Chapter 57

Changing Lifestyle Behavior

Rodney G. Bowden, PhD, Mike Greenwood, PhD, and Rafer Lutz, PhD

A majority of risk factors for the top ten causes of death in the United States can be controlled through a basic series of lifestyle changes. Behavioral patterns can influence risk for premature mortality and morbidity allowing primary prevention and behavior change as the preferred approach to decreases in disease states and improvements in quality of life. There has been a documented interest in preventing morbidity and mortality through specific behavior change approaches. Health behavior research has grown over the last two decades with theoretical approaches to health behavior change applied in practical ways. The science of health behavior change is ever evolving and requires a theoretical understanding of psychology, sociology, anthropology, epidemiology and group dynamics. Collaborative

efforts are now part of the landscape of behavior change requiring a rich understanding of large and diverse literatures (Glantz, Reimer, and Lewis, 2002). It is well established in the literature that a few basic behavioral approaches to health can dramatically alter risk for morbidity and mortality and include the following: 1) 2) 3) 4) 5) Avoid tobacco use Healthy diet based on the Food Guide Pyramid Activity patterns recommended by the 1996 Surgeon Generals report Moderate alcohol consumption if at all Decreasing risk for avoidable injuries

2 Though approach number three (Activity patterns recommended by the 1996 Surgeon Generals report) is well documented to decrease risk for early morbidity and mortality 60% of Americans are insufficiently active and 25% are sedentary (NCCDPHP, 2002). Additionally, participation in any form of exercise tends to decline with age (Corwyn and Benda, 1999). Hausenblas, Carron, and Mack (1997) reports a 50% dropout rate within six months of initiation of a physical activity program. Research conducted at the Cooper clinic spanning 23 years (1970-1993) found a reduction in all-cause mortality and CVD-mortality in men who exercised at moderate to high levels of intensity (Church et. al, 2001). Peters et al. (1983) found higher relative risks for men who were unfit when compared to fit persons. Additionally, sports play has been found by Paffenbarger et al. (1991) to reduce all-cause morality by 37% when compared to sedentary individuals. Anderson et al. (2000) discover a 50% reduction in mortality in women and men who were moderately and highly active. Similar results were found in the same participants who only biked to work with a 40% reduction in all-cause mortality. Finally, Joliffe et al. (2002) found a 27% reduction in all-cause mortality in the exercise-only intervention group. Consequently, the federal government calls for increases in moderate and vigorous exercise in its Healthy People 2010 document.

Behavioral Risk Factor Surveillance System An important public health issue is understanding why a majority of adults in developed countries are insufficiently active and struggle with exercise acquisition (Marshall and Biddle, 2001). Consequently, it has been suggested that a primary challenge for the

practicing exercise physiologist is to determine ways to facilitate and maintain participation

3 by the majority of the population in active lifestyle pursuits (Gorely and Gordon, 1995). Exercise adherence to physical activity is poor in most study populations (Rodgers et al., 2001). The need for interventions to promote changing behavior is well established in the literature. Exercise behavior is unique in that it is an acquisition behavior, whereas most research in health behavior involves behavior cessation. The discovery of effective means or interventions to improve exercise adherence has become a central focus of psychology and health as it is related to exercise (Rodgers et al., 2001). Various models are used to attempt to understand different stages of change including the Transtheoretical Model (TTM), Health Belief Model (HBM), Theory of Reasoned Action (TRA), and Theory of Planned Behavior (TPB). Additionally, constructs such as self-efficacy and social support perform vital roles in behavior change, and specifically exercise related behavior change.

TRANSTHEORETICAL MODEL Empirical evidence suggests that individuals attempting to change physical activity behavior move through a series of changes with numerous studies demonstrating a consistent positive relationship between exercise self-efficacy and stages of change (Marshall and Biddle, 2001). Much of the research that has made these discoveries has used the Transtheoretical Model (TTM). The TTM was developed as a general explanatory model of intentional behavior change (Nigg et al., 1999). The TTM has been used to understand different phases of motivational readiness to change for a variety of health behaviors (Schumann, et al., 2002) with a number of studies successfully applying the TTM to exercise adoption (Schumann, et al., 2002, Rich and Rogers, 2001). It has been demonstrated that TTM has been positively

4 associated with self-reported exercise behavior and measures of fitness in college and adult samples (Schumann, et al., 2002). Exercise behavior change occurs by a progression through different stages, implying that different motivational constructs are important at different stages (Nigg, 2001). TTM is based on the theory that people move through a series of stages in an attempt to change behavior and is why many scholars include the phrase stages of change when mentioning the TTM. The TTM has been studied in numerous age groups with patterns of change across the stages appearing to be similar across exercise populations (Rodgers et al., 2001). The stages identified for exercise are Precontemplation (no intention to exercise), Contemplation (intending to exercise within 6 months), Preparation (exercising some, but not regularly, Action (exercising regularly for less than least six months), and Maintenance (exercising for at least six months or more) (Marshall and Biddle, 2001, Nigg, 2001). The Termination stage is not used in the exercise literature and pertains to behavior cessation. The following stage descriptions are from Nigg, et al., 1999.

