In Theory…It Makes Sense.

1. In Theory…It Makes Sense. A Sample Overview of Behavior Change Theories and Their Practical Application Beverly Barber, RN Terry Stewart Denver Public Health

2. www.denverhealth.org/dph www.DenverPTC.org

3. Behavioral Science People change (or don’t change) a behavior for a variety of reasons!! But how do we explain it? • Seeks to understand how and why people do what they do • Psychology • Sociology • Anthropology

4. Behavioral Theory • Can be used to help understand the behavioral determinants of risk • Provides the basis for activities within a behavioral intervention • Guides the evaluation of an intervention • The constructs of theory suggest what to monitor and how to measure effectiveness

5. Behavior Change Theories & Models • Health Belief Model • Irwin M. Rosenstock • Social Cognitive (Learning) Theory • Albert Bandura • Theory of Reasoned Action • Martin Fishbein and Icek Ajzen • Transtheoretical Model/Stages of Change • James O. Prochaska and Carlo C. DiClemente

6. Health Belief Model (HBM) Premise: Health related behaviors depend on four key beliefs; all of which must be operating for a risk reducing / health promoting behavior to occur. • Key Components • Threat / Risk • Perceived susceptibility • Perceived severity • Outcome Expectations • Perceived benefits of performing a behavior • Perceived barriers of performing a behavior

7. HBM – Threat • Susceptibility • The recognition that personal behavior places one at risk for an infection/disease • “I don’t use condoms, so I’m at risk for HIV or STIs.” • Severity • The belief the infection/disease/condition will cause serious harm • “My father had a heart attack and he had to have triple by-pass surgery.”

8. HBM – Outcome Expectations • Decisional Balance The belief that the benefits of performing the behavior(s) need to outweigh the consequences of not performing it before behavior change will occur. • “If I work out I will feel better.” • “If I work out I won’t have time to watch American Idol.”

9. Social Cognitive (Learning) Theory Premise: Behavior is learned through direct experience or by modeling others’ behaviors through observation. Acquisition of a new skill is often required. The chances of behavior being repeated depends on the person’s assessment of its cost / benefits • Key Components • Self-efficacy • Can be increased through practice • Skill Acquisition • Outcome expectations • Positive or negative consequences • Reinforcement

10. Bend & Snap

11. Theory of Reasoned Action Premise: In order for behavior change to occur, one must have an intention to change. • Intentions are influenced by two major factors: • Attitudes: based on an individual’s beliefs about the positive and negative consequences of performing the behavior • Subjective norms • What significant others think or feel about behavior • Motivation to change behavior based on subjective norms

12. Subjective Norms • “None of my friends smoke, so I feel like I should quit.” or • “Seems like all my friends smoke, so I think I’ll try it.”

13. Behavioral Determinants • Perception of Personal Risk • Susceptibility • Severity • Knowledge • Attitudes & Beliefs • Intentions • Self-Efficacy • Skills • Perceived Norms • Social Norms • Social Support

14. Relapse Transtheoretical Modelaka, Stages of Change • Precontemplative • No recognition of need to change • Contemplative • Thinking about change • Preparation / Ready for Action • Short-term planning for change and initial attempts at the new behavior • Action • Consistently do the new behavior for less than 6 months • Maintenance • Performing the new behavior for more than 6 months

15. Denver Health Cardiovascular Disease Prevention A partnership between Denver Public Health and Denver Community Health Services 2006-2009

16. Background • CVD is the leading cause of mortality in Colorado, particularly in the Latino population • INTERHEART study (2004) demonstrated that 90% of population attributable risk is due to modifiable risk factors: • Smoking, dyslipidemia, HTN, DM, obesity, diet, exercise, psychosocial factors • In the general population, many have at least one risk factor; >90% of CVD events occur in persons with at least one risk factor

18. Intervention • Potential activities available for participants • Self-help tools, healthy nutrition and exercise activities, community-based exercise programs, and referrals to the Colorado QuitLine • Navigator will facilitate client’s transition to community-based programs • Navigator will follow-up with a client at 1-4 weeks and 6-10 weeks after enrollment to assist/encourage client in participating in selected programs • Additional follow-up will be performed as needed

20. Physical Activity • The Challenge • Despite the benefits of engaging in regular physical activity such as: reduction of cardiovascular disease and prevention of bone loss associated with aging, more than 60% of the adult population and more than half of the young people (aged 2-21) do not exercise regularly.15

