In Theory…It Makes In Theory…It Makes Sense.Sense.

A Sample Overview of A Sample Overview of Behavior Change Theories Behavior Change Theories

and Their Practical and Their Practical ApplicationApplication

Beverly Barber, RNBeverly Barber, RNTerry StewartTerry Stewart

Denver Public HealthDenver Public Health

www.DenverPTC.org

www.denverhealth.org/dph

Behavioral ScienceBehavioral Science Seeks to understand how and why Seeks to understand how and why

people do what they dopeople do what they do PsychologyPsychology SociologySociology AnthropologyAnthropology

People change (or don’t change) a behavior for a variety of reasons!!

But how do we explain it?

Behavioral TheoryBehavioral Theory Can be used to help understand the Can be used to help understand the

behavioral determinants of riskbehavioral determinants of risk Provides the basis for activities within Provides the basis for activities within

a behavioral interventiona behavioral intervention Guides the evaluation of an Guides the evaluation of an

intervention intervention The constructs of theory suggest what The constructs of theory suggest what

to monitor and how to measure to monitor and how to measure effectiveness effectiveness

Behavior Change Theories Behavior Change Theories & Models& Models

Health Belief ModelHealth Belief Model Irwin M. RosenstockIrwin M. Rosenstock

Social Cognitive (Learning) TheorySocial Cognitive (Learning) Theory Albert BanduraAlbert Bandura

Theory of Reasoned ActionTheory of Reasoned Action Martin Fishbein and Icek AjzenMartin Fishbein and Icek Ajzen

Transtheoretical Model/Stages of Transtheoretical Model/Stages of ChangeChange

James O. Prochaska and Carlo C. DiClementeJames O. Prochaska and Carlo C. DiClemente

Health Belief Model Health Belief Model (HBM)(HBM)

PremisePremise: Health related behaviors : Health related behaviors depend on four key beliefs; all of depend on four key beliefs; all of which must be operating for a risk which must be operating for a risk reducing / health promoting behavior reducing / health promoting behavior to occur.to occur.

Key ComponentsKey Components Threat / RiskThreat / Risk

Perceived susceptibilityPerceived susceptibility Perceived severityPerceived severity

Outcome ExpectationsOutcome Expectations Perceived benefits of performing a behaviorPerceived benefits of performing a behavior Perceived barriers of performing a behaviorPerceived barriers of performing a behavior

HBM – ThreatHBM – Threat SusceptibilitySusceptibility

The recognition that personal behavior The recognition that personal behavior places one at risk for an infection/diseaseplaces one at risk for an infection/disease

““I don’t use condoms, so I’m at risk for HIV or I don’t use condoms, so I’m at risk for HIV or STIs.”STIs.”

SeveritySeverity The belief the infection/disease/condition The belief the infection/disease/condition

will cause serious harm will cause serious harm ““My father had a heart attack and he had to My father had a heart attack and he had to

have triple by-pass surgery.” have triple by-pass surgery.”

HBM – Outcome HBM – Outcome ExpectationsExpectations

Decisional BalanceDecisional BalanceThe belief that the benefits of performing The belief that the benefits of performing the behavior(s) need to outweigh the the behavior(s) need to outweigh the consequences of not performing it before consequences of not performing it before behavior change will occur.behavior change will occur.

““If I work out I will feel better.”If I work out I will feel better.” ““If I work out I won’t have time to If I work out I won’t have time to

watch American Idol.”watch American Idol.”

Social Cognitive Social Cognitive (Learning) Theory(Learning) Theory

PremisePremise: Behavior is learned through direct : Behavior is learned through direct experience or by modeling others’ behaviors experience or by modeling others’ behaviors through observation. Acquisition of a new skill is through observation. Acquisition of a new skill is often required. The chances of behavior being often required. The chances of behavior being repeated depends on the person’s assessment of its repeated depends on the person’s assessment of its cost / benefitscost / benefits Key ComponentsKey Components

Self-efficacySelf-efficacy Can be increased through practiceCan be increased through practice

Skill AcquisitionSkill Acquisition Outcome expectationsOutcome expectations

Positive or negative consequencesPositive or negative consequences Reinforcement Reinforcement

Bend & SnapBend & Snap

Theory of Reasoned Theory of Reasoned ActionAction

PremisePremise: In order for behavior change to : In order for behavior change to occur, one must have an intention to occur, one must have an intention to change. change.

