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Promoting Healthy BehaviorVia Awareness of Others Change
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Behavior and Global Health
Physical good health eludes billions of people Death and disease frompreventablecauses
remain high
Behavior is a key factor in determining health
Health is a state of complete physical, psychological,
and social well-being and not simply the absence of
disease or infirmity. (World Health Organization, 1948)
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Health Promotion Means Changing
Behavior at MultipleLevelsA Individual:knowledge, attitudes, beliefs,
personality
B Interpersonal:family, friends, peers
C Community:social networks, standards,
norms
D Institutional:rules, policies, informal
structuresE Public Policy:local policies related to
healthy practices
Source: Adapted from National Cancer Institute, Theory at a Glance: A Guide for Health Promotion (2003),
available online at http://cancer.gov.
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A: Individual-Oriented Models
Individual most basic unit of health promotion
Individual-level models components of
broader-level theories and approaches Models
Stages of Change Model
Health Belief Model
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Stages of Change Model
Changing ones behavior is a process, not an
event
Individuals at different levels of change Gear interventions to level of change
Source: James O. Prochaska et al., In Search of How People Change: Application to Addictive
Behaviors,American Psychologist 47, no. 9 (1992): 1102-14.
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Behavior change is rarely a discrete, single event;
the patient moves gradually from being uninterested
(precontemplation stage)
to considering a change (contemplation stage)to deciding and preparing to make a change.
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Transtheoretical Model/Stages of
Change Understanding Change
Physicians should remember that behavior change is rarely adiscrete, single event. Physicians sometimes see patients who,after experiencing a medical crisis and being advised to changethe contributing behavior, readily comply. More often, physiciansencounter patients who seem unable or unwilling to change.During the past decade, behavior change has come to beunderstood as a process of identifiable stages through whichpatients pass. Physicians can enhance those stages by taking
specific action. Understanding this process provides physicianswith additional tools to assist patients, who are often asdiscouraged as their physicians with their lack of change.
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
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Transtheoretical Model/Stages of
Change The Stages of Change model4 shows that, for most
persons, a change in behavior occurs gradually, with
the patient moving from being uninterested, unaware
or unwilling to make a change (precontemplation), toconsidering a change (contemplation), to deciding
and preparing to make a change. Genuine,
determined action is then taken and, over time,
attempts to maintain the new behavior occur.Relapses are almost inevitable and become part of
the process of working toward life-long change
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
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Transtheoretical Model/Stages
of Change Prochaska and DeClemente, 1983
Developed for health risk behaviors
(especially smoking) Incorporates several theories of behavioral
change
Individuals go through 5 stages before newbehavior is adopted
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Transtheoretical Model/Stages
of Change Stage 1: Precontemplation
Unaware that a problem exists
Stage 2: Contemplation
Aware that a problem exists and thinking about making abehavioral change in the future
Stage 3: Preparation Feeling confident that making a change is possible and planning to
make such a change in the immediate future
Stage 4: Action Making a change
Stage 5: Maintenance Continuing to engage in the new, desirable behavior and avoiding
relapse
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Precontemplation Stage
During the precontemplation stage, patients
do not even consider changing. Smokers who
are "in denial" may not see that the advice
applies to them personally. Patients with high
cholesterol levels may feel "immune" to the
health problems that strike others. Obesepatients may have tried unsuccessfully so
many times to lose weight that they have
simply given up.
.
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
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Stages of Change Model
Contemplation Stage
During the contemplation stage, patients are
ambivalent about changing. Giving up anenjoyed behavior causes them to feel a
sense of loss despite the perceived gain.
During this stage, patients assess barriers
(e.g., time, expense, hassle, fear, "I know Ineed to, doc, but ...") as well as the benefits
of change.
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
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Stages of Change Model
Preparation Stage
During the preparation stage, patients prepare to
make a specific change. They may experiment with
small changes as their determination to changeincreases. For example, sampling low-fat foods may
be an experimentation with or a move toward greater
dietary modification. Switching to a different brand of
cigarettes or decreasing their drinking signals thatthey have decided a change is needed
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
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Action Stage
The action stage is the one that most
physicians are eager to see their patients
reach. Many failed New Year's resolutions
provide evidence that if the prior stages have
been glossed over, action itself is often not
enough. Any action taken by patients shouldbe praised because it demonstrates the
desire for lifestyle change.
Most people find themselves "recycling"
through the stages of change several times("relapsing") before the change becomes truly
established.
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
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Stages of Change Model
Maintenance and Relapse Prevention
Maintenance and relapse prevention involve
incorporating the new behavior "over the longhaul." Discouragement over occasional "slips"
may halt the change process and result in the
patient giving up. However, most patients find
themselves "recycling" through the stages ofchange several times before the change
becomes truly established.
