OWCH
Online Weight management Counseling
program for Healthcare providers
Module 3:
Models of Behavior Modification
Yale-Griffin Prevention Research Center
www.yalegriffinprc.org
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Modules for Lifestyle Counseling
• Module 1 provided an overview of the obesity
epidemic and explained the importance of lifestyle
counseling.
• Module 2 demonstrated how to write an exercise
prescription and give basic nutritional advice.
• Module 3 provides an overview of behavior
modification constructs that inform lifestyle
counseling efforts.
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Behavior Modification
• Integrating behavioral modification models into the primary
care setting has the potential to facilitate patients’ behavior
change.
• Improved health behavior may be achieved by:
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–
–
–
Individualizing intervention to patient characteristics & needs
Setting goals & problem solving with patients
Multiple follow-up contacts
Support of patient’s social and physical environment; integration
with community opportunities
•
Whitlock EP, et al. Multiple behavioral risk factor interventions in primary care. Summary of research evidence. American journal of
preventive medicine 2004;27:2:61 -79
Estabrooks PA, et al. Physical activity promotion through primary care. JAMA 2003;289;22:2913-16.
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The Five As
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The 5 As
Lifestyle change can be facilitated by:
•
•
•
•
Listening to patients
Considering patient priorities
Developing collaboration with patient
Incorporating patient values, preferences and social
environment
• The 5 As mnemonic helps to promote patient lifestyle
change: Assess, Advise, Agree, Assist and Arrange
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The 5 As: Assess
• Assess patient’s current health status.
• Assess patient’s physical abilities and current
level of physical activity.
• Assess patient’s current dietary habits.
• Assess patient’s readiness for change
Assessments can be done using a brief
questionnaire; office staff can assist.
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The 5 As: Advise
• Advise patient regarding health risks; relate
risks to patient’s recent lab results and/or
current symptoms.
• Advise patient on the potential benefits of
behavior change.
• Provide guidance for dietary change
• Provide exercise prescription using FITT
(Frequency, Intensity, Type & Time)
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The 5 As: Agree
• Agree with the patient if he/she is planning a
lifestyle improvement.
• Collaboratively develop a personalized action plan.
• Set specific goals for physical activity and
nutrition based on patient interest and confidence
in the behavior (time, duration, frequency).
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The 5 As: Assist
• Assist patient to identify personal barriers to adopting
lifestyle changes.
• Assist in developing strategies to overcome barriers.
• Assist to locate community opportunities for weight
loss and physical activity and social support.
Provide written copy of plan to patient and maintain in
office medical record.
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The 5 As: Arrange
• Arrange a plan for follow-up support and
problem solving.
• Telephone calls and mailed reminders
• Ex: “Our office nurse would like to contact you
next week to see how things are going.”
Estabrooks PA, et al. Physical activity promotion through primary care. JAMA 2003;289;22:2913-16.
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Algorithm for the Treatment of Obesity
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Serdula, M. K. et al. JAMA 2003;289:1747-1750.
Behavioral Models
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Theory-Based Behavioral Models
Integrating behavioral modification models into the primary care
setting has the potential to facilitate patients’ behavior change.
» Health Locus of Control
» Health Belief Model
» Social Cognitive Theory
» Transtheoretical Model (Stages of Change)
» Pressure System Model
Institute of Medicine. Health and Behavior: the Interplay of Biological, Behavioral, and Societal Influences. National
Academy Press. Washington, D.C. 2001
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Locus of Control
A behavior is dependent on the individual’s beliefs regarding the
value of the outcome (reinforcement) and the perceived probability
of that reinforcement occurring (expectancy).
•Reinforcement can be:
– Internal Locus
• Belief in level control and/or responsibility for own health
status; events result from one’s own behavior & actions.
– External Locus
• Belief that events are determined by the actions of others, fate or
chance (self-efficacy is likely to be low).
Identification of the locus of control (internal/external) will help the
clinician choose the most effective lifestyle counseling approach.
Gilbert, G.G., Sawyer, R.G., 2000, Health Education, Creating Strategies for School and CommunityHealth.Sudbury,
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Massachusetts. Jones and Bartlett.
