July 2005

Changing Behaviours Changing Behaviours to Increase Healthy to Increase Healthy

Physical ActivityPhysical ActivityPhysical Activity Resource Centre

Funded by the Government of Ontario

July 2005

Key Session Points

July 2005

Purpose of the Session

To help you identify practical ways to apply principles of best practice, behaviour change theory and research to the planning and implementation of physical activity initiatives in your community.

“The only person that likes change is

a wet baby.”

- source unknown

“Successful self-changing individuals

follow a powerful and, perhaps most important,

controllable & predictable course.”

James Prochaska

July 2005

July 2005

Understanding the change process

• What are the barriers that get in the way of being physically active on a regular basis?

• What are the things that make this behaviour easier?

July 2005

Theoretical Background

Stages of Change Model (SCM)

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July 2005

SCM

• Developed by Prochaska, DiClemente, Norcross

• Consists of 6 stages and 10 processes

• The idea behind the SCM is that behaviour change does not happen in one step

• People tend to progress through different stages on their way to successful change

• Each person progresses through the stages at his/her own rate

July 2005

Precontemplation

• Have no intention of changing behaviour in the foreseeable future

• May not see the behaviour as a problem for them

• resistant, unaware, unwilling• “It isn’t that I can’t see the

solution; I can’t see the problem.”

July 2005

Reasons for Precontemplation

• Reluctance – inertia or lack of information prevents the person from being fully aware

• Rebellion – active resistance or hostility to the problem or desired behaviour may exist

• Resignation – a belief in the inability to change (efficacy); a lack of energy for & investment in change

• Rationalization – determines there is no problem, the odds of risk are in their favour, or problem is someone else’s

July 2005

Contemplation

• Usually something happens that prompts change

• Aware that a problem exists & seriously considers action but has not yet made a commitment to action

• Ambivalent, aware, open, need convincing

• Lacks confidence & commitment• Open to information but waiting for that

“one thing” to move them• The end of this phase – anticipation,

activity, anxiety, excitement• “I want to stop feeling so stuck.”

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Decision Point

• An event, not a stage

• Concluded that the negatives of the behaviour outweigh the positives

• Chooses to change behaviour

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Decisional Balance

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Preparation

• Accepts responsibility to change• Evaluates & selects techniques for behaviour• Develops a plan – getting organized• Intent upon taking action soon & often reports

some steps taken• Combination of behavioural intentions & actions• Usually take serious action within a month• Some ambivalence remains• Relatively transitory stage• Anticipation, willingness

July 2005

Action

• Aware the problem exists & actively modifies their behaviour, experiences & environment

• Commitment is clear• Great deal of effort is expended• Have made a plan & begun to implement• Ambivalence is still an issue• Gains new insights & develops new skills• Learns to overcome the tendencies for

unwanted behaviour• Usually lasts 1-6 months• Change is more visible to others

July 2005

Maintenance

• Has made a sustained change

• Masters the ability to sustain the change with

minimal effort

• Remains alert to high-risk situations

• New pattern of behaviour has replaced the

old & is firmly established

• Self-controlled

• Threat of relapse becomes less intense

• Relapse likely after an initial slip

July 2005

Relapse

• Event not a stage

• May occur at any time

• Personal distress or social pressures are allowed to interrupt the behaviour change process

• Temporary loss of progress which resumes at an earlier stage

• Experience is educational to help prevent further lapses

• Most successful self-changers go through the stages 3-4 times; most return to Contemplation

July 2005

Stages of Change & Time

July 2005

Allegory of Changeby Portia Nelson

1. I walk down the street. There is a deep hole in the sidewalk. I fall in. I am lost.......I am helpless. It isn't my fault. It takes forever to find a way out.

2. I walk down the same street. There is a deep hole in the sidewalk. I pretend I don't see it. I fall in again. I can't believe I am in the same place, but it isn't my fault. It still takes a long time to get out.

3. I walk down the same street. There is a deep hole in the sidewalk. I see it is there. I still fall in..........it's a habit. My eyes are open. I know where I am. It is my fault. I get out immediately.

4. I walk down the same street. There is a deep hole in the sidewalk. I walk around it.

5. I walk down another street.

July 2005

Limitations of the Theory

• Individually based

• Ideally complemented with a broader approach to changing the environment

• Not generally population-based

• Resource intensive

July 2005

So how do you know what stage?

Nomogram• I am not currently … & am not

thinking of doing so in the coming month.

• I am not currently … but I have thought about …

• I am not currently … but I plan to do so within the next month.

• I am currently … but have only been doing so for the past 6 months or less.

• I am currently … and have been doing so for 7 months or more.

