Consistent Components of Behavior Change Theories

Abstract

Psychological theories provide a framework through which to conceptualize the individual and their health problems. Although considerable variability exists between theories, raising awareness and providing patients with clear and specific feedback are consistent links in the application of these models. Engaging in these practices significantly increases the likelihood of promoting behavioral change.

‘The application of psychological theories and models to health behavior change is an extension of EBM [evidence-based medicine]’

Evidence-based medicine (EBM) is the application of the most current and best research findings into clinical practice.^1,2 As part of EBM, expert committees have been established in order to systematically review the relevant research and produce a set of clinical guidelines to assist the health care provider (HCP) with everyday decision making. These guidelines outline how and when to perform screening tests, when to provide various services or treatments, how long patients are in need of hospitalization or care, and the recommended follow-up care. ³ Some of the criticisms of EBM are that it promotes too much uniformity resulting in a “cook book” approach to patients and ignores clinical expertise developed through the practice of medicine.^3,4 However, the use of EBM is not meant to preclude the importance and use of clinical expertise, rather it is intended to promote the use of evidence-based practices as a way to inform clinical expertise. ⁵ While EBM has its critics, overall it is intended to provide a scientific basis for medical practice and public policy, promote efficiency and best use of limited resources, and ensure that the best and most efficacious care is provided to patients. ⁶

The application of psychological theories and models to health behavior change is an extension of EBM. As discussed by Linke et al, ⁷ these models provide a framework for conceptualizing the patient’s health problems and behaviors in order to develop targeted treatment plans. Overall, these models are intended to help HCPs conceptualize their patient’s health problems and potential barriers to treatment in order to increase the use of efficacious lifestyle treatments. ⁸ Similar to clinical guidelines, these models may be seen as formulaic. However, unlike the guidelines, they are not prescriptive and allow the HCP to apply clinical expertise within an evidence based framework. Although considerable variability exists between these models of health behavior change, raising awareness and providing patients with clear feedback are consistent links across the implementation of theories. ⁹

Raising Awareness

The first step to addressing an issue from a lifestyle approach is to raise awareness to the issue. This may happen in multiple ways. For example, many education programs that take place in hospitals and community settings focus on this. Public health initiatives often use media outlets in order to raise awareness through media outlets. ¹⁰ HCPs may do this by providing information to patients during medical visits. Individuals are also more likely to become aware of their own issues when they engage in self-monitoring. ¹¹ Without awareness of problems, individuals are unlikely to engage in behavior change.^12,13

Providing Feedback

In addition to raising awareness, providing feedback is a critical component in any behavior change model. ¹⁴ The purpose of feedback is to identify potential barriers and issues relating to the patient’s behavior and progress. ¹⁴ Ultimately, feedback provides the patient with the needed information to effectively engage in behavior change and should be concentrated on the barriers being faced, the patient’s sense of efficacy, and progress toward achieving goals. Feedback has been shown to have dramatic effects on behavior. For example, when individuals are provided with feedback on physiological functions with the intention of improving health (ie, biofeedback), they are able to manipulate brainwaves,^15-18 muscle tone, ¹⁹ and heart rate. ¹⁹ Given that feedback systems are seen at even cellular levels, ²⁰ it is not surprising that a similar process is needed for behavior change.

Patients can be given this information in general or targeted ways. For example, generic feedback such as multiple health benefits can be gained through exercise, or certain dietary patterns are associated with cardiovascular disease are statements that would be considered true for an entire population. ¹⁴ Targeted feedback is based on an examination of the current behaviors or risk factors for a specific individual and may also assist in determining progress toward a goal. ²¹ Examples of targeted feedback include informing a patient that he or she is obese and needs to decrease their use of screen media or having a discussion regarding the lack of progress in quitting smoking. On the positive side, praising a patient for accomplishing goals also falls into this category.

Targeted feedback is typically more difficult for HCPs to provide. Targeted feedback, especially when it is “negative,” may be viewed by the HCP as discouraging to the patient, which may in turn make it less likely for patients to return for future visits. As feelings of discomfort and/or uncertainty increase in the HCP, the likelihood of targeted feedback being provided decreases. Additionally, targeted feedback requires a more time intensive assessment, and the time constraints experienced by HCPs ²² may make this type of feedback less likely to occur. Although there are multiple reasons that this information is difficult to discuss, patients are more satisfied with their care when physicians provide feedback effectively. ²³

Keys to Delivering Feedback

Several concepts have been identified that are beneficial when engaging in difficult conversations. HCPs are encouraged to use these approaches at all times but may find them particularly useful in providing “negative” direct feedback.

1. Unconditional positive regard involves acceptance of the patient without judgment. ²⁴ It may be demonstrated through a willingness to actively listen without interruption and without providing advice. It this thought that use of unconditional positive regard helps patients feel comfortable enough to address difficult subjects. ²⁵

2. Being genuine in the doctor–patient relationship involves an ability to relate to patients without “hiding behind a professional façade.” This may involve disclosure of appropriate personal experiences in order to enhance the relationship. ²⁶

3. Demonstrating empathy for the patient conveys a desire to understand the client’s point of view. ²⁵ Empathy is critical in order for the patient to experience the provider’s unconditional positive regard.

Overall, using these techniques, HCPs can create an environment in which feedback is most likely to be accepted by patients.

Conclusion

In an effort to provide the most effective treatments for patients, psychological theories can provide an evidence based framework through which to conceptualize the individual and their health problems. Although considerable variability exists between these models of health behavior change, the universal components to the application of these models include raising awareness and providing patients with clear and specific feedback. The use of these elements within a nonjudgmental and safe environment enhances the likelihood of promoting behavioral change.