Supporting behaviour change: using evidence-based methods in practice.
“Believe you can and you're halfway there.” ― Theodore Roosevelt
There are two recurring beliefs among both the general public, and unfortunately, many health and fitness professionals. Firstly, that sedentary lifestyles and poor diets are undertaken entirely through individual choice, and secondly that pointing out the error of a clients ways and then somehow injecting them with some motivation or knowledge will be the answer to their individual problems.This article will review some of the evidence around changing behaviour and will offer practical advice for exercise professionals that are keen to support their clients in making healthy lifestyle choices.
It's been known for some time that simply understanding the link between lifestyle choices and health does not always lead to people making the best decisions for their own health (Harrison et al, 1992) and over the years a number of psychological theories have been developed to try and examine the difference between those that are active and those that are not. Social Cognitive Theory (SCT) is one theory that suggests that an individuals knowledge and abilities stem from social interactions, experiences and other outside influences such as the media and a central theme of SCT is self-efficacy which is defined as a persons "situation-specific belief in his or her capabilities to perform a behaviour" (Bandura, 1997). Levels of self-efficacy can predict both the adoption and maintenance of physical activity and dietary changes (Ashford et al, 2010; Greaves et al, 2011) and higher levels of self-efficacy are associated with more effective weight loss (Gallagher et al, 2006,) increased exercise “readiness” (Biddle & Mutrie, 2008) and an increased ability to exercise at higher intensities. Higher levels of self-efficacy are also associated with more positive emotional states before, during and after a bout of physical activity.(Mcauley et al, 2003), which in turn can lead to increased chances of being active in the future.
People with high self-efficacy are more likely to use self-regulatory strategies such as goal setting, self-monitoring, planning and problem solving (Ayotte et al, 2010) and there is also a reciprocal relationship between self-efficacy and exercise: while levels of self-efficacy are related to uptake and adherence in a physical activity programme, increased levels of physical activity can also be a source of increased self-efficacy (Jackson, 2010). People will often cite barriers to exercise such as lack of time or resources but self-efficacy is seen to have a role in this process as it has been suggested that the perceived behavioural control over these barriers is a better predictor of physical activity rather than the barriers themselves (Ayotte et al, 2010).
Unfortunately, self-efficacy can also be negatively affected and repeated failures experienced when following diets and weight loss programmes can result in little confidence in an individual’s ability to succeed in future attempts, a fact that can help create a cycle of dieting programmes that is often seen as people move from one unsustainable diet to the next. As Bandura’s original definition identifies, self-efficacy is behaviour specific and not transferable so an individual can be quite a high achiever in work and other areas but low in confidence when it comes to making changes to physical activity levels.
Types of self-efficacy
When considering self-efficacy it has been suggested that there are different elements of the behaviour change process that require self-efficacy (Upton & Thirlaway, 2014). Exercise efficacy is the belief in your ability to successfully engage in physical activity across a range of modes, intensities, and duration while barriers efficacy is the belief that you can overcome obstacles or social, personal or environmental barriers. Scheduling efficacy is the confidence in your ability to plan physical activity behaviours into a routine and health-behavior efficacy is the belief that you are capable in engaging in health promoting behaviours such as meeting the physical activity guidelines. Just as self-efficacy is specific to a particular area of life, so there may be different aspects of self-efficacy within the area of physical activity.
Factors affecting self-efficacy
So it is all very well knowing that self-efficacy is important in predicting how successful our clients will be in changing their behaviour but how can we apply this knowledge to our practice? If we know that self-efficacy is important then next we need to look at the factors that affect self-efficacy and how we can influence these factors in a positive manner. Fig 1 outlines the key factors adapted from those laid out by Bandura (1997).
Mastery is said to be the most important factor in determining a person’s self-efficacy and is the feeling gained by completing a particular task that requires skill and/or hard-work. Vicarious experience is the knowledge gained by seeing someone like us benefit from a particular experience and verbal persuasion is the influence of others in encouraging, or discouraging us from a particular behaviour. It is worth noting that discouragement can have more effect on us negatively than encouragement can have on us positively, so at times we may have to work extra hard to undo the negative influence of significant others. Physiological and emotional states are important in allowing people to experience the normal responses to exercise and to embrace these as being linked to benefits rather than negative side-effects.
