Abstract
Health behavior modification is perhaps the single most important and fundamental concept in lifestyle medicine. Understanding the psychological theories that explain “why” people act as they do when initiating a health behavior change can be the key factor in determining program success or program failure. Application of these theories into clinical practice is both important and challenging. Presented in this article are examples of practical applications that one lifestyle medicine program has made with the psychological theories of the health belief model, the social cognitive theory, and the transtheoretical model.
‘Health behavior modification is perhaps the single most important and fundamental concept in lifestyle medicine.’
Health behavior modification is perhaps the single most important and fundamental concept in lifestyle medicine. Similar to a pharmacological reaction, health behavior modification can be considered the rate-limiting step when working with individuals who wish to participate in healthy lifestyle behaviors. For example, simply writing the perfect exercise prescription for an individual with high blood pressure is not enough. However, providing that individual with the personalized tools that he/she needs to successfully implement the exercise prescription can lead to exercise adherence and greater program success. Understanding the psychological theories that explain “why” people act as they do when initiating a health behavior change can be the key factor in determining program success or program failure. Application of these theories into clinical practice, however, can be challenging.
Tools can be developed from psychological theory concepts and can help an individual, at a personal level, make a health behavior change. One particular lifestyle medicine program in an employee health setting has used the health belief model, the social cognitive theory, and the transtheoretical model to develop practical tools that assist its participants with their health behavior change. The purpose of this article is to explain how these lifestyle medicine tools were developed and implemented from these 3 psychological theories.
Health Belief Model
The health belief model (HBM) theorizes that an individual is more likely to engage in a given health behavior if, among other things, that person perceives himself or herself as highly susceptible to a particular illness and that the behavior will decrease this susceptibility. 1 An example of a tool that can be used to practically implement the HBM is a health risk calculator. Several health risk calculators are available and can estimate a person’s risk of being diagnosed with various types of cancers, osteoporosis, depression, cardiovascular disease, and many other illnesses. Health risk calculators are available in both electronic and paper-based formats, and practitioners often use these tools to demonstrate certain disease susceptibility to their patients.
One commonly used risk assessment tool that is recommended in the current cholesterol guidelines (ATP III) is the Framingham hard coronary heart disease (CHD) risk calculator. 2 It was developed from the Framingham Heart Study and estimates an individual’s 10-year risk for myocardial infarction and coronary death. This particular risk calculator provides the practitioner and patient with a percentage numerical value that predicts the risk (eg, 10% risk for hard CHD). Similarly, the Framingham Heart Study has develop a general cardiovascular disease (CVD) calculator that predicts a person’s 10-year risk of experiencing one of several different types of cardiovascular-related events. 3 In either case, the practitioner has the responsibility of explaining to the patient how to interpret what the percentage numerical value means in practical terms. This can be challenging for the practitioner and confusing for the patient.
We have implemented a very simple method that shows an individual their risk for CVD, but in a way that is more easily understood. The method uses the paper-based format of the Framingham general CVD risk calculator. 4 This particular risk calculator not only predicts the numerical percentage value of a person’s risk for CVD in the next 10 years but also converts this percentage into an estimated heart/vascular age. Although the estimated heart/vascular age is not used for diagnosis or treatment decisions, research has demonstrated that using analogies such as “heart age” to describe a patient’s individual risk is a powerful education tool.4,5 This particular calculator is available in both electronic and paper-based formats. We use the paper-based format of this calculator because it allows the patient to more easily identify which particular variables are increasing their risk for CVD. The paper-based tool uses tables to assign a score to each variable (eg, age, blood pressure, smoking status). The total score is then placed on an additional table, which then provides the 10-year risk percentage and the heart/vascular age. The next step is to then simultaneously look at the patient’s actual biological age compared with their estimated “heart age.” In our experience, it is much easier for a person to grasp their CVD risk when comparing their actual age to their estimated heart age. Our experience of using the “heart age” method has been positive in helping patient’s perceive their susceptibility to CVD, as explained in the HBM.
The key to using this method, however, is in the application of another concept of the HBM. Using the paper-based format of the general CVD risk calculator allows us to work the numbers backwards to demonstrate that changing a patient’s lifestyle can lower their “heart age.” For example, adhering to an exercise program may lower their systolic blood pressure, which may lower their score and decrease their heart age. We may then further explain that participating in multiple lifestyle behaviors can lower their blood pressure even further and, therefore, significantly lower their heart age. The HBM posits that a person is more likely to participate in a given activity if they believe that engaging in the activity will make a difference in their susceptibility of acquiring the disease. Our experience shows this to be true when the using the “heart age” method.
