9/13/2011
Why this topic?
Behavior Modification
Strategies for Patient Adherence
to Exercise and Wellness
• Prescribing and promoting exercise and
educating patients on the importance and
value of exercise are key responsibilities of the
physical therapist
• There is limited information on how to get our
patients to comply with our therapy programs,
attendance, and continue with their HEPs
Megan Donaldson PT, PhD, FAAOMPT Ken Learman PT, PhD, OCS, COMT FAAOMPT
Assistant Professor
Associate Professor
Walsh University
Youngstown State University
North Canton, Ohio
Youngstown, Ohio
Presentation Outline
1.) Topic need and background stats
2.) Theories of Behavior Change
3.) Determinants of Exercise Adherence
4.) Exercise Adherence Strategies
5.) Behavior Change techniques for the 21st
Century
Why Study Exercise Behavior?
• Willful exercise participation is among the
healthy behavioral practices that require
further understanding.
• To emphasize this point, more than 75% of
citizens within the United State lead
completely sedentary lives.
Am J Health Behav.™ 2011;35(3):334-345
Overweight and obesity statistics
Getting Worse
National:
• Estimated 97 million adults in the U.S. are
overweight or obese
• 1/3 of U.S. adults are obese
• In 2008, medical costs associated with obesity
were estimated at $147 billion;
• Back in 2000, no state had an obesity
prevalence of 30% or more
• Now 2010, twelve states had obesity rates of
30% or more
• Between 1988–1994 and 2007–2008 the
prevalence of obesity increased in adults at all
income and education levels
– the medical costs paid by third-party payors for
people who are obese were $1,429 higher than
those of normal weight
http://www.cdc.gov/obesity/data/adult.html
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Impact of a “growing” problem
• Childhood obesity can have a harmful effect on
the body in a variety of ways.
– High blood pressure and high cholesterol
– Increased risk of impaired glucose tolerance, insulin
resistance and type 2 diabetes
– Breathing problems
– Joint problems and musculoskeletal discomfort
– Fatty liver disease, gallstones, and gastro-esophageal
reflux (i.e., heartburn)
– Social and psychological problems, such as
discrimination and poor self-esteem
EXERCISE STATISTICS
• 50% of kids age 12 to 21, do not participate
regularly in physical activity
• 10-15% of adults exercise 3 times per week for at
least 20 minutes
• Physical activity declines steadily through
adolescence from 70% at age 12 to 40% at age 21
• 10% of sedentary adults begin exercise programs
each year
• 50% of new exercisers will drop out within six
months
http://www.cdc.gov/obesity/childhood/basics.html, accessed 2011.
Barlow SE and the Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and
obesity: summary report. Pediatrics 2007;120 Supplement December 2007:S164—S192.
Han JC, Lawlor DA, Kimm SY. Childhood obesity. Lancet. May 15 2010;375(9727):1737—1748.
Sutherland ER. Obesity and asthma. Immunol Allergy Clin North Am. 2008;28(3):589—602, ix.
Biro FM, Wien M. Childhood obesity and adult morbidities. Am J Clin Nutr. May 2010;91(5):1499S—1505S
Exercise Adherence
The Problem…
• The ability to maintain an exercise program for
an extended time period
• One of the biggest health problems for
American adults, children and adolescents
• So you have the facts, now are you surprised
that your patient doesn’t like to exercise?
• How do you expect he/she to do her exercises
at home or when you are not watching?
– Possibly due in part to extensive reductions in
required physical education classes
Adherence
• Poor adherence to exercise and treatment is a
problem across a number of healthcare
disciplines including physical therapy (Vasey, 1990;
Friedrich et al., 1998; Campbell et al., 2001)
• Studies that report non-adherence with
treatment and exercise could be as high as
70% (Sluijs et al., 1993)
• 14% of physical therapy patients did not
return for follow up outpatient appointments
(Vasey, 1990)
Levels of Health Behavior
• Primary prevention
– Behaviors that a healthy person enacts in order to
maximize well being and avoid particular diseases
• Secondary prevention
– Behaviors that an individual undertakes after a
particular risk has been identified
• Tertiary prevention
– Behaviors are those that a persons undertakes in
order to control the progression of a disease or cure it
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Perceived self efficacy
THE THEORIES AND MODELS OF
EXERCISE BEHAVIOR AND CHANGE
Understanding Behavior Change
• Some models have received more evaluation
than others
• Each are helpful in some contexts and may
provide a useful structure to help us address the
maintenance of health behavior change and
adherence to treatment plans
• Developments and research evidence
frameworks explain the cognitive mechanisms of
behavior change and adherence to treatment in
the rehabilitation setting
• Perceived self efficacy is concerned with people’s belief
in their capabilities to produce given attainments
(Bandura 1997).