Precontemplation An Individual is not engaging in target behavior and does not intend to change. Most individuals are uniformed of the consequences of their present behavior. Most are unable to envision changing behavior. Many do not wish to think about changing and can become defensive when pressured to change, much like the addiction process with nicotine when users who do not wish to stop are pressured through societal norms. Some people may talk of changing their behavior but usually there is not a serious consideration to change.

5 Attempting to change someones behavior or stressing why they should change during this stage can be counterproductive.

Contemplation Contemplation is the stage where an individual is considering change. Individuals have been demonstrated in the literature to remain in this stage for as many as two years. Contemplators are ambivalent about change since they view the pros and cons of their present behavior as equivocal. The central element of this stage is serious consideration of problem resolution (Nigg et al., 1999). Individuals may require basic education about the positive benefits of exercise during this stage.

Preparation Individuals in the early stages of change will make small changes and/or may have a plan of action to change. Preparers have not reached the target criterion for a particular behavior to reach the next stage. This is not a stable stage of change, but preparers are more likely to progress to change than precontemplators or contemplators. Preparation appears to be the stage where balance between gains are losses are in balance (Marshall and Biddle, 2001). Education and social support can strongly influence an individual to move to the next stage.

Action This is where individuals are actively engaged in the new behavior. These changes have occurred in the last six months. This stage is unstable an may involve a series of relapses

6 from the new behavior to the old requiring a support network that may be as simple as an exercise class and/or an exercise partner.

Maintenance Individuals in this stage are sustaining habitual exercise over a period of time. During this period of sustained change, the individual is working to prevent relapse and to consolidate changes that have occurred during the action stage. Some individuals may still require social support, others may have moved to the point of making exercise habitual, needing less support.

Figure 1. Transtheoretical Model

Behavioral Intention
Precontemplation Contemplation Preparation Action Maintenance

Behavior

CHANGE MEDIATION Two factors that are important in mediation of the change process and should be discussed with TTM are: 1) An individuals self-efficacy for change and, 2) the decisional balance of perceived advantages and disadvantages of change (Marshall and Biddle, 2001, Rogers, et al., 20021).

Self-Efficacy Self-efficacy normally is situation specific confidence that an individual will have the ability to handle behavior change and not relapse into an old unhealthy behavior. Self-efficacy is supported by empirical evidence that suggests it is a necessary component of behavior change. Higher self-efficacy is associated with advancing stages (Marshall and Biddle, 2001; Rodgers et al., 2001, Nigg, 2001) and has been found to be one of the strongest determinants of exercise behavior (Nigg, 2001) (see Figure 2). Self-efficacy could be established through the help of a support network, but also be acquired by the individual through regular exercise that becomes habituated.

Decisional Balance Each of the stages is characterized by changes in decisional balance, the balance between benefits and costs associated with engaging in a behavior (Nigg, 2001). Theoretically, individuals will weigh the pros and cons of a particular behavior change and make a decision accordingly. Therefore, behavior changes are presumed to be associated with a systematic evaluation of the potential gains and losses associated with the new behavior (Marshall and Biddle, 2001). As exercise participants progress through each stage of change, decisional balance or gains and losses will become less or more important depending on the stage of change the individual is progressing through (see figure 3). For example, as behavior becomes

habituated, the pros may not be as important in determining behavior maintenance (Nigg, 2001). Additionally, though weighing the pros and cons is important in the decision making

8 process, they may not be a part of maintenance behavior (Nigg, 2001). Pros increase across the stages of change and peak in action while cons usually decrease with advancing stages (Marshall and Biddle, 2001).

Figure 2.

Changes in Self-Efficacy during Stages of Change

Self-Efficacy

Self-Efficacy

Importance of SE/Stage

PC

PR Stage of Change

Processes of Change Processes of change are the activities both covert and overt that individuals use to progress through the stages of the TTM. Ten processes have been empirically validated, but are beyond the scope of this chapter. Health Behavior and Health Education: Theory, Research,

9 and Practice by Glanz, Rimer, and Lewis (Eds. Josey-Bass publishers) provides a good discussion of these processes.