Health Belief Model (HBM)
• Focused on attitudes & beliefs of the individual
• An individual will take health-related action if he/she:
– Believes a negative health condition can be avoided
– Expects the health condition can be avoided by taking a
recommended action
– Believes in ability to succeed with the recommended
health action
Glanz, K., Rimer, B.K., Lewis, F.M., 2002. Health Behavior and Health Education: Theory,
Research and Practice. 3rd Ed, San Francisco, Jossey Bass.
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HBM: Key Concepts
CONCEPT
DEFINITION
APPLICATION
Perceived
Susceptibility
One’s belief regarding the
chance of getting a
condition
-Personalize risk based on a
characteristic or behavior
-Make perceived susceptibility more
consistent with actual risk
Perceived
Severity
One’s belief of how
serious a condition and its
sequelae are
Specify consequences of the risk and
the condition
Perceived
Benefits
One’s belief in the
efficacy of the advised
action to reduce risk of
seriousness of impact
Define action to take: how, when;
clarify the positive effects to be
expected
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HBM: Key Concepts, cont’d
Perceived
Barriers
One’s belief about the
tangible and psychological
costs of the advised action
Identify and reduce perceived barriers
through reassurance, correction of
misinformation, incentives, assistance
Cues to Action
Strategies to activate one’s
“readiness”
Provide how-to information, promote
awareness, employ reminder systems
One’s confidence in one’s
ability to take action
-Provide training
-Use goal setting
-Give verbal reinforcement
Self-Efficacy
Glanz, K., Rimer, B.K., Lewis, F.M., 2002. Health Behavior and Health Education: Theory, Research
and Practice. 3rd Ed, San Francisco, Jossey Bass Publishers.
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Social Cognitive Theory
• Based on interactions between behavior,
environment, and person forming the basis for action.
• Self-efficacy beliefs influence goals, outcome
expectations and perceived environmental
impediments.
• Interventions focus on individual’s control of
behavior and their environment.
• Goals must be realistic and attainable.
•Bandura A. Health promotion by social cognitive means. Health Educ Behav.2004 Apr;31:2:143-64
•Glanz, K., Rimer, B.K., Lewis, F.M., 2002. Health Behavior and Health Education: Theory, Research and Practice. 3rd
Ed, San Francisco, Jossey Bass.
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Transtheoretical Model (TTM)
• Model was developed for smoking cessation.
• Health behavior changes occur in 5 stages (Stages of
Change) reflecting patient motivation.
• Individualized intervention is based on readiness to
make lifestyle change. Affected by:
– Decisional Balance: reflects the pros and cons of the
behavior
– Self-Efficacy: situational confidence with ability to perform
task.
•Di Clemente C, Prochaska J. Self-change and therapy change of smoking behavior: a comparison of processes of change in cessation and
maintenance. Addict Behav 1982; 7: 133-142.
•Glanz, K., Rimer, B.K., Lewis, F.M., 2002. Health Behavior and Health Education: Theory, Research and Practice. 3rd Ed, San Francisco, Jossey
Bass.
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•Hall K, Rossi J. Meta-analytic examination of the strong and weak principles across 48 health behaviors. Preventive Medicine 2008; 46:3:266-27
TTM: Stages of Change
CONCEPT
DEFINITION
APPLICATION
PRECONTEMPLATION
Unaware of the problem and has
not thought about change;
perceives cons outweigh pros
Increase awareness of need for change,
personalize information on risks and
benefits
CONTEMPLATION
Recognizes problem; considering
change in the near future
Motivate, encourage to make specific
plans; highlight advantages of change
PREPARATION
Makes a plan; chooses a start
date; setting goals
Assist in developing concrete action,
day-to-day plan; discuss challenges
ACTION
Implementing specific action plan
Give feedback, problem solve, social
support, reinforcement; lapses may
occur
MAINTENANCE
Continuing desirable actions or
repeating periodic recommended
steps
Assist in coping, reminders, finding
alternatives, avoiding relapses.