July 2005

Strategies for each Stage- Precontemplation

• Increase awareness of need to change (risk, benefits)

• Give personalized information (e.g. benefits)

• Encourage thinking about change

• Offer to help is they do decide to change

• Recommend a solution

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Strategies for each Stage- Contemplation

• Motivate & increase confidence• Emphasize benefits of change &

identify barriers• Explore concerns & fears• Help resolve ambivalence

July 2005

Strategies for each Stage- Preparation

• Help individualize a plan for change

• Set realistic goals• Provide options &

logical information• Provide & have person

seek social support• Develop necessary

skills to take action• Motivation is key

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July 2005

Strategies for each Stage- Action

• Reaffirm commitment & follow-up• Teach behavioural skills• Provide educational materials• Stress benefits• Reduce barriers through problem-

solving• Access social support• Celebrate successes & use rewards• Continue follow-up

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Strategies for each Stage- Maintenance

• Plan for potential difficulties• Develop & utilize a support network• Reminder of benefits• Reassure about ability to sustain new

behaviour (efficacy)

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Strategies for Preventing Relapse

• Identify coping strategy for the short-term

• Analyze what went wrong; use lapse as a learning opportunity

• Plan next attempt at change & identify what will be different next time

• Persevere

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Processes of Change

The different types of strategies used to influence people in moving from one stage to another.

Two types:

Experiential – changes in the ways people think & feel

Behavioural – changes in the way people act

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Experiential Processes of Change

Consciousness Raising• Involves providing information

regarding the nature & risk of unsafe behaviours; gets people thinking about the issue

Dramatic Relief• Fosters the identification,

experiencing, & expression of emotions related to the risk the safer alternatives

July 2005

Experiential Processes of Change (2)

Social Liberation• An awareness of circumstances in the

environment that provides additional behavioural alternatives (e.g. I see fewer people doing …)

Self Re-evaluation• A re-appraisal of personally relevant

consequences associated with the changes

July 2005

Experiential Processes of Change (3)

Environmental Re-evaluation– An awareness of the impact that

one’s behaviour has on others

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Behavioural Processes of Change

Counterconditioning• Refers to replacing the

behaviour with a substitute

Stimulus Control• Concerns removing

cues or avoiding situations which trigger the behaviour

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Behavioural Processes of Change (2)

Reinforcement Management• How people reward themselves

(or are rewarded by others) (consider the original motivators)

Helping Relationships• Trusting others and accepting

their support or seeking professional assistance

6 Features of the Enabling Environment (The Communication Initiative)

Social- nature of personal relationships; expectations of class, position, age, gender; access to knowledge, information.

Cultural- the behaviors and attitudes considered acceptable in given contexts - eg. relating to sex, gender, drugs, leisure, participation

Ethical and Spiritual- influence of personal and shared values and discussion about moral systems from which those are derived - can include rituals, religion and rights of passage

                                      

                                                   

Legal- laws determining what people can do and activities to encourage observance of those laws

Political- systems of governance in which change will have to take place - can, for example, limit access to information and involvement in social action

Resource- affect what is required to make things happen - covers human, financial and material resources; community knowledge and skills; and items for exchange

July 2005

Tools

Authors: James O. Prochaska, John C. Norcross, Carlos C. Diclemente

Format: Paperback, 1st ed., 304pp.

ISBN: 038072572X

Publisher: Morrow,William & Co

Pub. Date: August  1995

July 2005

Tools

Transtheoretical Model / Stages of Change Overview (University of South Florida)

http://hsc.usf.edu/~kmbrown/Stages_of_Change_Overview.htm

The Stages of Changehttp://www.skysite.org/primer/stagesofchange.html

July 2005

Stages of Change related to Marketing Strategies

Developed by Andreasen (1995):

Stages of Change Marketing Theory

Precontemplation Create awareness, interest & change

values

Contemplation Persuade, motivate

Action Create action

Maintenance Maintain change

July 2005

Motivation

• McLelland & Atkinson

• Identified three types of people:

– Affiliation

– Achievement

– Power / Prestige

July 2005

Affiliator

• Goal is to be with others & enjoy mutual friendships

• Seeks out relationships• Likes to work with other people• Sensitive to feelings, needs of

others• Supports others in achieving

goals• Talks about feelings

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Achiever

• Experiences success in a situation which requires excellent or improved performance.

• Concerned with results, personal best

• Sets goals, takes risks to get there

• Innovative, restless

• Likes to be challenged

• Likes to work alone

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Prestige/Power Person

• Wants to have an impact or an influence on others.