Figure 3. Contribution of Pros and Cons to Decisional Balance

Decisional Balance
Cons Pros

Contribution to Decision

PC

P Stage of Change

APPLICATION OF TRANSTHEORECTICAL MODEL Early research suggests changes with TTM occur in a linear fashion, but later research suggest a cyclic pattern whereby individuals progress and digress through the stages in an effort to create lasting change (Marshall and Biddle, 2001). A primary function of the TTM is to create stage-matched interventions for individuals attempting to change behaviors. Stage-matched interventions help to promote retention for exercise initiation progressing an

10 individual through the various stages of change ultimately having a behavior becoming habituated. For example, someone in the precontemplation stage could receive feedback designed to increase their pros of changing to help them progress to contemplation (Prochaska, 1999). Someone in the preparation stage may need interventions that involve social support (i.e. someone to workout with) such as a jogging or cycling club. Precontemplators and contemplators may require an educational intervention to increase their understanding of why exercise is important and why 30 minutes of aerobic activity may be difficult at first, but ultimately lead to a better quality of life in the near future. Furthermore, even though self-efficacy can be viewed as an outcome of behavior change rather than predictor, precontemplators, contemplators and preparers may need interventions that attempt to improve self-efficacy.

HEALTH BELIEF MODEL The Health Belief Model (HBM) concerns the effects of beliefs on health and the decision process in making behavior change. The model was originally developed to explain why some people who are healthy take specific action to avoid illness, while others do not engage in health preventive behaviors. The HBM is one of the most studied and used theories in health education (Janz, Champion, and Strecher, 2002). It has been used successfully in a number of studies with varying populations, health conditions, and health interventions (Frewen, Schomer, and Dunn 1994). The HBM can be used to understand change and maintenance as it relates to exercise behavior but has been applied to exercise interventions as well. The HBM provides a comprehensive framework for understanding psychosocial factors associated with compliance (Frewen et al., 1994). The core components of the HBM

11 are the following and are found in Health Behavior and Health Education: Theory, Research, and Practice by Glanz, Rimer, and Lewis (Eds. Josey-Bass publishers). See figure 3.

Perceived Susceptibility: The individual has perceived susceptibility to contracting a morbid condition.

Perceived Severity: The degree to which an individual believes that contracting the illness could have serious physical, psychological and/or social consequences. The combination of perceived susceptibility and perceived severity has been labeled perceived threat.

Perceived Benefits: Belief that intended action would lessen the perceived severity and/or susceptibility of a disease. The HBM suggests that a person will not change behavior even if they have a high degree of perceived threat unless that action is perceived as efficacious.

Perceived Barriers: A individual conducts a cost-benefit analysis to determine if a particular health action would be effective enough to overcome such factors as pain, inconvenience, unpleasant side effects etc.

Other variables of interest: Cues to action, age, gender, ethnicity, personality, and socioeconomic status are believed to play a role in the HBM, but have not been studied conclusively. Cues to action could be internal or external and could include symptoms (internal) or suggestions by a physician, friend or relative (external). Cues to action trigger a response causing an individual to begin an exercise program.

Generally through study of health behavior using the HBM it has demonstrated for most individuals to change to a behavior they must believe: 1) That they are susceptible to a morbid outcome (if they dont exercise they will have heart disease, cancer, cerebrovascular

12 disease etc.), 2) they must believe that the morbid condition would have serious consequences (disability and/or death etc.), 3) they must believe that the behavior change would alter their susceptibility to the morbid condition and 4) that the barriers to change are outweighed by the benefits. Understanding these findings will enable a exercise practitioner to enhance individualized health-promotion (such as exercise) strategies (Taggert and Connor, 1995). Finally, behavior can be predicted from the expectation that the action will prevent or ameliorate the health problem (Frewen et al., 1994).