• There is no all purpose measure of perceived self
efficacy as there is limited explanatory and predictive
value because most of the items in all purpose test
may have little or no relevance to the domain of
functioning. (Martin 2010)
• Self-efficacy is thought to be predictive of the amount
of effort an individual will expend in initiating and
maintaining a behavioral change,
– it is an important element of many of the theories
Belief and Attitude
• Prominent in the theoretical models are
constructs of “beliefs” and “attitudes”
• Beliefs are the conclusions about the truth of
something and are cognitive elements in the
picture of how people evaluate and respond
to ideas
• Attitudes are the affective (emotional)
elements based on the individuals personal
feelings and emotions regarding a belief
Schwarzer, R.; Lippke, S.; Luszczynska, A. “Mechanisms of health behavior change in persons with chronic illness or
disability: The Health Action Process Approach (HAPA).” Rehabilitation Psychology, v. 56 issue 3, 2011, p. 161-70.
EXERCISE BEHAVIOR
THEORIES & MODELS
1.) Health Belief Model,
2.) Theory of Reasoned Action and Planned
Behavior
3.) Self-Determination Theory
4.) Transtheoretical Model
5.) Social Cognitive Models
6.) Information-Motivation-Strategy Model
Health Beliefs Model
• The Health Belief Model focuses primarily on beliefs
as the motivators of health behavior of the individual
– 1.) Perceived susceptibility (an individual's
assessment of their risk of getting the condition)
– 2.) Perceived severity (assessment of the
seriousness of the condition, and its potential
consequences)
– 3.) Perceived barriers (assessment of the
influences that facilitate or discourage adoption of
the promoted behavior)
– 4.) Perceived benefits (assessment of the positive
consequences of adopting the behavior)
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Health Beliefs Model
Demographic
Characteristics
Perceived
susceptibility to a
disease
Clues to Action
Perceived severity or
threat of a disease
Perceived benefits
Likelihood of
engaging in
preventive or
treatment
behavior
Perceived barriers
Self Efficacy
http://en.wikipedia.org/wiki/File:Healthbeliefmodel.png#filelinks
Created in OpenOffice.org Draw, based on Figure 7.2 page 137 of "Psychology in Practice; Health" Philip Banyard, published by Hodder & Stoughton 2002.
Theory of Reasoned Action
• Theorizes that people’s behaviors are primarily
governed by their intentions, which are developed
from their attitudes toward and social norms regarding
those behaviors
• According to the theory of reasoned action, if people
evaluated the suggested behavior as positive (attitude),
and if they think their significant others wanted them
to perform the behavior (subjective norm), this results
in a higher intention (motivation) and they are more
likely to do so
Sheppard, B.H.; Hartwick, J. & Warshaw, P.R. (1988). The theory of reasoned action: A meta-analysis of past research with recommendations for
modifications and future research. Journal of Consumer Research, 15, 325–343.
Transtheoretical Model of Change
• Several processes of change were identified
– 1. consciousness raising
– 2. choosing among options
– 3. contingency control (resources to help a person
change their environment and associated system
of rewards and punishments)
Prochaska J. Systems of Psychotherapy: A transtheoretical anaylsis. Homewood, IL Dorsey Press; 1979.
Prochaska JO, DiClemente CC. Stages and process of self-change of smoking: towad and integrative model of change. J Consult Clin Psychol
1983:51; 390-5.
