assessment of exactly what the individual wants to change. An of exactly what the individual wants to change. An analysis of several components of the behavior that you analysis of several components of the behavior that you may want to change must occur before any change can may want to change must occur before any change can take place. One must understand: take place. One must understand:

Behavior Change StrategiesBehavior Change Strategies

FREQUENCY FREQUENCY of the behaviorof the behavior DURATION AND LONGEVITYDURATION AND LONGEVITY of of

the problemthe problem SERIOUSNESS (SERIOUSNESS (i.e., the trouble i.e., the trouble

the behavior is causing and the the behavior is causing and the consequences)consequences)

BASISBASIS for the problem behavior for the problem behavior (i.e., Why are you doing this?)(i.e., Why are you doing this?)

ANTECEDENT(S)ANTECEDENT(S) (i.e., What (i.e., What is causing this behavior?)is causing this behavior?)

Consider your own health and health-related Consider your own health and health-related behaviors. Is there a behavior that you could behaviors. Is there a behavior that you could change to improve your health? If you are willing change to improve your health? If you are willing to change that behavior to benefit your health, to change that behavior to benefit your health, then apply the concepts you have learned in this then apply the concepts you have learned in this class session to the following steps: class session to the following steps:

-Ask yourself what it is that you want to change.-Ask yourself what it is that you want to change. -Be specific about your current behavior.-Be specific about your current behavior. -Develop strategies and intermediate goals that -Develop strategies and intermediate goals that

will help you to reach the ultimate goal.will help you to reach the ultimate goal. -Identify the situations that may make you -Identify the situations that may make you

susceptible to the undesirable behavior.susceptible to the undesirable behavior. -With careful consideration, planning, and a lot -With careful consideration, planning, and a lot

of motivation and hard work, you can change of motivation and hard work, you can change your health and your life for the better!your health and your life for the better!

Steps to Good HealthSteps to Good Health Health experts have identified 8 key behaviors Health experts have identified 8 key behaviors

that will help people live longer, healthier lives: that will help people live longer, healthier lives: Eat breakfast everydayEat breakfast everyday Manage weight Manage weight Participate in regular physical activity (20 minutes of Participate in regular physical activity (20 minutes of

exercise 4 times per week)exercise 4 times per week) Eat a balanced dietEat a balanced diet Do not use tobaccoDo not use tobacco Consume little or no alcoholConsume little or no alcohol Get regular sleep, at least 7 hours a nightGet regular sleep, at least 7 hours a night Conduct regular self-exams and have yearly medical Conduct regular self-exams and have yearly medical

check-upscheck-ups

Other ways to improve the Other ways to improve the quality of life and possibly quality of life and possibly add years to the lifespan.add years to the lifespan.

Taking a little time for ourselves each day Taking a little time for ourselves each day and doing something that we enjoy doing, and doing something that we enjoy doing, even if it is only for a short period of time, is even if it is only for a short period of time, is one of the best ways to help to control the one of the best ways to help to control the stressors in life. stressors in life.

Controlling, not eliminating, stress is a Controlling, not eliminating, stress is a tremendous asset to anyone’s health status. tremendous asset to anyone’s health status.

Having and maintaining meaningful Having and maintaining meaningful relationships with family and friends is relationships with family and friends is important because we need other human important because we need other human beings in our lives to be healthy. beings in our lives to be healthy.

All of these types of activities increase the All of these types of activities increase the quality and perhaps the quantity of life.quality and perhaps the quantity of life.

Behavior ChangeBehavior Change

If we are not doing some of the behaviors that If we are not doing some of the behaviors that we want to do, or could do, to be healthier, we we want to do, or could do, to be healthier, we have the ability to change our behavior patterns.have the ability to change our behavior patterns.

We must first identify specific behavior patterns We must first identify specific behavior patterns and then try to understand the reasons for them.and then try to understand the reasons for them.