• Tries to shape opinions

• Wants to change things

• Exercises power to benefit others

• Concern for position, respect, reputation

• May be charismatic

• Can be verbally aggressive, forceful

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Motivational Ideas (Health Canada)

• Recommend setting personal goals to work toward

• Use questionnaires to assess personal readiness to change

• Emphasize incremental changes • Encourage use of logs to monitor progress • Use physical activity and fitness appraisals to

determine each individual's level of preparedness • Create messages about physical activity that

target personal values such as helping the environment and raising self-esteem

July 2005

Motivational Ideas (2)

• Encourage people to make a commitment; they will be more likely to carry out the behaviour

• Find a spokesperson to whom your audience can relate, preferably someone within the community who was successful in changing his/her behaviour

• Engage respected role models as effective motivational speakers

• Motivate people through friendly competition with the use of rewards, recognition and prizes for participation

July 2005

Motivational Ideas (3)

• Organize competitive events between individuals, neighbourhoods and organizations

• Collaborate with physicians and encourage them to speak to their patients about the benefits of physical activity

• Use reminders to be physically active to reinforce good intentions such as keeping gym shoes by the door or car, hiding the remote control or writing a note to be physically active and putting it in a place you are sure to see it

• Post Canada's Physical Activity Guide at work on your fridge or front door

July 2005

Conditions for Success - (Fishbein)

Generally speaking it appears that in order for a person to perform a given behaviour:

1. The person must have formed a strong positive intention (or made a commitment) to perform the behaviour.

2. There are no environmental constraints that make it impossible to perform the behaviour.

3. The person has the skills necessary to perform that behaviour.

4. The person believes that the advantages (benefits, anticipated positive outcomes) of performing the behaviour outweigh the disadvantages (costs, anticipated negative outcomes).

July 2005

Conditions for Success (2) - (Fishbein)

5. The person perceives more social (normative) pressure to

perform the behaviour than to not perform the behaviour.

6. The person perceives that performance of the behaviour is more

consistent than inconsistent with his or her self image, or that it’s

performance does not violate personal standards that activate

negative self-actions.

7. The persons emotional reaction to performing the behaviour is

more positive than negative.

8. The person perceives that he or she has the capabilities to

perform the behaviour under a number of different

circumstances.

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July 2005

Tools

Facilitating Sustainable Behaviour Changehttp://www.burnet.internationalhealth.edu.au/freestyler/gui/files/fsb_change.pdf

Behaviour Change & Social Marketinghttp://www.hc-sc.gc.ca/english/socialmarketing/social_marketing/whatis.html

July 2005

Application to Physical Activity

Programming

July 2005

Ideas for Awareness Campaigns

• SummerActive

• WinterActive

• Contests

• Others?????

• How might you enhance the effectiveness of these?

July 2005

July 2005

Ideas for Educational / Skill Development Programs

• Walk This Way!

• Fitness Classes

• Others ????

• How might you enhance the effectiveness of these?

July 2005

CDC Recommended Strategies

• Opportunities to sample the desired behaviour• Model the desired behaviour• Provide opportunities for safe, guided practice• Encourage self-reporting and self-discovery• Build in cues for action• Contract for success• Enhance self-efficacy

July 2005

Ideas for Environmental Supports

• Trails• Stair signs• Others???

• How might you enhance the effectiveness of these?

July 2005

• Flex time in workplaces• Subsidies for memberships• Others???

• How might you enhance the effectiveness of these?

Ideas for Policies

July 2005

CDC Recommended Interventions

Strongly Recommended:• Community-wide Campaigns

• Individually adapted health behaviour change program

• School based PE

• Social support interventions in community settings

• Creation of enhanced access to places for physical activity combined with information outreach activities

• Point-of-decision prompts for stairs

July 2005

CDC Recommended Interventions

Insufficient Evidence• Mass Media Campaigns

• Classroom-based Health Education focused on information provision & behavioural skills

• Classroom-based Health Education focused on reducing TV viewing and video game playing

• College-age PE & health education

• Social support interventions in family setting

July 2005

CDC Recommended Interventions

Pending• Transportation policy &

infrastructure changes to promote non-motorized transit

• Urban planning approaches, including zoning & land use, neighbourhood & street design, & cluster development

July 2005

Additional Tools

Increasing Physical Activity: A report on recommendations of the task force on Community Preventive Serviceshttp://www.cdc.gov/mmwr/pdf/rr/rr5018.pdf

Promoting Physical Activity in Your CommunityHuman Kinetics475 Devonshire Road, Unit 100Windsor, Ontario N8Y 2L5Phone: (800) 465 - 7301

Health Behaviour & Health Education:Theory Research and Practice (Karen Glanz, Frances Marcus Lewis, Barbara K. Rimer) 1-55542-243-8

July 2005

Contact information

Physical Activity Resource Centre

www.ophea.net/parc1-888-446-7432

Louise DawProvincial Consultant

Louise@ophea.org 519.646.2121