Health Beliefs Model
• Self efficacy was added to the model and
improved that ability of this model to predict
behavior outcomes
• Meta-analysis of this model identified that
benefits and barriers were consistently the
strongest predictors
• Predictive of behavior, but only weakly so in
comparison to social cognitive theory and
especially as compared to the theory of reasoned
action
Carpenter, CJ. “A meta-analysis of the effectiveness of health belief model variables in predicting
behavior.” Health Communication, v. 25 issue 8, 2010, p. 661-9.
Theory of Planned Behavior
• Expansion on TRA to
target situation in which
the individual does not
have full control over the
behavior in question
• Behavior control is similar
to self efficacy
– Individual’s confidence that
he/she can enact change
– Improves predictive ability
of the model
Armitage CJ, Conner M. Efficacy of the Theory of Planned Behavior: a meta-analysis review. Br. J Soc Phychol. 2001
Madden TJ. Ellen PS. Ajzen I. A compariosn of the Theory of Planned Behavior and the Theory of Reasoned Action. Pers Soc
Psychol Bull. 1992;18(1);3-9
TRANSTHEORETICAL MODEL
Stage 1 = Pre-contemplation:
Person isn’t performing self-change behavior
and doesn’t intend to start. Initial notice of a
problem
Stage 2 = Contemplation:
Person isn’t performing the self-change behavior
but are thinking about starting. Action seriously
considered
Prochaska J. Systems of Psychotherapy: A transtheoretical anaylsis. Homewood, IL Dorsey Press; 1979
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TRANSTHEORETICAL MODEL
Stage 3 = Preparation: Person recently started
preparing to initiate self-change behavior such
as buying clothing and shoes, purchasing a
fitness membership or lining up an exercise
partner
Stage 4 = Action: Person has initiated the selfchange behavior consistently for a short period
of time. Trying to become more systematic
Prochaska J. Systems of Psychotherapy: A transtheoretical anaylsis. Homewood, IL Dorsey Press; 1979
The Evidence of the Transtheoretical
Model
• A meta-analysis revealed that the distinction
in the various processes of change were less
clear in studies of exercise than psychotherapy
and addictive behavior
• The model breaks down further when
timeframes are included in staging
TRANSTHEORETICAL MODEL
Stage 5 = Maintenance: Person has maintained
the self-change behavior consistently for 6
months or more and plans to continue doing so.
Reached habitual stage
Stage 6 = Relapse Prevention: Person encounters
serious lifestyle change after reaching
maintenance stage and has to adjust self change
program to prevent relapse. Making needed
adjustments to maintain lifestyle change
Prochaska J. Systems of Psychotherapy: A transtheoretical anaylsis. Homewood, IL Dorsey Press; 1979
Some thoughts based on the models
• The Transtheoretical model highlights two
important concepts about behavior change:
– Verbal communication and cognitive processing in the
early stages of change are important
– If the clinician’s focus and direction are too different
from the patient or if they are working at different
levels of change process, patient’s may become
resistant to change and quit PT or drop out
– Effective communication is key for early stage change
and identifying the appropriate level of the patient to
target interventions
Marshall SJ. Biddle SJ. The Transtheortical Model of behavior change: a meta-analysis of applications to phsyical activity and exercise. Ann Behav
Med. 2001: 23:229-46.