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
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Stages of Change Model
More individuals are at the preparation and
action stages than are at the
contemplation stage Interpretation: Faculty are being pushed to make
changes before they recognize the problem?
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
TABLE 3
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TABLE 3Questions for Patients in the Precontemplation andContemplation Stages*
Precontemplation stageGoal: patient will begin thinking about change. "What would have to happen for you to know that this is a
problem?""What warning signs would let you know that this is a problem?""Have you tried to change in the past?"
Contemplation stageGoal: patient will examine benefits and barriers to change. "Why do you want to change at this time?"
"What were the reasons for not changing?""What would keep you from changing at this time?""What are the barriers today that keep you from change?""What might help you with that aspect?""What things (people, programs and behaviors) have helped in thepast?""What would help you at this time?""What do you think you need to learn about changing?"
*--The change can be applied to any desirable behavior (e.g.,smoking or drinking cessation, losing weight, exercise).Information from Miller WR, Rollnick S. Motivationalinterviewing: preparing people to change addictive behavior.New York: Guilford, 1991:191-202.
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
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Stages of Change Model (cont.)
Precontemplation
Action Decision
Maintenance Contemplation
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The Stages of Change model4 encompasses many conceptsfrom previously developed models. The Health Belief model,19the Locus of Control model20 and behavioral models fit togetherwell within this framework. During the precontemplation stage,
patients do not consider change. They may not believe that theirbehavior is a problem or that it will negatively affect them(Health Belief Model19), or they may be resigned to theirunhealthy behavior because of previous failed efforts and nolonger believe that they have control (external Locus ofControl20). During the contemplation stage, patients struggle
with ambivalence, weighing the pros and cons of their currentbehavior and the benefits of and barriers to change (HealthBelief model19).
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
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Health Belief Model
Perceived susceptibility and severity of ill
health
Perceived benefits and barriers to action Cues to action
Self-efficacy
Source: Irwin M. Rosenstock et al., Social Learning Theory and the Health Belief Model, Health
Education Quarterly 15, no. 2 (1988): 175-85.
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Helping the 'Stuck' Patient
The goal for patients at the precontemplation stage isto begin to think about changing a behavior. The task
for physicians is to empathetically engage patients incontemplating change (Table 2).6 During this stage,patients appear argumentative, hopeless or in"denial," and the natural tendency is for physicians totry to "convince" them, which usually engendersresistance.
Patient resistance is evidence that the physician hasmoved too far ahead of the patient in the changeprocess, and a shift back to empathy and thought-provoking questions is required. Physicians canengage patients in the contemplation process by
developing and maintaining a positive relationship,personalizing risk factors and posing questions thatprovoke thoughts about patient risk factors and theperceived "bottom line."
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
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The wording of questions and the patient's style of
"not thinking about changing" are also important. As
precontemplators respond to questions, rather than
jumping in and providing advice or appearingjudgmental, the task for physicians is to reflect with
empathy, instill hope and gently point out
discrepancies between goals and statements. Asking
argumentative patients, "Do you want to die fromthis?" may be perceived as a threat and can elicit
more resistance and hostility. On the other hand,
asking patients, "How will you know that it's time to
quit?" allows patients to be their "own expert" and
can help them begin a thought process that extends
beyond the examination room.
Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'
Approach to Helping Patients Change Behavior. American Family Physician 61/5
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B: Interpersonal Level:
Social Learning Theory Interaction of individual factors, social
environment, and experience
Reciprocal dynamic Observational learning
Capability of performing desired behavior
Perception of self-efficacy
Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall,
1986).
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C: Community-Level Models
Analyze how social systems function
Mobilize communities, organizations, and
policymakers Use sound conceptual frameworks
Community Mobilization
Organizational Change
Diffusion of Innovations Theory
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Community Mobilization
Encompasses wider social and political
contexts
Community members assess health risks,take action
Encourages empowerment, building on
cultural strengths and involving
disenfranchised groups
Source: National Cancer Institute, Theory at a Glance: A Guide for Health Promotion: 18; Paolo Freire,
Pedagogy of the Oppressed (New York: Continuum, 1970.); Saul Alinsky, Rules for Radicals: A Pragmatic
Primer for Realistic Radicals (New York: Vintage Books, 1971; revised edition, 1989).
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For More Information
Elaine M. Murphy, Promoting Healthy
Behavior, Health Bulletin 2(Washington, DC:
Population Reference Bureau, 2005).
Available online at www.prb.org
http://www.prb.org/http://www.prb.org/