Behaviour Change

1. Behaviour Change Past & current theories of how to get people from thinking to doing PART 1 Corinne Hodgson Corinne S. Hodgson & Associates Inc. 2014

2. Overview CSH Associates - From thinking to doing • Part 1 • Traditional theories such as Transtheoretical Model, Model of Reasoned Action/Planned Behaviour, and Social Cognitive Theory • Opportunities from other areas of psychology: achievement theory, self theory, and self-determination theory • Part 2: Health Action Process Approach and Self-Regulation • Part 3: New models from interactive health (Fogg, Eyal)

3. Online behaviour change tools: Systematic review of 85 RCTs CSH Associates - From thinking to doing • Webb TL et al. (JMIR 2010 12(1):e 14) used Michie & Prestwich coding scheme (Health Psychology 2010;29(1):1-8) to identify theory of behaviour change • Theories included: • Transtheoretical model (12 studies) • Social cognitive model (12 studies) • Reasoned action/planned behaviour (9 studies) • Elaboration likelihood (2 studies) – communications theory of how attitudes are formed/people are persuaded • 1 study each: • Extended parallel process – 4 factors affect how people will respond to fear message: self-efficacy, response efficacy, perceived susceptibility, and severity of the threat • Self-regulation – how people monitor & manage their behaviour • Precaution adoption process – 7 cognitive stages: unaware, unengaged, undecided, decided not to act or decided to act, acting, and maintenance • Diffusion of innovations • Health belief – belief in a personal threat + belief in effectiveness of proposed behaviour = likelihood of changing behaviour • Social norms – group-held beliefs about how people should behave

4. Three most commonly-used theories CSH Associates - From thinking to doing Transtheoretical Model (Prochaska, 1977) Essence: change is a process and you can move closer to – or further away from – change depending upon Self-efficacy Decisional balance

5. Transtheoretical Model (Prochaska, 1977) CSH Associates - From thinking to doing

6. Strengths & weakness of Transtheoretical Model Weaknesses Good at telling you where people are but weak on process whereby they move between stages Strengths • If you know people’s stage, you can tailor messages so you meet them “where they are” & not alienate them • Large evidence base • Can work with any theory of behaviour change (hence “trans-theoretical) CSH Associates - From thinking to doing

7. Three most commonly-used theories of behaviour change CSH Associates - From thinking to doing Theory of Reasoned Action (Fishbein & Ajzen 1975) / Theory of Planned Behaviour (Ajzen 1985) As name implies, infers people are making rational choices (“economic man”)

8. Theory of Reasoned Action Behavioural beliefs Attitude toward behaviour Evaluation of behavioural outcomes Normative beliefs Behavioural intention Behaviour Subjective norm Motivation to comply CSH Associates - From thinking to doing

9. Theory of Planned Behaviour Behavioural beliefs Attitude toward behaviour Evaluation of behavioural outcomes Normative beliefs Subjective norm Behavioural intention Behaviour Motivation to comply Control beliefs Perceived behavioural control Perceived power CSH Associates - From thinking to doing

10. Strengths & Weaknesses of Theory of Reasoned Action/Planned Behaviour Weaknesses Reality is that people often don’t make “rational” choices or “plan” their behaviour Assumes that behaviour change naturally follows development of intention Strengths • Well-established theories that have been used for years > lots of experimental and practical evidence • Easy to understand CSH Associates - From thinking to doing

11. Three Most Commonly-used Theories CSH Associates - From thinking to doing Social Cognitive Theory What we think (cognition) influences our behaviour but is heavily influenced by what we learn from others (social)

12. Social Cognitive Theory (Miller & Dollard 1941, Bandura 1980s) Personal Factors: Beliefs Self-efficacy Self-control Expectations Social Factors: Environment Observational learning Social modelling Reinforcement CSH Associates - From thinking to doing More holistic approach Behaviour is the result of a combination of:

13. Social Cognitive Theory Weaknesses Weak at understanding the process by which individuals decide to change – especially if they are “going against the flow” Strengths • Well-established theory • Acknowledges the important role of environment and other people • Because it addresses environment, useful for issues such as smoking CSH Associates - From thinking to doing

14. Other theories CSH Associates - From thinking to doing • May be time to look at other theories and other areas of psychology to understand the complex process by which people move from just thinking about change to actually taking action • Few theories have yet to capitalize on learnings from: • Achievement Theory (Achievement Goal or Goal Orientation) • Self Theory or Mindset • Self-Determination Theory

15. Achievement Goal or Goal Orientation (Eisen, Nicholls, Elliott) CSH Associates - From thinking to doing • Ego or performance orientation: focus is on doing well and demonstrating your competence to others • Problem: when tasks get difficult may feel anxious or helpless; afraid of failure so may quit or avoid harder tasks • Task or learning orientation: focus is on learning – enjoys the process & not worried about the outcome or outcome compared to others

16. Self Theory or Mindset (Dweck 2006) CSH Associates - From thinking to doing • Developed out of achievement literature • Two basic mindsets: • Fixed or Entity: belief that basic ability or talent are fixed traits • Growth or Incremental: belief that people can develop their abilities through effort and persistence Elliot and Dweck 2005

17. Mindset & Achievement Goals Trichotomous Achievement Goal Framework CSH Associates - From thinking to doing Adapted from Elliott and McGregor 2001

18. Self Theory Applications CSH Associates - From thinking to doing • To date, Mindset or Self theory has been used primarily in education • Exciting aspect is that even simple changes can give people more of a “growth” mindset • Focus on level of effort not outcome • Prime with messages or stories on how intelligence is malleable and can be improve