What can we do to help?
Once we know what factors can affect self-efficacy we can start to consider what we can do to influence the self-efficacy of our clients. Here are some ideas (adapted from Upton & Thirlaway, 2014 and Jackson, 2010):
- Use activities that provide an opportunity to learn new skills eg dance
- Find activities that people enjoy
- Keep an exercise log that can retrospectively show improvement over a number of months.
- Set people up to achieve, gradually increasing the frequency and intensity of the activity so people can achieve the new targets.
- Explore past personal successes and highlight achievements.
- Use sport to in a positive, non-threatening, supportive environment to provide opportunities for overcoming feelings of “I'm not the sporty type”
- Maximise the exposure to positive modelling experiences.
- Introduce new participants to more experienced successful participants.
- Demonstrate new activities while being aware of the complexity of some movements. Identify the degree of learning needed and break activities down to realistic parts.
- Use text and video to capture the positive experiences of successful participants (see this example from our ActiveChoices programme)
- Imagery can be used to recreate past success or to visualise desired future successes.
- Use positive and encouraging feedback.
- Develop social support networks and buddy systems.
- Call people to encourage them in between personal contacts.
- Use social media to provide support from others.
- Capture supportive messages from friends and family by asking for written or video feedback on how well the participant is doing.
- Use a behavioural contract, e.g. the client agrees to exercise three times a week for 6 weeks.
- The use of positive self-talk may be an appropriate strategy for some people.
- Teach people how to become more aware of what is normal and abnormal when exercising. explain how many of the symptoms of exercise (increased heart rate, fatigue) are normal and can be precursors to better health in the long term
- Provide opportunities to discuss emotions and maximise opportunities for connecting feelings of well-being with physical activity. discuss and record feelings of energy and success after a bout of physical activity and use these to prompt clients prior or during future activity sessions.
Beyond factors discussed here, Greaves et al (2011) reviewed elements of successful lifestyle interventions aimed at integrating SCT and/or other behaviour change theories and identified common techniques such as cue avoidance, self-monitoring, stimulus control, planning problem solving, relapse prevention, coping strategies, and goal setting but identified social support as being key to changing behaviour and suggested that participants should be encouraged to seek out others that are important to them and will be supportive (eg family, friends). Greaves (2014) has also recommended that programmes use established, well defined behaviour change techniques and adopt a person-centred, empathy-building approach, that builds on what people already know. Michie et al (2013) have also reviewed many lifestyle intervention studies and produced what they term a taxonomy of behaviour change strategies [click here for more], a tool that is very useful in studying different programmes but also in developing and optimizing new programmes.
It’s possible to be a good exercise professional without knowing about these theories and some will use many of these techniques naturally in doing their job and interacting with clients. Others however, might benefit from reflecting on how many of these strategies they employ in their day-to-day practice as research has shown (Pavey et al, 2011) that as an example, many exercise referral schemes are lacking in their inclusion of appropriate behaviour modification strategies.and this is having an impact on the quality of the intervention. So whether you are a good instructor that wants to be great or an emerging exercise professional it is important to take the time to find out more about the latest evidence in behaviour change techniques.
All of the sources referenced in this article are listed below along with other articles that may be of interest.
(original post, 2014)
References and Further Reading
Abraham, C., & Michie, S. (2008). A taxonomy of behavior change techniques used in interventions. Health psychology, 27(3), 379.[full text]
American College of Sports Medicine. (2013). ACSM's Behavioral Aspects of Physical Activity and Exercise. Lippincott Williams & Wilkins.