Social Cognitive Theory
• There are some similarities of this model and
the Health Belief Model
• Critically this model includes cognitive
elements of self-efficacy as part of the
personal factors and expectancies
Social learning/social cognitive theory
• Behavioral change is
determined by
– Environmental
– Personal
– Behavioral elements
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Information Motivation Strategy
Model
Information- Motivation Strategy
Model
• Conceptual approach to guiding adherence
and health behavior change
• Simplifies and consolidates many components
of the previous models and including a
boarder range of health-related behaviors
• Basic principles underlying this model and before
someone can achieve health behavior change a
patient must undergo
Information
Motivation
– Knowledge that the change is necessary (information)
– Have the desire to change (motivation)
– Necessary tools to achieve and then maintain the
change (strategy)
• Significant amount of evidence links each of
these components to positive patient outcomes
including behavior change and adherence
Health Behavior
Change and/or
Adherence
Strategy
REASONS ADULTS EXERCISE
DETERMINANTS OF EXERCISE
ADHERENCE
• Weight control for appearance and health
• Health benefits--particularly for cardiovascular
problems (i.e., hypertension)
• Stress and depression management
• Enjoyment
• Building self-esteem
• Social and affiliation benefits
EXERCISE BARRIERS
•
•
•
•
•
•
•
•
Lack of time
Lack of energy
Lack of motivation
Social support barriers
Health and fitness barriers
Other commitments
Resource barriers
Programming barriers
personal
factors
environmental
factors
EXERCISE ADHERENCE STRATEGIES
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BEST EXERCISE ADHERENCE
STRATEGIES
Make exercise fun and enjoyable
Tailor exercise frequency, duration and
intensity to the exerciser
Promote group exercise
Keep daily exercise logs
Reinforce success
Find a convenient place to exercise
BEHAVIOR MODIFICATION
APPROACHES
•
•
•
•
•
•
•
•
•
•
Behavior modification approaches
Reinforcement approaches
Cognitive-behavioral approaches
Decision Making approaches
Social support approaches
Intrinsic approaches
REINFORCEMENT APPROACHES
• Charting attendance and participation
• Rewarding attendance and participation
• Feedback and testing
Prompts and Charts
Behavior contracts
Perceived choice
Stimulus control
COGNITIVE-BEHAVIORAL APPROACHES
•
•
•
•
•
EXERCISE ADHERENCE STRATEGIES
DECISION MAKING APPROACHES
• Pros and Cons list
Goals
Self talk
Thought focus strategies
Association
Dissociation
– Personal barriers
http://www.womenwritingnow.com/writing-therapy-tips-for-building-selfesteem.html
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SOCIAL SUPPORT APPROACHES
INTRINSIC APPROACHES
• Social support from
partner, group or
class
• Know where to go for
what you need
• Must trust and
respect person to go
to them for support
• Focus on the experience
• Focus on the process
• Engage in meaningful
physical activity
Adherence Strategies Evidence
• Research suggests behavior modification has a
greater impact on increasing physical activity
than other approaches such as cognitivebehavioral modification
• Lack of research regarding the best behavioral
modification strategies and techniques to
motivate adults to exercise
• Two techniques in behavior modification that
have brought about the most success in
adherence have been
– 1.) behavior contracting
– 2.) stimulus control
Behavior Contract
• A behavior contract is an appropriate technique
to motivate adults to exercise because it creates
intrinsic motivation, is an individualized
technique that increases:
– Locus of control (Homme, & Hazler, 1999; Homme, Csanyi, Gonzales,
& Rechs, 1970; Kelley & Stokes, 1982; Langstaff & Volkmor, 1975),
– Creates consistency of goals (Gambrill, 1987; Tharp & Wetzel,
1969),
– Encourages active participation and selfdetermination (White-Blackburn, Semb, & Semb, 1977),
– Teaches independence and self-control (Homme, Csanyi,
Gonzales, & Rechs, 1970; Kabler, 1976).
Dishman & Buckworth, 1997
Owen & Sallis, 1999
Sample of a Behavior Contract
Who needs a contract
• Ask yourself 3 questions:
– Is the behavior changeable?
– Is the behavior measureable?
– Is the behavior persistent?
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Writing Behavior Contract Tips
Stimulus Control
• Make the contract specific and individualized
• Write the goal stated as the desired behavior,
NOT as the behavior to be stopped
• Make the contract measurable and observable
• Some patients may require appropriate
consequences (talk with your referring docs
about this) and rewards
• Include the patient in this contract and goal
writing
• Stimulus control is a behavioral technique in
which prompts are supplementary stimuli
used to increase the likelihood that an
individual will produce a specific response
such as exercise in the presence of the stimuli
that will eventually control behavior (Billingsley &
Stimulus Control
Stimulus Control Examples
• Step 1) First step is for the client to self-monitor
his or her exercise behavior
• Step 2) Work with patient to developing an
environment conducive to promoting exercise
(Dishman, 1988)
– The time, place, and individuals that compose the
environment for exercise will then represent the cues
for those who adhere to the exercise program
• Step 3) Decrease of cues for competing behaviors
Romer, 1983; Snell, 1983).
• Stimulus control involves providing stimuli
that will increase the chances of engaging in
the desired behavior.
