Throughout my time at university I studied a unit in health and exercise psychology with a specific focus on behaviour change. This gave me the opportunity to write essays on behaviour change theory which essentially directed my focus for my dissertation. Here is my theoretical approach to behaviour change essay...
A justification for a theoretical approach to reduce overweight and obesity through the use of exercise in older adults (ages 45 to 75).
Obesity is a condition in which a person is significantly overweight with a BMI of 30 or greater (Clark, Lucett and Sutton 2011). In the UK individuals within the age bracket of 66 to 74 are the most likely to be overweight or obese, with there being a 70% prevalence of overweight and obesity among all age groups from the age of 45 and upwards (Baker 2019). Many factors contribute to the increased levels of obesity in older adults such as poor diet, socioeconomic background and isolation. However, one of the main contributing factors towards obesity is physical inactivity (NHS 2019). As age increases, physical activity (PA) levels begin to slowly fall with a rapid decline around the age of 75 (NHS 2019). It is recommended that older adults should reduce the total time being sedentary and that they should partake in at least 150 minutes of moderate intensity PA over the course of a week (Upton and Thirlaway 2014), in order to minimise the risk of obesity and other consequential physical and mental health problems that can affect an individual’s quality of life, such as cardiovascular disease and depression. Win et al., (2011) found that inactivity was significantly correlated with the threat of cardiovascular mortality due to depressive symptoms in older adults.
Therefore, an important target is to increase physical inactivity in individuals aged 45 to 75 who are either in the motivational phase (MP) or volitional phase (VP) of behaviour change. Furthermore, the targeted population should also have an exercise history, low self-efficacy and minimal knowledge of the risks associated with physical inactivity as an older adult. The identified performance objectives for this specific population are to have a positive attitude towards PA , to have knowledge on the benefits of PA/risks of physical inactivity and to state a firm intention to participate in regular exercise. The aim of this intervention is to get inactive older adults to participate in the recommended 150 minutes of moderate exercise per week, through the use of psychological theories underpinned by behaviour change techniques that target the three performance objectives which then may have a direct impact on obesity levels within this population.
The chosen psychological theory is an extended Health Action Process Approach (HAPA) Model by inclusion of one additional variable which is social support. The HAPA is a psychological theoretical framework that can be used to predict behaviour change, making a direct distinction between the MP that leads to the intention and the VP that leads to the health behaviour. The model was chosen based on these two phases to approach the intervention as a whole to provide a full overview and tackle the intention behaviour gap. It includes three constructs: Outcome Expectancies (the foreseen effects as a result of engaging in a behaviour), Risk Perceptions (the subjective judgement of the severity of the risk) and Task Self-Efficacy (a person’s confidence in their capability to complete a task) which all lead into intention and then it attempts to bridge the intention behaviour gap with Action Planning (detailed plans that outline the actions needed to reach a specific goal) and Coping Planning (detailed plans to help an individual cope with a situation when they do not meet a specific goal) along with Coping Self-Efficacy (the idea that a person is able to cope) and Recovery Self-Efficacy (the belief that an individual has the ability to participate in a behaviour after a setback), with it being one of the only models to clearly differentiate between the various types of self-efficacy. In a meta-analysis by Zhang et al., (2019) results supported the separation of self-efficacy into phase-specific types. Furthermore, Parschau et al., (2012) found that individuals who wanted to change but did not make any plans to became less motivated over time and therefore planning was associated with advancement out of the MP. Overall the HAPA aims to change behaviour targeting individuals both in the MP and VP through expectations, risk, self-efficacy, intention and planning which is specific to the target population.
Extended HAPA:
In terms of applying the HAPA to PA in older adults in the MP, specifically looking at the amount of variance each construct has within intention, Barg et al., (2012) suggested that action (task) self-efficacy and outcome expectancies explained 57% of the variance in intentions with action self-efficacy being the bigger predictor. This is further supported by Caudroit et al., (2011) who found that action self-efficacy (p <.001) and risk perception (p <.01) were significantly related to PA intention, with these two variables and outcome expectancies accounting for 48% of the variance in intention. Furthermore, Maher and Conroy (2015) found that intentions had a strong positive correlation with task self-efficacy (r= .83). The data from these studies imply that task self-efficacy, outcome expectancies and risk perceptions explain around 50% of the intention, thus are significant predictors of the intention, even when specifically applied to older adults and exercise.