Anderson, E. S., Wojcik, J. R., Winett, R. A., & Williams, D. M. (2006). Social-cognitive determinants of physical activity: The influence of social support, self-efficacy, outcome expectations, and self-regulation among participants in a church-based health promotion study. Health Psychology, 25(4), 510.[full text]
Ashford, S., Edmunds, J., & French, D. P. (2010). What is the best way to change self‐efficacy to promote lifestyle and recreational physical activity? A systematic review with meta‐analysis. British journal of health psychology,15(2), 265-288.[full text]
Ayotte, B. J., Margrett, J. A., & Hicks-Patrick, J. (2010). Physical activity in middle-aged and young-old adults the roles of self-efficacy, barriers, outcome expectancies, self-regulatory behaviors and social support.Journal of Health Psychology, 15(2), 173-185.[abstract]
Bandura, A. (1997). Self-efficacy: the exercise of control. New York: W.H. Freeman.
Bandura, A. (1994). Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopedia of human behavior (Vol. 4, pp. 71-81). New York: Academic Press. (Reprinted in H. Friedman [Ed.], Encyclopedia of mental health. San Diego: Academic Press, 1998). [full text]
Biddle, S. J. H. & Mutrie, N. (2008) Psychology of Physical Activity: Determinants, Well-Being and Interventions. Oxon: Routledge [full text]
Gallagher, K. I., Jakicic, J. M., Napolitano, M. A., & Marcus, B. H. (2006). Psychosocial factors related to physical activity and weight loss in overweight women. Medicine and science in sports and exercise, 38(5), 971-980.[abstract]
Gray, C. M., Hunt, K., Mutrie, N., Anderson, A. S., Leishman, J., Dalgarno, L., & Wyke, S. (2013). Football Fans in Training: the development and optimization of an intervention delivered through professional sports clubs to help men lose weight, become more active and adopt healthier eating habits. BMC public health, 13(1), 232.[full text]
Greaves, C. (2014) Prevention of T2DM: Supporting lifestyle behaviour change [online] [full text]
Greaves, C. J., Sheppard, K. E., Abraham, C., Hardeman, W., Roden, M., Evans, P. H., & Schwarz, P. (2011). Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC public health, 11(1), 119.[full text]
Green, J. and Tones, K. (2010) Health Promotion: Planning and promotion (2nd Ed) London: Sage
Harrison, J. A., Mullen, P. D., & Green, L. W. (1992). A meta-analysis of studies of the health belief model with adults. Health Education Research,7(1), 107-116.
Jackson, D. (2010). How Personal Trainers Can Use Self-Efficacy Theory to Enhance Exercise Behavior in Beginning Exercisers. Strength & Conditioning Journal, 32(3), 67-71.[abstract]
Maddison, R., Hoorn, S. V., Jiang, Y., Mhurchu, C. N., Exeter, D., Dorey, E., ... & Turley, M. (2009). The environment and physical activity: The influence of psychosocial, perceived and built environmental factors. International Journal of Behavioral Nutrition and Physical Activity, 6(1), 19.[full text]
McAuley, E., Jerome, G. J., Marquez, D. X., Elavsky, S., & Blissmer, B. (2003). Exercise self-efficacy in older adults: social, affective, and behavioral influences. Annals of Behavioral Medicine, 25(1), 1-7.[abstract]
Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., ... & Wood, C. E. (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behavior change interventions.Annals of behavioral medicine, 46(1), 81-95.[abstract] [key content]
Mosher, C. E., Fuemmeler, B. F., Sloane, R., Kraus, W. E., Lobach, D. F., Snyder, D. C., & Demark‐Wahnefried, W. (2008). Change in self‐efficacy partially mediates the effects of the FRESH START intervention on cancer survivors' dietary outcomes. Psycho‐Oncology, 17(10), 1014-1023.[full text]
Pavey, T. G., Taylor, A. H., Fox, K. R., Hillsdon, M., Anokye, N. K., Campbell, J. L., ... & Taylor, R. S. (2011). Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis. Bmj, 343, d6462.[full text]
Upton, D. and Thirlaway, K. (2014) Promoting Healthy Behaviour: A Practical Guide. London: Routledge.
White, S. M., Wójcicki, T. R., & McAuley, E. (2012).Social cognitive influences on physical activity behavior in middle-aged and older adults.The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 67(1), 18-26.[full text]
Williams, S. L., & French, D. P. (2011). What are the most effective intervention techniques for changing physical activity self-efficacy and physical activity behaviour—and are they the same?. Health education research, 26(2), 308-322.[full text]