19. Application to health? CSH Associates - From thinking to doing • Similar fixed/entity attitudes can be observed in health: • “I’m not the athletic type” • “I have no willpower” • “I’ve always been fat”

20. Self-Determination Theory (Decci & Ryan 1970s) CSH Associates - From thinking to doing • Motivation can stem from yourself (intrinsic) or outside yourself (extrinsic) • Intrinsic motivation stems from 3 basic universal psychological needs to feel: • Close to others (relatedness) << power of peers/social norms • Good at something (competence) • In control of your life (autonomy) • Often simplified into “intrinsic motivation is good” and “extrinsic motivation is bad” but actually more complex

21. Self-Determination Regulation Financial Incentives Reasonable behaviour change goals? Ultimate goal CSH Associates - From thinking to doing Decci& Ryan. Handbook of Self-Determination Research (2002)

22. Relationship between stages of change & type of motivation CSH Associates - From thinking to doing A study of 175 people with type 2 diabetes measured self-determined motivation for exercise and stage of change at baseline, 3 months & 6 months • Progressors: large increase in self-determined exercise motivation from baseline to 3 months and another, smaller increase from 3 to 6 months • Non-progressors (n=37) had an initial large increase in self-determination from baseline to 3 months but then it declined over next 3-6 months Source: Fortier et al J Health Psychology 2012

23. Balance between internal & external motivators for physical activity may vary across stages CSH Associates - From thinking to doing • Pre-contemplation: extrinsic motives (appearance & weight) dominated over intrinsic (enjoyment & revitalization) • Contemplation: domination of extrinsic motivation not as strong • Preparation: extrinsic motivation even weaker • Action: extrinsic motives again dominant over intrinsic • Maintenance: intrinsic motives more important than extrinsic Markland and Ingeldew (2007)

24. Motivation may also vary across life stages CSH Associates - From thinking to doing Retrospective study of women’s motivation for physical activity: Childhood: autonomously & intrinsically motivated – active because it was fun Adolescence: combination of autonomous & non-autonomous – active because it is a form of socializing Younger adulthood or motherhood: mostly non-autonomous – to get back in shape Middle adulthood: combination of autonomous & non-autonomous – appearance, weight control & health Older adulthood: mostly autonomous – to be healthy Source: Fortier & Kowal, 2007

25. Summary CSH Associates - From thinking to doing Both extrinsic and intrinsic motives may be present at the same time Which one is dominant may vary at different stages of change and at different stages of life

26. Strengths CSH Associates - From thinking to doing Theory of motivation so trying to get at why we behave the way we do & how we can change Large body of experimental research from different fields: education, physical activity, healthy eating, etc. Validated questionnaires Experiments in other countries showing it crosses cultures www.selfdeterminationtheory.org

27. Relationship to behaviours (outcomes) Social Factors: autonomy support (parents, peers, authority figures) Psychological mediators: Autonomy Competence Relatedness Motivation Intrinsic Integrated Identified Introjected External Amotivation Outcomes Well-being indices Affective indices Behavioural indices Cognitive indices Adapted from Standage & Treasure (2007) CSH Associates - From thinking to doing

28. Nurturing Motivation Relatedness Autonomy Competence CSH Associates - From thinking to doing “Discuss with your family and make a decision on how you want to proceed to make improvements in your chosen activity.”

29. Tactics CSH Associates - From thinking to doing • Support person’s sense of autonomy by giving choices & explaining rationale • Optimize relatedness by • Making users feel respected and cared for – give them opportunities to express their opinions • Form groups for relatedness & social support • Be empathetic – recognize that there are down sides to change • Boost feeling of competency by providing positive but realistic feedback and non-controlling guidance or information on how to attain health-related goals (avoid “you should do this…”) • Emphasize working to improve yourself or your record rather than competing with others or being evaluated Sheldon, William, Joiner. Self-Determination Theory in the Clinic, Motivating Physical and Mental Health(2003)

30. Coming up in Part 2 CSH Associates - From thinking to doing Health Action Process Approach Self-regulation For more information or for a consultation, email the principal at corinne@cshassociates.com.

31. Short list of references CSH Associates - From thinking to doing Bandura A. Self-Efficacy in Changing Societies. Cambridge University Press (1995) Decci EL, Ryan RM (eds). Handbook of Self-Determination Research. University of Rochester Press (2002) Elliot AJ, Dweck CS (eds). Handbook of Competence and Motivation. Guildford Press (2005) Glanz K, Rimer BK, Lewis FM (eds). Health and Behavior and Health Education, Theory, Research, and Practice (3rded). Jossey-Bass (2002) Haggar MS, NLD Chatzisarantis (eds). Intrinsic Motivation and Self-Determination in Exercise and Sport. Human Kinetics (2007) Heckhausen J, Dweck CS (eds). Motivation and Self-Regulation Across the Life Span. Cambridge University Press (1998) Sansone C, Harackiewicz JM (eds). Intrinsic and Extrinsic Motivation, The Search for Optimal Motivation and Performance. Academic Press (2000) Michie S, Prestwich A. Are interventions theory-based? Development of a theory coding scheme. Health Psychology2010;29:1-8 Sheldon KM, Williams G, Joiner T. Self-Determination Theory in the Clinic, Motivating Physical and Mental Health. Yale University Press (2003) Stroebe W. Dieting, Overweight and Obesity, Self-Regulation in a Food-Rich Environment. American Psychological Association (2008) Webb TL, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. JMIR 2010;12(1):e4