Intentions are influenced by two major Intentions are influenced by two major factors:factors: Attitudes: based on an individual’s beliefs Attitudes: based on an individual’s beliefs

about the positive and negative about the positive and negative consequences of performing the behaviorconsequences of performing the behavior

Subjective normsSubjective norms What significant others think or feel about What significant others think or feel about

behaviorbehavior Motivation to change behavior based on Motivation to change behavior based on

subjective normssubjective norms

Subjective NormsSubjective Norms ““None of my friends smoke, so I None of my friends smoke, so I

feel like I should quit.”feel like I should quit.”oror

““Seems like all my friends smoke, Seems like all my friends smoke, so I think I’ll try it.” so I think I’ll try it.”

Behavioral DeterminantsBehavioral Determinants Perception of Perception of

Personal RiskPersonal Risk Susceptibility Susceptibility SeveritySeverity

KnowledgeKnowledge Attitudes & BeliefsAttitudes & Beliefs IntentionsIntentions

Self-EfficacySelf-Efficacy SkillsSkills Perceived Perceived

NormsNorms Social NormsSocial Norms Social SupportSocial Support

Transtheoretical ModelTranstheoretical Modelaka, Stages of Changeaka, Stages of Change

PrecontemplativePrecontemplative No recognition of need to changeNo recognition of need to change

ContemplativeContemplative Thinking about changeThinking about change

Preparation / Ready for ActionPreparation / Ready for Action Short-term planning for change and initial attempts at Short-term planning for change and initial attempts at

the new behaviorthe new behavior ActionAction

Consistently do the new behavior for less than 6 monthsConsistently do the new behavior for less than 6 months MaintenanceMaintenance

Performing the new behavior for more than 6 monthsPerforming the new behavior for more than 6 months

Relapse

Denver Health Denver Health Cardiovascular Cardiovascular

Disease PreventionDisease Prevention A partnership between A partnership between

Denver Public Health and Denver Denver Public Health and Denver Community Health ServicesCommunity Health Services

2006-20092006-2009

BackgroundBackground

CVD is the leading cause of mortality in CVD is the leading cause of mortality in Colorado, particularly in the Latino Colorado, particularly in the Latino populationpopulation

INTERHEART study (2004) demonstrated INTERHEART study (2004) demonstrated that 90% of population attributable risk is that 90% of population attributable risk is due to modifiable risk factors:due to modifiable risk factors: Smoking, dyslipidemia, HTN, DM, obesity, diet, Smoking, dyslipidemia, HTN, DM, obesity, diet,

exercise, psychosocial factorsexercise, psychosocial factors In the general population, many have at In the general population, many have at

least one risk factor; >90% of CVD events least one risk factor; >90% of CVD events occur in persons with at least one risk factoroccur in persons with at least one risk factor

InterventionIntervention

Potential activities available for participantsPotential activities available for participants Self-help tools, healthy nutrition and exercise Self-help tools, healthy nutrition and exercise

activities, community-based exercise programs, activities, community-based exercise programs, and referrals to the Colorado QuitLine and referrals to the Colorado QuitLine

Navigator will facilitate client’s transition to Navigator will facilitate client’s transition to community-based programscommunity-based programs

Navigator will follow-up with a client at 1-4 weeks Navigator will follow-up with a client at 1-4 weeks and 6-10 weeks after enrollment to and 6-10 weeks after enrollment to assist/encourage client in participating in selected assist/encourage client in participating in selected programsprograms

Additional follow-up will be performed as neededAdditional follow-up will be performed as needed

Physical ActivityPhysical Activity

The ChallengeThe Challenge Despite the benefits of engaging in Despite the benefits of engaging in

regular physical activity such as: regular physical activity such as: reduction of cardiovascular disease reduction of cardiovascular disease and prevention of bone loss and prevention of bone loss associated with aging, more than 60% associated with aging, more than 60% of the adult population and more than of the adult population and more than half of the young people (aged 2-21) half of the young people (aged 2-21) do not exercise regularly.do not exercise regularly.1515

Exercise: BenefitsExercise: BenefitsCardiovascular Risk FactorsCardiovascular Risk Factors