However, before any changes can take place, However, before any changes can take place, there must be a state of readiness present. there must be a state of readiness present.

Readiness is the state of being that precedes Readiness is the state of being that precedes behavioral change, relying on the presence of behavioral change, relying on the presence of knowledge, attitudes, skills, and resources that knowledge, attitudes, skills, and resources that make change possible. make change possible.

PREDISPOSING FACTORSPREDISPOSING FACTORS: These : These include life experiences, cultural and include life experiences, cultural and ethnic inheritance, and current beliefs ethnic inheritance, and current beliefs and attitudes. Examples are age, sex, and and attitudes. Examples are age, sex, and income.income.

ENABLING FACTORSENABLING FACTORS: These include : These include skills, abilities, and resources that make skills, abilities, and resources that make change easier or more difficult.change easier or more difficult.

REINFORCING FACTORSREINFORCING FACTORS: These : These include encouragement and support from include encouragement and support from significant people in our lives.significant people in our lives.

Perceived seriousness of Perceived seriousness of health problemhealth problem..

A particular health problem must be believed A particular health problem must be believed to be serious enough to warrant a behavior to be serious enough to warrant a behavior change.change.

For example, how many people do you know For example, how many people do you know who do not believe that lung cancer will who do not believe that lung cancer will happen to them, despite the fact that they happen to them, despite the fact that they smoke? smoke?

The person must understand and The person must understand and acknowledge the fact that a particular health acknowledge the fact that a particular health problem can be developed or acquired. problem can be developed or acquired.

Cues to actionCues to action

The individual must understand the The individual must understand the presence of cues to action that presence of cues to action that caused or activated the problem caused or activated the problem behavior. For example, the key to a behavior. For example, the key to a behavioral change for one obese behavioral change for one obese individual may hinge upon the individual may hinge upon the realization that his/her chronic realization that his/her chronic depression is a trigger for depression is a trigger for overeating, leading to obesity. overeating, leading to obesity.

To change behavior patterns, we must believe that we To change behavior patterns, we must believe that we can control what we do. Indeed, the can control what we do. Indeed, the THEORY OF THEORY OF REASONED ACTIONREASONED ACTION maintains that our behaviors maintains that our behaviors are a result of our intentions to perform actions. are a result of our intentions to perform actions.

Intention is produced by an attitude toward an action Intention is produced by an attitude toward an action and beliefs about what others may want us to do. and beliefs about what others may want us to do. Unfortunately, many people feel that behaviors “just Unfortunately, many people feel that behaviors “just happen,” that is, without any conscious control. Where happen,” that is, without any conscious control. Where this belief exists, behavioral changes are immediately this belief exists, behavioral changes are immediately precluded.precluded.

Significant others also will affect our behavior, and by Significant others also will affect our behavior, and by acting positively or negatively, they can become acting positively or negatively, they can become behavioral change agents. Many people are highly behavioral change agents. Many people are highly influenced by the approval or disapproval of people influenced by the approval or disapproval of people close to them. These people may be family, friends, close to them. These people may be family, friends, and/or the community. and/or the community.

A support network of people is a tremendous asset to A support network of people is a tremendous asset to people struggling to change behaviors.people struggling to change behaviors.

IssueIssue

Healthy behaviors and lifestyles have great potential to Healthy behaviors and lifestyles have great potential to help individuals avoid illness and prevent or exacerbate help individuals avoid illness and prevent or exacerbate serious and expensive chronic conditions including heart serious and expensive chronic conditions including heart disease, cancer, stroke and diabetes. disease, cancer, stroke and diabetes.

Decades of clinical research have produced evidence-Decades of clinical research have produced evidence-based interventions that can improve healthy behaviors based interventions that can improve healthy behaviors related to smoking, diet, exercise, and weight control, related to smoking, diet, exercise, and weight control, resulting in better management of high blood pressure and resulting in better management of high blood pressure and cholesterol, diabetes and reduced risk factors for some cholesterol, diabetes and reduced risk factors for some cancers. cancers.