• Examples: place exercise shoes, water bottle
in sight, picture of HEP on mirror in bathroom,
copy of exercise log by the TV remote, exercise
photos on the refrigerator door as a constant
reminder
(Martin & Dubbert, 1987)
Stimulus Control Ideas
• The clinician can promote this process by
helping the client identify specific times and
locations that promote adherence, so that
there are no competing cues, and the
individual can successfully adhere to his or her
exercise program
• “Meet group at 6am on the running trail”
http://www.mooreonrunning.com/2010/12/motivation-to-run.html
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Compliance Charts
• Modifying behavior comes with being
consistent
• Using a system of rewards and consequences
may help facilitate good compliances.
– Attendance of all visits without no shows and
rescheduling of all visits results in a 1 month
fitness pass at then end of physical therapy.
– For diet, one “binge” day per week
Improving Exercise and HEP Adherence
Group Exercise
• Group training builds in
accountability
• The group is let down
when you don’t attend
• Socialization is lost if
patient does not attend
• Vicarious experiences
are helpful for
motivation
• Another factor to take
into consideration is
that research has
indicated that exercising
alone will result in a
greater dropout rate
than exercising as a
group
Exercise Adherence and Behavior
Change
• Behavioral techniques are important
contributors to a successful exercise program
– Contracting and stimulus control are thought to
be the promoters of exercise adherence behavior
• Goal setting and self-monitoring help maintain
exercise adherence behavior
Exercise Adherence and Behavior
Change
• Follow up with your
patient
• Ask to see their log
• Ask to see them perform
a few of their HEP to
ensure good form
• Ask them which exercises
they are doing
• “Which ones do you like”
Schwarzer, R.; Lippke, S.; Luszczynska, A. “Mechanisms of health behavior change in persons with chronic illness or disability: The Health Action
Process Approach (HAPA).” Rehabilitation Psychology, v. 56 issue 3, 2011, p. 161-70.
Pearson, ES. “Goal setting as a health behavior change strategy in overweight and obese adults: A systematic literature review examining
intervention components.” Patient Education and Counseling, 2011.
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Behavior Change
• Both behavior modification and cognitive
behavioral methods have demonstrated success
in reducing the dropout rate of exercisers
• Utilizing reinforcement for healthy behaviors,
contracting, self-monitoring, instruction, goal
setting, increasing self-efficacy, and assisting in
relapse prevention improves adherence to
physical activity programs by roughly 15% to
20%
(Dishman & Buckworth, 1997)
Goals
• Goals should be flexible
• Goals need to be individually tailored and
OWNED by the patient
• Goals should also be realistic with respect to the
time necessary to achieve the goal and the
client's expectations.
– more effective to set smaller, more achievable goals
so the client can experience success (Annesi, 1996)
– Baby steps…..
• Check goal setting and achievement progress
regularly for motivation and feedback
(Annesi, 1996)
Goal Contracting
• Write goals with your
patient and give them a
copy in their own words
– Use these in a modified
version for your
documentation
• Make it a contract with
the patient with regular
checking up
Goals and Contracting
• Contracting is a technique used in conjunction
with goal setting
• Develop a contract that clearly describes the
exercise program, the clients' goals, the benefits of
doing the activity/exercise, and what is expected
from the client
• Be aware, before developing the contract, of the
client's readiness level (Transtheoretical Model)
• Once the client signs the contract he or she is
assuming responsibility for the exercise program
and the goals become intrinsically embedded
(Prochaska et al., 1991)
Goal Framing
• Framing goals may influence whether or not a
person stays actively engaged in pursuit of
their goal
• Research shows that people who think about
their goals as steps towards increasing their
skills (instead of performance indicators)
remain engaged in trying to achieve those
goals even following failure
Goal and Behavior Change Contracting
• Contracts have been found to be effective across
a variety of domains
• Applies subtle social pressure by reminding
people that they have promised to follow up on
the things that they made a commitment
• Currently, limited evidence that contracts can
potentially contribute to improving adherence
– but there is insufficient evidence from large, good
quality studies to routinely recommend contracts for
improving adherence to treatment or preventive
health regimens
Bosch-Capblanch, X.; Abba, K.; Prictor, M.; Garner, P. “Contracts between patients and healthcare practitioners for improving patients' adherence to
treatment, prevention and health promotion activities.” Cochrane Database Syst Rev, issue 2, 2009,
Elliott ES, Dweck CS. Goals: An approach to motivation and achievement. J pers Soc Psychol. 1988; 54(1):5-12
Gerber, JB.; Bloom, PA.; Ross, JS. “The physical activity contract--tailored to promote physical activity in a geriatric outpatient setting: a pilot
study.” Journal of the American Geriatrics Society, v. 58 issue 3, 2010, p. 604-6.