Increase in exercise tolerance - Increase in exercise tolerance - CVD risk CVD risk factorfactor improved muscle function and aerobic capacityimproved muscle function and aerobic capacity

Reduction in body weight - Reduction in body weight - CVD risk factorCVD risk factor Reduction in blood pressure - Reduction in blood pressure - CVD risk factorCVD risk factor Reduction in bad (LDL) cholesterol - Reduction in bad (LDL) cholesterol - CVD CVD

risk factorrisk factor Increase in good (HDL) cholesterol -Increase in good (HDL) cholesterol -

improves CVD risk factorimproves CVD risk factor Increase in insulin sensitivity - Increase in insulin sensitivity - CVD risk factorCVD risk factor

Recreation CentersRecreation Centers Clients eligible to receive 3-month passes to Clients eligible to receive 3-month passes to

Denver Park and Recreation centersDenver Park and Recreation centers Participating centers: Barnum, Azatlan, and RudeParticipating centers: Barnum, Azatlan, and Rude Able to participate in all activities offered at the Able to participate in all activities offered at the

centerscenters Exercise classes appropriate for beginners:Exercise classes appropriate for beginners:

Water aerobics, walking clubs, stretch and tone, Water aerobics, walking clubs, stretch and tone, yoga, Tai Chi, introduction to weights, etcyoga, Tai Chi, introduction to weights, etc

Access to VOA/Arthritis Foundation Gentle Access to VOA/Arthritis Foundation Gentle Exercises with the Healthy Aging Program Exercises with the Healthy Aging Program

Nutrition ProgramsNutrition Programs

A series of 6 interactive classesA series of 6 interactive classes NutritionNutrition Food shoppingFood shopping Food safetyFood safety Physical activityPhysical activity Disease preventionDisease prevention Cooking demonstrationCooking demonstration

Classes offered at the local recreation Classes offered at the local recreation centerscenters

Adult CessationAdult CessationPromote Colorado Quitline & QuitNetPromote Colorado Quitline & QuitNet

The 5 A’sThe 5 A’s

Address AgendaAddress Agenda Attend to the patient’s agendaAttend to the patient’s agenda• • Explain that you would like to talk about Explain that you would like to talk about

some healthy choices for them to considersome healthy choices for them to consider

The 5 A’sThe 5 A’sAskAsk• • What does the patient know about the connection What does the patient know about the connection

between his or herbetween his or her behavior and the possibility for disease?behavior and the possibility for disease?• • How does the patient feel about the behavior?How does the patient feel about the behavior?• • Is the patient interested in changing the behavior?Is the patient interested in changing the behavior?• • What are the patient’s fears about change?What are the patient’s fears about change?• • Has the patient tried to change the behavior Has the patient tried to change the behavior

before? What did and didn’tbefore? What did and didn’t work?work?• • It is important to spend adequate time in this It is important to spend adequate time in this

stage. Patient counseling is more effective when stage. Patient counseling is more effective when patients know that the physician/provider patients know that the physician/provider understands their perspective.understands their perspective.

The 5 A’sThe 5 A’s If you have limited time, spend most of it If you have limited time, spend most of it

on assessment and then incorporate what on assessment and then incorporate what you learn into a few words of advice.you learn into a few words of advice.

AdviseAdvise• • Tell the patient that you strongly advise Tell the patient that you strongly advise

behavior changebehavior change• • Personalize reasons for change (e.g., “By Personalize reasons for change (e.g., “By

quitting smoking you will help yourquitting smoking you will help your daughter have fewer asthma attacks.”)daughter have fewer asthma attacks.”)• • Discuss the immediate and long-term Discuss the immediate and long-term

benefits of changebenefits of change

The 5 A’sThe 5 A’sAssistAssist• • Provide accurate, complete information about Provide accurate, complete information about

risk and risk and give the patient written materials give the patient written materials to take hometo take home

• • Address the patient’s feelings and provide Address the patient’s feelings and provide supportsupport

• • Address barriers to changeAddress barriers to change• • Discuss steps toward behavior changeDiscuss steps toward behavior change• • Get attending physicians, residents or Get attending physicians, residents or

preceptors preceptors involved for additionalinvolved for additional support, more extensive advice and referralssupport, more extensive advice and referrals

The 5 A’sThe 5 A’sArrange Follow-upArrange Follow-up• • Reaffirm the planReaffirm the plan• • Schedule follow-up appointment or Schedule follow-up appointment or

phone callphone call

Counseling tipsCounseling tipsSuggestions for Counseling:Suggestions for Counseling: Precontemplation to Contemplation: Precontemplation to Contemplation:

Demonstrate unconditional acceptance of the person. Demonstrate unconditional acceptance of the person. Give information with low pressure. Give information with low pressure.

