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7/29/2019 Changing Lifestyle Behavior
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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) Avoid tobacco use
2) Healthy diet based on the Food Guide Pyramid
3) Activity patterns recommended by the 1996 Surgeon Generals report
4) Moderate alcohol consumption if at all
5) Decreasing risk for avoidable injuries
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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 itsHealthy 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
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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
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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.
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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
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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
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).
Precontemplation Contemplation Preparation MaintenanceAction
Behavioral Intention
Behavior
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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 ofbehavior
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
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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
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,
PC C PR A M
ImportanceofSE/Stage
Stage of Change
Self-Efficacy
Self-Efficacy
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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
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
PC C P A M
ContributiontoDecision
Stage of Change
Decisional Balance
Cons Pros
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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
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are the following and are found in Health Behavior and Health Education: Theory, Research,
and Practiceby 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
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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 Likelihood of ActionModifying Factors
Perceived susceptibility
To severity of disease
Age, sex, ethnicity
Personality
Socioeconomics
Knowledge
Perceived threat of
disease
Cues to Action
Education
Symptoms
Media
Perceived benefits minus
Perceived barriers to
behavior change
Likelihood of behavior
change
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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 by-
product 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
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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
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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
norms and perceived behavioral control over the exercise behavior. Additionally, self-
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
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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.
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Figure 4. Theory of Planned Behavior
Behavioral
BeliefsAttitude Toward
Behavior
SubjectiveNorm
Perceived
Behavioral
Control
BehavioralIntention Behavior
Evaluations of
behavioral
outcomes
Normative
Beliefs
Motivation to
comply
Control
Beliefs
Perceived
Power
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