CEU Corner: Behavior Change Science: Help Clients Stick With Their Program

This issues CEU Corner and Quiz Feature overviews research on current theories, models and techniques that will shed light on the secrets to lasting success.

by Maria Luque, PhD

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AFAA’S CEU CORNER™ is one of the best continuing education offers available. By simply reading and studying this comprehensive article and completing the corresponding online quiz, you can earn 2 AFAA/0.2 NASM CEUs for a $35 fee. Visit afaa.com today! © 2019 Athletics and fitness association of America

Stephanie is your newest fitness client. She’s 42 years old and works 50 hours a week as a certified public accountant. She would like to quit smoking, give up junk food and get active—all the foundations of a healthy lifestyle.

Fast-forward 6 months. Stephanie is still smoking and still lunching on cheeseburgers. She keeps skipping workouts. Why can’t she exercise regularly or stick to a healthy eating plan? Stephanie may not even know why herself. If that’s the case, then how can you help her behave differently? There’s no shortage of health education campaigns encouraging her to change her ways. The challenge is to help her use that education to make lasting behavior changes.

Influencing Stephanie’s health behavior is much more critical than creating exercise routines, reviewing food choices, monitoring progress and being supportive. To succeed in helping Stephanie adopt and maintain a healthier lifestyle, you need to understand the mechanisms—the how and why—and the theories behind behavior change science.

The Roots of Behavior Change

Where do you start? Research encourages adopting a theoretical base for behavior change interventions because that will work better than a random, theory-free approach (St. Quinton 2017). When you incorporate the elements of a well-studied theory, you can identify the key factors and processes that affect people’s ability to adopt physical activity and wellness strategies (Hagger & Chatzisarantis 2014).

A lot of research has delved deeply into behavior change to show why different interventions work for one person but not another. Selecting the right theoretical base can be a crucial step in developing successful fitness and lifestyle programming. But this is a daunting task, owing to the sheer number of theories. This article will help you navigate some of the research on behavior change science and show you ways to apply some of the most important theories.

Four Proven Paths to Behavior Change

At least 83 formal theories of behavior change have been developed, and more emerge all the time (Teixeira & Marques 2017). That seems like a sky-high number, but you don’t need to know them all. The most thoroughly tested strategies are the Health Belief Model, Social Cognitive Theory, the Theory of Planned Behavior and the Transtheoretical Model.

HEALTH BELIEF MODEL

The Health Belief Model focuses on how Stephanie’s attitudes and beliefs explain and predict her behaviors. The theory behind the HBM is that Stephanie’s desire to prevent illness and her belief that a specific action can achieve that goal will motivate her to implement healthy behavior changes. One challenge with the HBM is that people who do not feel susceptible to a disease/condition are less likely to want to change their behaviors.

The HBM has been applied in the development of behavior change for 40 years, amassing a large body of empirical evidence of its success. A literature review found that 78% of studies exploring the HBM reported significant improvements in adherence (Jones, Smith & Llewellyn 2014).

The HBM has five core concepts: perceived susceptibility, perceived severity, perceived benefits, perceived barriers and cues to action (see “Health Belief Model: 5 Concepts,” above). The strongest predictors of behavior are perceived benefits and perceived barriers (Jones, Smith & Llewellyn 2014). One of the biggest drawbacks of the HBM is that it does not weigh the economic, environmental or socio-structural factors affecting change.

SOCIAL COGNITIVE THEORY

Social Cognitive Theory is based on the belief that behavior results from continuous interactions among environment, individual and behavior. It’s built on the idea that when Stephanie understands health risks and benefits, the precondition for change exists within her. If she doesn’t know how her lifestyle habits affect her health, then she doesn’t have much reason to endure the challenges of giving up her favorite bad habits (Bandura 2004).

SCT proposes that behavior is a deliberate and conscious process for seeking positive outcomes and avoiding negative ones. It notes that while environment can alter people’s behavior, people can alter their environments to achieve desired outcomes (Lee et al. 2018). SCT identifies four determinants of behavior: self-efficacy, outcome expectations, goals and socio-structural factors (see Figure 1).

THEORY OF PLANNED BEHAVIOR

The Theory of Planned Behavior is one of the most widely used and well-researched theories applied to exercise. Several literature reviews show its efficacy in predicting and explaining physical activity. The TPB combines clients’ expectations about performing a behavior with the value that clients attach to that behavior (Tenenbaum & Eklund 2014) (see Figure 2).

The TPB defines four main psychological factors affecting behavior change: attitude (positive or negative evaluation of performing a behavior), intention (willingness), subjective norms (perceived social pressure) and perceived behavioral control. Two of the strongest behavior predictors are intention and perceived behavioral control (perceived ease or difficulty).

One of the biggest drawbacks of the TPB is the consistently imperfect link between intentions and actual behavior change. As Stephanie’s example shows, many people have good intentions but fail to carry them out (Hagger & Chatzisarantis 2014).