Continue to praise and support
•
•
Searight R. Realistic Approaches to Counseling in the Office Setting. American Family Physician; 2009;79:4:277-84
Glanz, K., Lewis, F.M., & Rimer, B.K. , 2000. (3rd Eds.) Health Behavior and Health Education:Theory Research and20
Practice. San Francisco, CA: Jossey-Bass Publishers.
TTM: Self-Efficacy
• Situation-specific confidence; coping with frustration.
• Important predictor of weight outcomes.
• Enables the individual to perform a behavior change
successfully and deal with times of temptation.
• Assists with pursuit of goals despite difficulties & lapses.
• Self-efficacy may improve as goals are met as well as
with verbal support from others.
•Glanz, K., Lewis, F.M., & Rimer, B.K. , 2000. (3rd Eds.) Health Behavior and Health Education:Theory Research and
Practice. San Francisco, CA: Jossey-Bass Publishers.
•Palmeira A et al. Predicting short-term weight loss using four leading health behavior change theories. International Journal
of Behavioral Nutrition and Physical Activity 2007, 4:4-14
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TTM: Processes of Change
Ten actions individuals utilize to proceed through the
stages of change; serve as guides for designing
interventions.
1. Consciousness raising
6. Helping relationships
2. Dramatic relief
7. Counterconditioning
3. Self-reevaluation
8. Reinforcement management
4. Environmental reevaluation
9. Stimulus control
5. Self-liberation
10. Social liberation
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TTM: Processes of Change
1.
Consciousness raising: Increasing awareness and acquiring new
knowledge that support behavior change.
2.
Dramatic relief: Feeling the unpleasant emotions that accompany
3.
Environmental reevaluation: Seeing the negative or positive
4.
Self-reevaluation: Understanding behavior change is a component
5.
Self-liberation: Diligence in one’s commitment to change behavior.
‘unhealthful behavioral risks’.
affects of one’s healthful or unhealthful behaviors on their social and
physical environment.
of one’s identity.
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TTM: Processes of Change
6. Helping relationships: Finding and utilizing a social environment
supporting behavior change.
7.
Counter-conditioning: Replace unhealthy behaviors with healthier
alternatives.
8.
Reinforcement management: Provide more rewards for healthy
behavior change and reduce rewards for unhealthy behavior change.
9.
Stimulus control: Eliminate cues to negative behaviors and add new
cues to encourage positive behaviors.
10. Social Liberation: Recognizing that opportunities supporting
positive behavior change are improving.
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Pressure System Model
PSM
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Pressure System Model (PSM)
•Applies stages of change to counseling interventions in primary
care environments:
• 2-question algorithm identifies patient's counseling focus
• Separates the two elemental goals of behavioral counseling:
1. Raising motivation
2.
Overcoming resistance
• PSM derives its name from meteorology – differences in
barometric pressure determine wind direction.
–
Movement will go from high to low pressure. As motivation
increases, resistance will be overcome- or vice versa.
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Katz DL. Behavior Modification in Primary Care: the Pressure System Model. Prev Med. 2001;32:66-72
Pressure System Model (PSM)
• Behavior change requires the right “MO”:
– M = Maximizing Motivation
– O = Overcoming Obstacles
• Raising motivation is a standard approach for behavioral
counseling in a primary care setting using motivational
interviewing
Motivation must exceed resistance for behavior change.
Change will not occur if perception of difficulty is greater than
the rewards.
Katz DL. Behavior Modification in Primary Care: the Pressure System Model. Prev Med. 2001;32:66-72
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Motivational Interviewing
• Style of patient-practitioner communication,
specifically designed to resolve ambivalence and build
intrinsic motivation for patients’ behavior change.
• Focuses on creating a comfortable atmosphere without
pressure, coercion or confrontation.
• Patients are better able to:
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–
–
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Share their concerns about changing
Understand their reasons for or against making changes
Make informed decisions
Feel invested in their choices
• Encourages self-efficacy.
Adapted from Borrelli B.(2006). Using Motivational Interviewing to Promote Patient Behavior Change and 28
Enhance Health. Medscape Family Medicine.