21. Exercise: BenefitsCardiovascular Risk Factors • Increase in exercise tolerance - CVD risk factor improved muscle function and aerobic capacity • Reduction in body weight - CVD risk factor • Reduction in blood pressure - CVD risk factor • Reduction in bad (LDL) cholesterol - CVD risk factor • Increase in good (HDL) cholesterol - improves CVD risk factor • Increase in insulin sensitivity - CVD risk factor

22. Recreation Centers • Clients eligible to receive 3-month passes to Denver Park and Recreation centers • Participating centers: Barnum, Azatlan, and Rude • Able to participate in all activities offered at the centers • Exercise classes appropriate for beginners: • Water aerobics, walking clubs, stretch and tone, yoga, Tai Chi, introduction to weights, etc • Access to VOA/Arthritis Foundation Gentle Exercises with the Healthy Aging Program

24. Nutrition Programs • A series of 6 interactive classes • Nutrition • Food shopping • Food safety • Physical activity • Disease prevention • Cooking demonstration • Classes offered at the local recreation centers

25. Adult Cessation Promote Colorado Quitline & QuitNet

26. The 5 A’s Address Agenda Attend to the patient’s agenda • Explain that you would like to talk about some healthy choices for them to consider

27. The 5 A’s Ask • What does the patient know about the connection between his or her behavior and the possibility for disease? • How does the patient feel about the behavior? • Is the patient interested in changing the behavior? • What are the patient’s fears about change? • Has the patient tried to change the behavior before? What did and didn’t work? • It is important to spend adequate time in this stage. Patient counseling is more effective when patients know that the physician/provider understands their perspective.

28. The 5 A’s If you have limited time, spend most of it on assessment and then incorporate what you learn into a few words of advice. Advise • Tell the patient that you strongly advise behavior change • Personalize reasons for change (e.g., “By quitting smoking you will help your daughter have fewer asthma attacks.”) • Discuss the immediate and long-term benefits of change

29. The 5 A’s Assist • Provide accurate, complete information about risk and give the patient written materials to take home • Address the patient’s feelings and provide support • Address barriers to change • Discuss steps toward behavior change • Get attending physicians, residents or preceptors involved for additional support, more extensive advice and referrals

30. The 5 A’s Arrange Follow-up • Reaffirm the plan • Schedule follow-up appointment or phone call

31. Counseling tips Suggestions for Counseling: • Precontemplation to Contemplation: Demonstrate unconditional acceptance of the person. Give information with low pressure. • Contemplation to Preparation: Address the discomforts associated with change. Suggest small changes in thinking to get big changes in action. • Preparation to Action: Set a date for action and maintain realistic expectations. Suggest action-oriented programs. Expect 3 or 4 cycles of success and failure. • Action to Maintenance: Suggest strategies to prevent relapses. Anchor benefits to long term repetition of behavior.

32. Planning for nutrition changes • Making a Plan • What goal's can you set for yourself now? • Before my next visit, I am going to: • Eat fried foods less often • Aim to eat 5 or more fruits and vegetables per day • Eat smaller portions and less fatty foods • Instead of regular soda and sweet teas, drink water, 100% juice mixed with sparkling water, or skim milk • Make time for regular meals • Exercise regularly (try for 5 times a week) • Keep healthy snacks around • Make an appointment with a dietitian

33. Planning for Activity • Making a Plan • What goals) can you set for yourself now? • Before my next visit, I am going to: • Walk a little bit every day (with friends, kids, dog) • Exercise regularly (try for 5 times a week) • Join a local sports team, gym, or exercise class • Walk, bike, or take the bus instead of driving • Take the stairs and park farther away • Make an appointment with a personal trainer • Watch less TV Other:____________________________________________

34. Client Centered Approach

35. References • 12. Kottke TE, Battista RN, DeFriese GH, et al. Attributes of successful smoking cessation interventions in clinical practice: a meta-analysis of 42 controlled trials. JAMA 1988;259: 2882-9. • 15. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996.

36. Thank You! • Beverly Barber, RN Denver Public Health Cardiovascular Disease Prevention beverly.barber@dhha.org 303-436-7246 • Terry Stewart Denver Public Health Denver STD/HIV Prevention Training Center terry.stewart@dhha.org 303-436-7267