Policy makers are exploring incentives that may encourage Policy makers are exploring incentives that may encourage behaviors that promote health, reduce disease, and reduce behaviors that promote health, reduce disease, and reduce corresponding health care costs. corresponding health care costs.

Among the options under consideration is an expanded use Among the options under consideration is an expanded use of financial incentives to encourage healthy behaviors, of financial incentives to encourage healthy behaviors, which can include providing discounts on health insurance which can include providing discounts on health insurance premiums or deductibles.premiums or deductibles.

Policy StatementPolicy Statement The American Heart Association, American Cancer, The American Heart Association, American Cancer,

Society, and American Diabetes Association support Society, and American Diabetes Association support comprehensive wellness programs in the workplace.comprehensive wellness programs in the workplace.

However, all three groups believe that financial However, all three groups believe that financial incentives used to motivate behavior should not be incentives used to motivate behavior should not be tied to premiums, deductibles or other coinsurance tied to premiums, deductibles or other coinsurance paid by employers. paid by employers.

Many individuals with chronic conditions will find it Many individuals with chronic conditions will find it difficult to meet the standards set by wellness plans difficult to meet the standards set by wellness plans and could end up paying higher premiums in the and could end up paying higher premiums in the individual and small group markets – just as they do individual and small group markets – just as they do now. Furthermore, the individual’s right to privacy now. Furthermore, the individual’s right to privacy about their personal health status in the workplace about their personal health status in the workplace can be compromised by these programs.can be compromised by these programs.

The current regulatory environment gives employers The current regulatory environment gives employers some latitude to offer wellness incentives through some latitude to offer wellness incentives through premium adjustments as long as the incentive premium adjustments as long as the incentive programs meet certain criteriaprograms meet certain criteria

Policy StatementPolicy Statement

Attempts to use financial incentives to Attempts to use financial incentives to encourage wellness should be closely encourage wellness should be closely regulated to make certain that they are not regulated to make certain that they are not discriminatory. These programs should also discriminatory. These programs should also include evaluations to assess the impact on include evaluations to assess the impact on disparate populations and include an disparate populations and include an analysis of desired outcomes and analysis of desired outcomes and unintended consequences. unintended consequences.

These findings can be used to support These findings can be used to support future program designs and public policy future program designs and public policy decision-making.decision-making.

Policy StatementPolicy Statement The most significant barrier that employees note for The most significant barrier that employees note for

not engaging in healthy lifestyle behaviors are lack of not engaging in healthy lifestyle behaviors are lack of time to exercise before, during, and after work; and time to exercise before, during, and after work; and lack of convenience and location of programs, lack of convenience and location of programs, screenings and exercise facilities.screenings and exercise facilities.

Based on evidence to date, reducing these barriers by Based on evidence to date, reducing these barriers by offering health promotion services such as smoking offering health promotion services such as smoking cessation programs, fitness centers, weight loss cessation programs, fitness centers, weight loss programs and exercise classes on-site, and offering programs and exercise classes on-site, and offering healthy vending and food choices throughout the healthy vending and food choices throughout the workplace environment will be more effective in workplace environment will be more effective in improving employee health – and reducing employer improving employee health – and reducing employer health care costs – than applying financial incentives health care costs – than applying financial incentives through their employer sponsored insurance plan. through their employer sponsored insurance plan.

Financial incentives offered directly to the employee Financial incentives offered directly to the employee and paired with these measures, may also be effective. and paired with these measures, may also be effective. Some employers offer incentives for people who quit Some employers offer incentives for people who quit smoking or lose weight, often in the form of nominal smoking or lose weight, often in the form of nominal cash awards or gift certificates. Numerous options are cash awards or gift certificates. Numerous options are available to employers that are not tied to the available to employers that are not tied to the employee’s costs for health insurance. employee’s costs for health insurance.