Liberman, A.; Rotarius, T. “Behavioral contract management: a prescription for employee and patient compliance.” The Health Care Manager,
v. 18 issue 2, 1999, p. 1-10.
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Intrinsic Motivation
Intrinsic Motivators
• Caution when implementing behavior
modification techniques with external rewards
sometimes diminish the intrinsic motivation
• Some patient’s develop by the body changes that can
be produced through exercise such as weight loss or
increase of muscle tone and definition
• By maintaining a level of enjoyment, the individual will
feel motivated to continue with the exercise program
• Frequently, asking the client his or her level of
enjoyment will increase maintenance
• In addition, those clients who believe in the value of
exercise for their specific benefit have a greater
possibility of incorporating and maintaining exercise as
part of their lifestyle (Dishman, Sallis, & Orenstein, 1985)
Deci, EL.; Koestner, R.; Ryan, RM. “A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation.”
Psychological Bulletin, v. 125 issue 6, 1999, p. 627-68; discussion 692-700.
Motivational Interviewing
• Behavioral modification strategy developed to
assist in substance abuse care but found to
have wider spread implications
• 4 steps
Listening to the Client
• Time must be allotted to allow the client to
work through what changes should occur in
their lives
• Empathy is important
– Listening to the client
– Help client to identify reasons for change
– Let Internal resistance to exist
– Provide the client assurance
Identify Importance of Change
Work Through Resistance
• Client driven and HCP supported identification
of importance of change
• Client needs to internalize the stated
arguments and will likely develop resistance to
change
• HCP must respect this resistance as part of the
process
• Allow the internal resistance to exist
• Work through the internal resistance with the
client
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Client Assurance
• Time must be taken to assure the client that
they are capable of making the desirable
behavioral change
• Self-belief encourages success in modification
Evidence
• MI resulted in greater weight loss and BMI
reduction
• ES of 0.51 in one Meta-analysis and 0.56 in
another
• Individual studies
Rollnick S et al. Motivational Interviewing in Healthcare: Helping patients change behavior. New York. Guilford Press; 2008.
Armstrong MJ et al. Motivational interviewing to improve weight loss in
overweight and/or obese patients: a systematic review and meta-analysis
of randomized controlled trials. Obes Rev. 2011;12(9):709-23
Reality….
“At Risk Group”
• Outreach groups
– Need a safe place to do exercises
• Patients/clients may receive
emotional support from other
individuals that exercise with
them (Martin & Dubbert, 1987)
• It is expected that if clients are
not motivated to exercise, the
possibilities of dropout from the
exercise program are high
Identify Safe
places to reduce
barriers
Schwarzer, R.; Lippke, S.; Luszczynska, A. “Mechanisms of health behavior change in persons with chronic illness or disability: The Health Action
Process Approach (HAPA).” Rehabilitation Psychology, v. 56 issue 3, 2011, p. 161-70.
Facilitating Behavior Change
Facilitating Behavior Change
• Facilitating treatment adherence and relapse
prevention, the patient/client must internalize
the concept that he or she can succeed in this
doing the task or activity (Sonstroem, 1997)
• Exercise programs must be composed of one
small goal that can be reached in a short period
of time and a long-term goal (Dishman & Buckworth, 1997)
• The purpose of the PATIENT DRIVEN short-term
goal is to ensure a feeling of self-efficacy as he or
she achieves this goal
• Tailoring of the exercise program is one of the
fundamental keys in exercise adherence and
maintenance
• Research has shown that clients who believed
that their program is specifically designed for
them continue longer than those who don't
have that same impression
(Ganley & Sherman, 2000)
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Facilitating Behavior Change
• Creating an internal locus of control
• Research shows that individuals who believe
that they are able to produce change have the
highest performance rate (Carter, Lee, & Greenockle,
1987)
• These changes may include self-efficacy
regarding aerobic exercise and greater internal
locus of control of health benefits (Labbe & Welsh,
Strategies for Increasing Self-Efficacy
• People acquire their self-efficacy beliefs from
the following four sources:
– past performance
– vicarious experiences (observing others perform)
– verbal persuasion
– physiological cues
1993)
Martin LR, Haskard-Zolnierek KB, DiMatteo MR. Health Behavior Change and Treatment Adherence. 2010 Oxford University
Press.