As mentioned previously, an extended version of the HAPA will be used. In older adults it is found that the social support (SS) network is very weak but Cousins (1995) implies that elderly women over the age of 70 felt encouraged to exercise through the support of active friends in around 50% of cases which was then significantly correlated with exercise rate. SS has been found to be an important aspect of interventions when specifically aimed at PA in sedentary middle and older aged individuals (Eyler et al, 1999). In terms of SS being added to the HAPA, Parschau et al., (2014) found that it is related to both intention and also exercise. Furthermore, SS in the form of family and friends along with attitudes accounted for 37% of the variance in intention (Hamilton and White 2008). Therefore, task self-efficacy, outcome expectancies, risk perceptions and social support could all have a significant impact on PA intention, though it must be noted that these constructs have not been tested together.
When looking at the VP of the HAPA and more specifically the relationship between intention and behaviour, Scholz et al., (2008) found that intention accounted for 17% of the variance in behaviour (vigorous PA) which is further supported by Caudroit et al., (2011) who found that PA intention and coping self-efficacy explained 39% of the variance in PA behaviour. This therefore suggests that intention has an impact on behaviour, however in the HAPA action and coping planning is used to bridge the intention behaviour gap so that individuals are able to successfully plan and have coping strategies. Wiedemann et al., (2011) found that when assessing action and coping plans as mediators between intention and behaviour change that action and coping planning accounted for 15% of the variance in behaviour change. In addition to this, the HAPA also includes maintenance (coping) and recovery self-efficacy. Parschau et al., (2014) found that maintenance self-efficacy (r = .73) and recovery self-efficacy (r = .78) were both associated with behaviour, even when specifically applied to adults with obesity.
In order to target the specific constructs in the MP certain behaviour change techniques (BCT) have been used successfully. For example, self-affirmation is a commonly used BCT that helps to reduce resistance towards a threatening health message (Steele 1988). It allows the individual to self-affirm and therefore provides a willingness to accept an important message. In relation to the extended HAPA model, self-affirmation can be used to target risk perceptions by reducing the resistance towards the health message so that it is more likely to be accepted in order to have an impact on behaviour change. Cooke et al., (2014) found that the use of self-affirmation in relation to PA can in fact promote exercise behaviour, with those who self-affirmed demonstrating stronger intentions and positive attitudes whilst also reporting higher levels of PA. Therefore the use of self-affirmation for behaviour change has been shown to be successful in relation to PA. Furthermore, education and enablement can be used to target outcome expectancies and social support in the form of information about the risks and benefits of PA and reducing the barriers to increase capability/opportunity. This is present in the COM-B model (Michie et al., 2011) and is referred to as intervention functions. Olander et al., (2013) found that ‘planning social support/social change’ gives individuals more control over their participation in PA by receiving more practical support. For that reason the use of education and enablement as BCT’s to target both outcome expectancies and social support can be used to further target exercise behaviour.
In addition to this when targeting intention, superordinate goals have been used in order to allow individuals to state a firm intention by setting goals of value to be accomplished in order to set a definite intention. Taylor et al., (2006) found that superordinate goals can influence patients’ attitudes and intention in relation to self-regulation. However, it has to be taken into consideration that this was used to target hypertensive individuals, but the use of superordinate goals in relation to exercise in older adults may have a positive effect on behaviour.
Similarly, in terms of the VP, monitoring goal progress has been used successfully as an effective self-regulation strategy. Harkin et al., (2016) found that interventions that were designed to promote progress monitoring had an effect on goal attainment. Additionally, Olander et al., (2013) stated that some of the most effective BCT’s, such as ‘prompt practice’ can be the most effective in helping obese individuals engage in PA targeting both self-efficacy and behaviour. This has been used in practice in which text message reminders were used to encourage individuals to participate in PA targeting both intention and behaviour, which resulted in increased exercise frequency (Prestwich, Perugini and Hurling 2009). Therefore, the use of ‘prompts’ and ‘monitoring’ could be useful in targeting PA and thus obesity in older adults by targeting both intention and behaviour and the gap in between.
In conclusion, the extended HAPA is aimed at reducing physical inactivity in older adults by targeting specific performance objectives for that population and identifying specific BCT’s that target individual constructs within the HAPA.
References
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