BackgroundBackgroundThe incidence of chronic disease and the The incidence of chronic disease and the

resulting financial costs have led some major resulting financial costs have led some major health care purchasers to experiment with health care purchasers to experiment with premium reductions to encourage healthy premium reductions to encourage healthy

behaviors.behaviors. • • The reward for the wellness program must not exceed The reward for the wellness program must not exceed

20 percent of the cost of employee only coverage under 20 percent of the cost of employee only coverage under the plan;the plan;

• • The program must be reasonably designed to promote The program must be reasonably designed to promote health or prevent disease;health or prevent disease;

• • The program must give individuals the opportunity to The program must give individuals the opportunity to qualify for the reward under the program at least once qualify for the reward under the program at least once per year;per year;

• • The reward must be available to all individuals, and a The reward must be available to all individuals, and a reasonable alternative standard for obtaining the reward reasonable alternative standard for obtaining the reward has to be available to any individual for whom it is has to be available to any individual for whom it is unreasonably difficult to satisfy the standard due to a unreasonably difficult to satisfy the standard due to a medical condition, or for whom it is medically inadvisable medical condition, or for whom it is medically inadvisable to attempt to satisfy the standard; and to attempt to satisfy the standard; and

• • The plan must disclose in materials describing the The plan must disclose in materials describing the program the availability of a reasonable alternative program the availability of a reasonable alternative standard. standard.

Some programs has developed five Some programs has developed five preventive healthy behaviors, including: preventive healthy behaviors, including:

completing a health risk assessment; completing a health risk assessment; selecting a primary care physician; selecting a primary care physician; pledging to remain at a healthy weight or pledging to remain at a healthy weight or

to participate in weight management to participate in weight management programs if morbidly obese; programs if morbidly obese;

pledging to remain smoke free or to pledging to remain smoke free or to participate in smoking-cessation participate in smoking-cessation programs; programs;

pledging to participate in disease pledging to participate in disease management programs, if applicable. It’s management programs, if applicable. It’s unclear if this program has resulted in unclear if this program has resulted in firms decliningfirms declining

Policy ConsiderationsPolicy Considerations Several policy issues should be considered when evaluating Several policy issues should be considered when evaluating

health insurance premium adjustments to promote healthy health insurance premium adjustments to promote healthy behaviors.behaviors.

1) Differentiating benefits (e.g. cost-sharing based on 1) Differentiating benefits (e.g. cost-sharing based on modifying premiums, reducing deductibles, or offering modifying premiums, reducing deductibles, or offering credits) based on health status and risk profiles in employer credits) based on health status and risk profiles in employer sponsored health insurance have real potential for sponsored health insurance have real potential for unintended consequences;unintended consequences;

• • Premium surcharges or other cost-sharing measures can Premium surcharges or other cost-sharing measures can make coverage less affordable. People who can’t afford make coverage less affordable. People who can’t afford coverage may have reduced access to therapies and coverage may have reduced access to therapies and interventions that can help curb unhealthy behaviors (e.g. interventions that can help curb unhealthy behaviors (e.g. prescription cessation medication, medically supervised prescription cessation medication, medically supervised weight loss programs, medications to control cholesterol and weight loss programs, medications to control cholesterol and blood pressure, etc.)blood pressure, etc.)

• • Premium surcharges or other cost-sharing measures are a Premium surcharges or other cost-sharing measures are a blunt instrument. blunt instrument.

• • Tying financial incentives to lifestyle choices can lead to a Tying financial incentives to lifestyle choices can lead to a slippery slope. Lifestyle adjustments can be used as a proxy slippery slope. Lifestyle adjustments can be used as a proxy for discrimination based on health status that would for discrimination based on health status that would otherwise be disallowed. In the future, what other lifestyle otherwise be disallowed. In the future, what other lifestyle choices might be penalized?choices might be penalized?

Thank you for Thank you for attentionattention