Social Cognitive Theory
The social cognitive theory (SCT) states that behavior change is influenced by individual factors in addition to the social and physical environment. 1 Self-efficacy is the main construct of the SCT and refers to the confidence that an individual has in his or her ability to successfully perform a particular behavior. Self-regulation strategies can be used to enhance self-confidence. According to the SCT, self-monitoring one’s own health behaviors can lead to greater self-efficacy and ultimately greater success when implementing healthy lifestyle behaviors. 1
Our program has developed 2 tools that use the SCT. The first is a lifestyle journal that is specific to our program. On a daily basis, our program participants are required to record their minutes of purposeful physical activity, servings of fruits and vegetables, number of hours of sleep from the previous night, stress level, the number of alcoholic drinks they consumed that day, blood pressure with a home monitor, and other variables. Tracking this information over time has not only increased the participants’ self-awareness of their lifestyle habits but has also enhanced their awareness of how each of their lifestyle behaviors can have an influence on one another. For example, the lifestyle journal allows the participants to recognize that increased stress and lack of sleep can increase their blood pressure. Similarly, they also recognize that consistent exercise and adequate fruit and vegetable consumption can lower their blood pressure. In our experience, using a lifestyle journal that is specific to our program goals has led to greater self-efficacy and program success. 6
Another self-regulation strategy that we incorporated in our program was the notion that a balanced approach to healthy lifestyle activities is more important than simply concentrating on any single healthy behavior. To do this, we created the Composite Lifestyle Index (CLI).6,7 The CLI was developed by using a leveled scoring system for the lifestyle behaviors of physical activity, healthy eating, sleep, stress management, alcohol consumption, and tobacco use. The CLI combines the scores of each behavior and calculates a single numerical value based on the participants’ activities over the previous 2 weeks. We explain to the participants that their CLI is like the grade point average (GPA) of a student and provides a snapshot of multiple healthy lifestyle behaviors that can be tracked and compared over time. Pilot data from the CLI shows a statistically significant and positive correlation with health-related quality of life. In other words, as CLI increases, so does quality of life. 7 The CLI is a practical application of SCT because it is a self-regulation tool that can also reinforce the benefits of participating in healthy lifestyle behaviors with improvements in quality of life and self-confidence.
Transtheoretical Model
The transtheoretical model (TTM) describes the stages that an individual goes through on their way toward implementing a new behavior, such as quitting tobacco use or starting an exercise program. 8 The TTM regards change not as a single event or moment in time but rather a process that unfolds over time. As such, there are 5 stages of TTM: Precontemplation, Contemplation, Preparation, Action, and Maintenance. 9
In our program, we have put TTM to practical use in a questionnaire format where the results help us identify which lifestyle behaviors the participant may experience the most success with implementation. 9 The tool is called the “Readiness to Participate” questionnaire and asks the participant to self-identify their “readiness” to participate in 16 different healthy behaviors. The healthy behaviors range from exercise participation and fruit/vegetable consumption, to taking medications as prescribed and wearing a seat belt. TTM stages are reworded with descriptive phrases that categorize their responses into 1 of the 5 TTM stages. We then make note of the activities that are identified as being in the Preparation or Action stage. This tells us that the participant is planning to implement the behavior or has already recently implemented the behavior. 9
We then give them a second questionnaire that lists the same 16 healthy behaviors, but asks them to rate their “confidence” with successfully implementing the activity. This tool is called the “Confidence to Participate” questionnaire and is another example of practical use of the SCT by measuring self-efficacy. We then match the healthy behaviors that are scored as “Very Confident” with those on the “readiness” questionnaire in the Preparation or Action stage. These are the behaviors that will be most easily implemented in our lifestyle medicine program, and therefore are the initial behaviors we recommend the participant begin to implement. From our experience, this method builds confidence (self-efficacy) early in the program, which makes the participant more willing to tackle other healthy lifestyle behaviors.
Conclusion
Understanding psychological theories is important to the practitioners of lifestyle medicine because health behavior modification may be the single most important factor when designing a lifestyle medicine program. Lifestyle medicine practitioners should be encouraged to use psychological theories to develop tools that can lead to a more personalized program for each individual in their program. This can then result in greater individual and overall program success.