TRANSTHEORETICAL MODEL

The Transtheoretical Model is based on empirical evidence suggesting that people go through five stages of readiness to change. To help Stephanie work toward success, you will need to understand when and how she is likely to change her behavior. That will mean tailoring exercise programs to the stage she’s in now.

How do you identify that stage? The TTM recognizes five stages: precontemplation, contemplation, preparation, action and maintenance (see “Transtheoretical Model: 5 Stages,” below).

Progression through these stages is cyclical, not linear. Stephanie may move back and forth depending on the stimuli and barriers she faces. Indeed, relapse is an important part of the process. You can use relapses to teach Stephanie how to stay in the maintenance phase (Hall, Gibbie & Lubman 2012). For example, you can explain that cyclical behavior is normal and expected and that she can always pick up where she left off. This dynamic, rather than all-or-nothing, view of behavior change is one of the biggest strengths of the TTM (Marshall & Biddle 2001).

Choosing the Right Strategy

Each theory has strengths and drawbacks because of its particular focus on constructs, stages and phases. Thus, you have to decide which focus is appropriate for each client’s specific goals.

For example, the Health Belief Model does not account for environmental and social-cultural factors, while Social Cognitive Theory relies heavily on continuous interactions between people and their environments. Thus, if a client’s lack of physical activity is heavily influenced by his or her peers, work or family, SCT might be the better approach.

Choose an approach based on the client’s desired outcomes and circumstances. Start by identifying the problem, goal and units of practice. Don’t select a theory only because it’s intriguing, familiar or popular. One strategic way to select the right theory is to use “a logic model of the problem and work backward to identify potential solutions” (Green & Kreuter 2005) (see Figure 3).

Behavior Change Coaching and Scope of Practice

It’s important for fitness professionals to stay within their scope of practice. Coaching involves a set of skills related to, but different from, those used in counseling, therapy and consulting. Fitness pros do not analyze a client’s childhood, for example, but rather focus on the present. How might the client’s current situation be improved? What are some possible solutions? The main goal is for the client to “graduate” and continue on the path established through the partnership.

Behavior Change Techniques

While behavior change models form the conceptual foundation for exercise programs, behavior change techniques are the “active ingredients” (Teixeira & Marques 2017). They represent the “smallest identifiable components that in themselves have the potential to change behavior” (Michie et al. 2018).

The major behavior change techniques are contingency contracting, premacking, stimulus control, modeling and relaxation training (Kirschenbaum 2014).

CONTINGENCY CONTRACTING. This technique includes “explicit agreements specifying expectations, plans and/or contingencies for the behavior(s) to be changed” (Kirschenbaum 2014).

Contingency contracting has four stages: Establish specific and clear target behaviors (such as dietary activities and workout quantity and length), monitor progress, deliver consequences, and maximize generalization (establish reinforcing factors such as joining a healthy-eating group or getting an exercise partner).

PREMACKING. This involves reinforcing a desired behavior by pairing it with a likely behavior. For example, Stephanie could organize a football-watching party at home, where she could serve healthy snacks, rather than go to a sports bar that’s serving fried appetizers and beer.

STIMULUS CONTROL. Evidence shows that impulsive automatic factors drive many behaviors (Hagger & Chatzisarantis 2014), and controlling stimuli aims to reduce impulsiveness. For instance, Stephanie could take healthy food to work so it would be easier to avoid the temptation of going out for cheeseburgers at lunch or grabbing free doughnuts in the break room.

MODELING. With modeling, Stephanie would learn by seeing somebody else doing things she wants to do. Two types of modeling help people change: behavioral coaching (e.g., explaining and demonstrating proper execution of an exercise, having clients imitate it, and correcting their form) and assertiveness training (e.g., learning to fend off peer pressure to eat foods that don’t fit the desired plan).

RELAXATION TRAINING. This training teaches clients proven methods to help them find a state of relaxation. Examples include progressive muscle relaxation, cued relaxation and deep breathing.

Helping Clients Surmount Behavioral Obstacles

Knowing the barriers to physical activity, healthy eating and other healthy behaviors is crucial to helping clients change their behavior for the long haul. There are four primary categories of barriers:

  • environmental—climate, space, equipment
  • social—work, family commitments, lack of social support
  • behavioral—concerns about appearance, lack of interest
  • physical—chronic fatigue, generalized pain, body limitations
    (Boscatto, Duarte & Gomes 2011)

Keep in mind that clients often confront multiple barriers. For instance, most life-threatening conditions in the U.S. are influenced by several risk factors, including use of tobacco and alcohol, physical inactivity, and poor nutrition. Researchers found that 92% of people who smoked had at least one additional risky behavior, and 9 out of 10 overweight women had at least two eating or activity risk behaviors (Prochaska, Spring & Nigg 2008).

Given Stephanie’s habits, you know she needs help dealing with multiple behaviors. That means “bundling” services such as workouts and basic nutrition guidance into one program. That way, she can achieve more of her immediate goals (weight loss, strength development, etc.) while you promote the maintenance of these behaviors well into the future.