Motivational Interviewing
STANDARD
Approach to Behavioral
Counseling
MOTIVATIONAL INTERVIEWING
Approach to Behavioral Counseling
Focused on fixing the problem
Focused on patient's concerns, goals, values
Authoritarian relationship
Egalitarian partnership; client self-direction
Assumes patient is motivated
Match intervention to patient level
Advise, warn, persuade
Emphasize personal choice; elicits from client
Ambivalence = the patient is in denial
Ambivalence = normal part of the change process
Goals are prescribed
Goals are collaboratively set
Resistance is met with provider
argumentation and correction
Resistance is an interpersonal pattern influenced by
provider behavior; provider should shift responses
Miller W, Rollnick S. Motivational Interviewing. The Guilford Press; Second Edition edition (April 12, 2002) 29
Motivational Interviewing
OARS Approach:
- Open-ended questions
- Affirmations
- Reflective listening
- Summaries
Empathy by clinicians using the OARS approach in motivational
interviewing promotes an attitude of acceptance, supports
collaboration, and builds a solid foundation of practitioner-patient
communication.
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OARS Approach
• Open-ended questions:
– Help elicit less “biased” information in comparison to close-ended
questions which put the patient in a passive role.
– Usually begin with “Tell me about…”
• “Tell me about how your activity plan is going?”
• Affirmations:
– Statements of appreciation and understanding are important for
building and maintaining rapport.
– Offer positive affirmations to patients by acknowledging their efforts to
make changes (small and large).
• “You took a big step by coming here today.”
• “That is great that you were able to be active every day this week.”
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OARS Approach
• Reflective listening:
– Involves trying to better understand what the patient means by
reflecting it back in a short statement.
– Helps keep the patient thinking and talking about change.
• Patient: “It is difficult for me to move around.”
• Physician: “Sounds like you are finding it difficult to be physically active.”
• Summaries:
– Used to transition to another topic (usually mid-consultation).
– Involves highlighting both sides of a patients ambivalence.
• “You have several reasons for wanting to be physically active. You say you
would like to get more exercise. On the other hand, you say that finding
time is a hassle. Is that how you are feeling?”
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PSM: Five Counseling Scenarios
COUNSELING SCENARIO
APPLICATION
Patient is precontemplative and
has not attempted behavior
change
Intervention should focus on raising
motivation and should focus on what
should be changed and how it can be
done
Patient is contemplative or
preparative and has not
attempted behavior change
Motivation should be elevated,
strategies should be identified to
overcome potential barriers, and
focus should be on why changes should
be made and how it can be done
Patient is modifying behavior or
is maintaining behavior change
Maintaining motivation should be
encouraged, strategies should be
developed for new obstacles, focus
should be on how and why to sustain
changes
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PSM: Five Counseling Scenarios
COUNSELING SCENARIO
APPLICATION
Patient has a lapse to original
behaviors
Intervention should discuss cause(s) of
lapse, assuage feelings of remorse,
encourage motivation, and reinstate and
maintain internal locus of control
Patient is precontemplative or
contemplative and has attempted
to modify behavior
Motivation and self-esteem should be
raised, locus of control should once again
be internalized, discuss external
influences, and strategies should be
developed to overcome barriers
Katz DL. Behavior Modification in Primary Care: the Pressure System Model. Prev Med. 2001;32:66-72
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Summary of Module 3
• There is strong evidence associating the risks of
sedentary lifestyle and weight gain to increased
morbidity and mortality.
• Lifestyle counseling for weight maintenance or loss
may have significant benefits.
• Behavioral change models with Motivational
Interviewing (MI) techniques may help facilitate
patients’ behavioral changes.
• Module 4 provides a specific strategy for
incorporating lifestyle counseling in a primary care
setting.
•
•
Katz DL. Behavior Modification in Primary Care: the Pressure System Model. Prev Med. 2001;32:66-72
Katz DL, et al. Impact of an educational intervention on internal medicine residents’ physical activity
counseling: The Pressure System Model. J Eval Clin Pract. 2008; 14: 294-299.
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