Contemplation to Preparation:Contemplation to Preparation: Address the Address the discomforts associated with change. Suggest small discomforts associated with change. Suggest small changes in thinking to get big changes in action.changes in thinking to get big changes in action.

Preparation to Action:Preparation to Action: Set a date for action and Set a date for action and maintain realistic expectations. Suggest action-maintain realistic expectations. Suggest action-oriented programs. Expect 3 or 4 cycles of oriented programs. Expect 3 or 4 cycles of success and failure.success and failure.

Action to Maintenance:Action to Maintenance: Suggest strategies to Suggest strategies to prevent relapses. Anchor benefits to long term prevent relapses. Anchor benefits to long term repetition of behavior.repetition of behavior.

Planning for nutrition Planning for nutrition changeschanges

Making a PlanMaking a Plan What goal's can you set for yourself now?What goal's can you set for yourself now? Before my next visit, I am going to:Before my next visit, I am going to:

Eat fried foods less oftenEat fried foods less often Aim to eat 5 or more fruits and vegetables per dayAim to eat 5 or more fruits and vegetables per day Eat smaller portions and less fatty foodsEat smaller portions and less fatty foods Instead of regular soda and sweet teas, drink Instead of regular soda and sweet teas, drink

water, 100% juice mixed with sparkling water, or water, 100% juice mixed with sparkling water, or skim milkskim milk

Make time for regular mealsMake time for regular meals Exercise regularly (try for 5 times a week)Exercise regularly (try for 5 times a week) Keep healthy snacks aroundKeep healthy snacks around Make an appointment with a dietitianMake an appointment with a dietitian

Planning for ActivityPlanning for Activity Making a PlanMaking a Plan What goals) can you set for yourself now?What goals) can you set for yourself now? Before my next visit, I am going to:Before my next visit, I am going to:

Walk a little bit every day (with friends, kids, dog)Walk a little bit every day (with friends, kids, dog) Exercise regularly (try for 5 times a week)Exercise regularly (try for 5 times a week) Join a local sports team, gym, or exercise classJoin a local sports team, gym, or exercise class Walk, bike, or take the bus instead of drivingWalk, bike, or take the bus instead of driving Take the stairs and park farther awayTake the stairs and park farther away Make an appointment with a personal trainerMake an appointment with a personal trainer Watch less TVWatch less TV

Other:____________________________________________Other:____________________________________________

Client Centered Client Centered ApproachApproach

ReferencesReferences 12. Kottke TE, Battista RN, DeFriese GH, et al. 12. Kottke TE, Battista RN, DeFriese GH, et al.

Attributes of successful smoking cessation Attributes of successful smoking cessation interventions in clinical practice: a meta-analysis interventions in clinical practice: a meta-analysis of 42 controlled trials. of 42 controlled trials. JAMA JAMA 1988;259: 2882-9.1988;259: 2882-9.

15. U.S. Department of Health and Human 15. U.S. Department of Health and Human Services. Services. Physical Activity and Health: A Report Physical Activity and Health: A Report of the Surgeon General. of the Surgeon General. Atlanta, GA: Centers for Atlanta, GA: Centers for Disease Control and Prevention, National Center Disease Control and Prevention, National Center for Chronic Disease Prevention and Health for Chronic Disease Prevention and Health Promotion, 1996.Promotion, 1996.

Thank You!Thank You! Beverly Barber, RNBeverly Barber, RN

Denver Public Health Denver Public Health Cardiovascular Disease PreventionCardiovascular Disease Preventionbeverly.barber@dhha.orgbeverly.barber@dhha.org303-436-7246303-436-7246

Terry StewartTerry StewartDenver Public HealthDenver Public HealthDenver STD/HIV Prevention Training CenterDenver STD/HIV Prevention Training Centerterry.stewart@dhha.orgterry.stewart@dhha.org303-436-7267303-436-7267