Strategies for Increasing Self-Efficacy
• Enactive Attainments – personal experiences
of success
– Set small steps toward behavior change so that
success can be experienced early
– Discuss with patients their past successes so that
these are prominent
Martin LR, Haskard-Zolnierek KB, DiMatteo MR. Health Behavior Change and Treatment Adherence. 2010 Oxford University
Press.
Strategies for Increasing Self-Efficacy
• Vicarious Experiences- Seeing the successes of
similar others
– Share the success stories of others (no names
HIPAA)
– Engage patients in groups where they can view
successful change
– Participation in groups also means that dropping
out affects others
Martin LR, Haskard-Zolnierek KB, DiMatteo MR. Health Behavior Change and Treatment Adherence. 2010 Oxford University
Press.
Strategies for Increasing Self-Efficacy
• Verbal Persuasion- being told that
one is capable
– Assure the patient of their ability
– Provide rationale for your belief
about the patient’s capability to be
successful
• Physiological arousal
– Help patients channel their feelings
into their workout or activity and use
that “nervous” “anxious” or
“frustration” energy
BEHAVIOR CHANGE TECHNIQUES
FOR THE 21ST CENTURY
Martin LR, Haskard-Zolnierek KB, DiMatteo MR. Health Behavior Change and Treatment Adherence. 2010 Oxford University
Press.
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Technology in Behavior Change
• When new behaviors are
considered fun,
adherence may be
enhanced
• Technology has been used
to make physical activity
fun (Bailey,2011)
• Nintendo Wii, Dance
Dance Revolution,
Microsoft Kinect all are
interactive games that
increase activity
Am J Prev Med 2002;22(4S):73–107)
Gaming & Physical Activity
• Interactive gaming can be used to increase
fitness and improve balance
– Wii tennis and boxing created moderate activity
levels for pts with chronic stroke (Hurkmans,2001)
– Wii increased balance in healthy women aged 3060 (Nitz,2010)
• Games are intergenerational and some report
that participating brings families together and
is considered “quality time”
http://www.gamertell.com/technologytell/article/84-year-woman-crowned-community-wiibowling-champion/
Music/TV
• iPods or their equivalent are used to make the
exercise environment more fun
• Audio or visual stimulation may make time
pass faster while exercising
• Subjects report that a gaming exercise cycle
makes it more enjoyable than riding a
standard stationary bike increasing adherence
(Rhodes,2009)
Monitors of Physiologic Effort
• HR monitors, power
meters, real-time GPS
all give routine
feedback which can
help motivate exercisers
to attain higher level
goals
• Feedback can prevent
subjects from exercising
too hard which can
discourage participation
Internet Feedback
• Online exercise logs to record details of
workouts
• Social networking for group support of
exercise or behavioral modification efforts
(Vincz,2010)
Hand Held Devices
• Customized smartphones can be
used to track dietary intake and
physical activity giving color coded
feedback real-time
• The effects of this technology are
currently under investigation
(Coons,2011)
• Systematic review suggests that
self-monitoring these variables
works. (Burke,2011)
• A PDA has been shown to be
effective for self-monitoring of diet
and exercise (Burke,2011)
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9/13/2011
Summary
• Best predictor of future behavior is previous
behavior
• Change readiness may be identified by using
models and should take strategies early to modify
behavior
• Behavior change methods may change depending
on stage, but self-efficacy is a strong predictor of
success
• Technologies can be used to tap into the
generation gap, but listen to your patient and
make it individualized for them
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