Figure 3. Health Belief Model

Individual Perceptions

Modifying Factors

Likelihood of Action

Age, sex, ethnicity Personality Socioeconomics Knowledge

Perceived benefits minus Perceived barriers to behavior change

Perceived susceptibility To severity of disease

Perceived threat of disease

Likelihood of behavior change

Cues to Action Education Symptoms Media

13 THEORY OF REASONED ACTION and THEORY OF PLANNED BEHAVIOR The theory of reason action (TRA) was developed as a framework to explain volitional behavior. (Hausenblas, et al., 1997). It uses a basic assumption that people behave in a sensible and rational manner by taking into account available information and considering the potential implications of their behavior (Hausenblas, Carron, and Mack, 1997). A

cornerstone of TRA is intention, or how hard a person is willing to work to achieve a specific behavior change. Intention is considered a direct determinant of behavior in the TRA that is influenced by the attitude (attitude toward performing behavior), and subjective norms (social pressures to perform behavior). Attitude toward performing a behavior is a function of cognitive belief structures with two subcomponents: An individuals belief about carrying out a behavior, and the positive and negative evaluations of those consequences (Hausenblas, Carron, and Mack, 1997). An individual may believe in improved health through regular exercise, but may also know the physical discomfort associated with exercise. Subjective norms are a byproduct of a individuals beliefs about a behavior combined with the beliefs of a social support network (family, friends etc.). The Theory of Planned Behavior (TPB) introduces a third concept referred to as perceived behavioral control (perceived ease or difficulty of performing a behavior). Both theories focus on theoretical constructs as they relate with individual motivational factors as determinants of the likelihood of performing a specific behavior (Montano and Kaspryzk, 2002 ). Meta-analytic work by Hausenblas, Carron, and Mack (1997) found the greatest predictor for exercise behavior using the TRA and TPB was intention, which was strongly

14 related to attitude. Subjective norm was less likely to be predictive of exercise behavior. Hausenblas et al. also discovered the use of perceived behavioral control has better

prediction of exercise behavior when control over the behavioral control is incomplete. In other words, an individual may have an strong intention to exercise, and a positive attitude towards exercise, but have less control over outside factors that can inhibit exercise such as family life, work etc. (much similar to perceived barriers in the HBM). Therefore is it reasoned by Hausenblas et al., that an individuals perceived control must be addressed to provide more accurate prediction of intention and behavior. When an individual perceives more volitional control over the behavioral goal, intention is more likely to be a predictor of exercise behavior. Therefore, the TPB seems to be more predictive over TRA due to the identification of general barriers to performing exercise behaviors. Secondarily, Hausenblas et al. discovered that attitude may play a significant role in exercise behavior. The greatest commitment to exercise was held by those individuals who have more positive beliefs about exercise. The question then becomes, how does an exercise specialist change the attitude of clients who are attempting behavior change, specifically to exercise behavior.

Antecedents to Exercise Behavior The ability to identify factors that predict exercise behavior has been addressed through the TPB model. Research by Hagger et al. (2001) suggests that antecedents can change with age suggesting attitude and normative behavior may become more negative with age. Predisposing factors such as attitude about exercise and prior exercise habits can predict adult exercise behavior (Conner and Armitage, 1998). Exercising children who value

15 activity are more likely to be exercising adults and more likely to have a positive attitude about exercise. Consequently, parents, friends, co-workers, physicians and peers can also be reinforcing factors that aid a person in exercise behavior change, beginning in adolescence. Additionally, perceived self-efficacy is a major antecedent to exercise behavior and is discussed on page seven of the manuscript (van-Ryn, Lytle, Kirscht, 1996). More detail on antecedents will be presented in a later chapter.

CONCLUSIONS The understanding and promotion of health-related exercise and physical activity needs to be based on appropriate theory (Biddle and Nigg, 2000). Theory allows the exercise scientist to genuinely understand all constructs and antecedents to exercise behavior. An understanding of the overt processes that promote exercise behavior is necessary to design effective intervention strategies (Corwyn and Benda, 1999). Exercise behavior and intention to exercise is comprised of a number of constructs that are interactive and dynamic. Each theory should be used in light of the other as each share some specific components and should be viewed as complementary and modifiable to assimilation. Individuals should be questioned to discover what stage of change they are in at the present as each stage has implications for change and more importantly implications for interventions. Stage of change can be influenced by attitude, intentions, subjective Additionally, self-

norms and perceived behavioral control over the exercise behavior.

efficacy can play a major role in intention and behavioral control. All of this can be influenced by the individuals belief in their susceptibility to disease and the severity of a disease which many times may not change until the disease state is present. To fully

16 understand behavior change and specifically exercise behavior, which usually is over long periods of time, requires longitudinal research (Nigg, 2001) and an understanding of human psychology as it relates to exercise behavior. Creating effective strategies to assist in

exercise initiation and adherence requires a full understanding of the participant and of application of theory.

17

Figure 4. Theory of Planned Behavior

Behavioral Beliefs

Attitude Toward Behavior

Evaluations of behavioral outcomes

Normative Beliefs

Subjective Norm

Behavioral Intention

Behavior

Motivation to comply

Control Beliefs Perceived Behavioral Control Perceived Power

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