Summary: Putting Theory Into Practice

How often have we seen clients abandon their workouts after reaching their weight loss goals? That’s the behavior we want to turn around. Employing sound behavior change theories is central to making that happen.

All of the behavior change science models discussed in this article have been successfully applied to physical activity and healthy eating. Thus, you can apply any of them with your clients.

Avoid the urge to depend on personal preference and familiarity when choosing a behavior change theory. Using a logic model (see Figure 3) can help you choose wisely.

Behavior change techniques require careful selection to match clients’ goals. One client might benefit from contingency contracting, while another might not respond well to having a “contract” but could respond well to relaxation training. As clients confront the stages and barriers of behavior change, you’ll have to continually adjust your techniques.

So, yes, you can help Stephanie succeed. Now that you have a greater understanding of the theoretical underpinnings of behavior change science, you will be better able to help all of your clients effectively switch to new, healthy behaviors and maintain them for months and years to come.

Knowing the barriers to physical activity, healthy eating and other healthy behaviors is crucial to helping clients change their behavior for the long haul.

REFERENCES

ACS (American Cancer Society). 2017. More than 4 in 10 cancers and cancer deaths linked to modifiable risk factors. Accessed Oct. 3, 2018: cancer.org/latest-news/more-than-4-in- 10-cancers-and-cancer-deaths-linked-to-modifiable-risk-factors.html.

Armstrong, M.J., et al. 2013. Motivational interviewing-based exercise counselling promotes maintenance of physical activity in people with type 2 diabetes. Canadian Journal of Diabetes, 37 (4, Suppl.), S3.

Bandura, A. 2004. Health promotion by social cognitive means. Health Education & Behavior, 31 (2), 143–64.

Boscatto, E.C., Duarte, M.F.S., & Gomes, M.A. 2011. Stages of behavior change and physical activity barriers in morbid obese subjects. Revista Brasileira de Cineantropometria e Desempenho Humano, 13 (5), 329–34.

CDC (Centers for Disease Control and Prevention). 2017. Physical inactivity: What’s the problem? Accessed Oct. 3, 2018: cdc.gov/healthcommunication/toolstemplates/entertainment ed/tips/PhysicalInactivity.html.

CDC. 2018. Fast facts: Diseases and death. Accessed Oct. 3, 2018: cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm.

Christie, D., & Channon, S. 2014. The potential for motivational interviewing to improve outcomes in the management of diabetes and obesity in paediatric and adult populations: A clinical review. Diabetes, Obesity & Metabolism, 16 (5), 381–87.

Glanz, K., & Bishop, D.B. 2010. The role of behavioral science theory in development and implementation of public health interventions. Annual Review of Public Health, 31 (1), 399–418.

Green, L.W., & Kreuter, M.W. 2005. Health Promotion Planning: An Educational and Ecological Approach (4th ed.). New York: McGraw-Hill.

Hagger, M.S., & Chatzisarantis, N.L.D. 2014. An integrated behavior change model for physical activity. Exercise and Sport Sciences Reviews, 42 (2), 62–69.

Hales, C.M., et al. 2017. Prevalence of obesity among adults and youth: United States, 2015–2016. NCHS Data Brief No. 288. Hyattsville, MD: National Center for Health Statistics.

Hall, K., Gibbie, T., & Lubman, D.I. 2012. Motivational interviewing techniques: Facilitating behaviour change in the general practice setting. Australian Family Physician, 41 (9), 660–67.

Jones, C.J., Smith, H., & Llewellyn, C. 2014. Evaluating the effectiveness of health belief model interventions in improving adherence: A systematic review. Health Psychology Review, 8 (3), 253–69.

Kirschenbaum, D. 2014. NASM Behavior Change Specialist Course.

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Lee, C.G., et al. 2018. Social cognitive theory and physical activity among Korean male high-school students. American Journal of Men’s Health, 12 (4), 973–80.

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Marshall, S.J., & Biddle, S.J.H. 2001. The transtheoretical model of behavior change: A meta-analysis of applications to physical activity and exercise. Annals of Behavioral Medicine, 23 (4), 229–46.

Mayo Clinic. 2018. Cognitive behavioral therapy. Accessed Oct. 3, 2018: mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610.

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Michie, S., et al. 2018. Evaluating the effectiveness of behavior change techniques in health-related behavior: A scoping review of methods used. Translational Behavioral Medicine, 8 (2), 212–24.

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Prochaska, J.J., Spring, B., & Nigg, C.R. 2008. Multiple health behavior change research: An introduction and overview. Preventive Medicine, 46 (3), 181–88.

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Teixeira, P.J., & Marques, M.M. 2017. Health behavior change for obesity management. Obesity Facts, 10 (6), 666–73.

Tenenbaum, G., & Eklund, R.C. 2014. Encyclopedia of Sport and Exercise Psychology. Los Angeles: SAGE Publications.

Meet our experts

Author_Maria-Luque_bw MARIA LUQUE, PHD, is a health educator, fitness expert, fitness studio general manager, presenter and writer. She holds graduate and postgraduate degrees in health sciences and teaches at the College of Health and Human Services at Trident University International.

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