SELF-REGULATION IN HEALTH AND ILLNESS, FROM ... - ICMCC

icmcc.org

SELF-REGULATION IN HEALTH AND ILLNESS, FROM ... - ICMCC

SELF-REGULATION THEORY

AND HEALTH BEHAVIOUR

CHANGE

Stan Maes, Ph.D.

Leiden University

The Netherlands


COMMUNICATION OF A MESSAGE

RECEIVED

50 %

UNDERSTOOD

25 %

REMEMBERED

12,5 %

ACCEPTED

6,25

ACTED UPON

3 %

MAINTAINED

1,5 %

E.g. Patient Package leaflet for ANTIBIOTICS (Mc. Guire et. Al.).


INTRODUCTION

Within Western countries:

development from dependency of health

care system to responsibility for own lives:

the right to make autonomous decisions in

health and illness.

COMPLIANCE (obedience)

ADHERENCE (adoption of advice)

SELF-MANAGEMENT (responsibility for

control) SELF-REGULATION

* Self-Regulation = a sequence of actions

and/ or steering processes intended to

attain a personal goal.

* Personal goals are thoughts about

(un)desired consequences to be (avoided)

achieved.


EXTERNAL REGULATION

If your cholesterol is too high a

sensor will sent a signal to lock the

kitchen door and to get you

running for four hours…..


THE MEDICAL SOLUTION

I will help you to lower your stress.

I will prescribe you chocolate.


Mechanisms involved in SR are:

a) Goal selection and representation

b) Goal level setting

c) Goal monitoring

d) Planning

e) Progress evaluation

f) Problem solving

g) Emotion & action modulation

These mechanisms unfold in phases:

(1) goal selection, setting &

construal/representation;

(2) active goal pursuit and

(3) goal attainment, maintenance and

disengagement.


I. GOAL SELECTION, SETTING &

CONSTRUAL/REPRESENTATION:

1) Cognitive determinants of goal

selection

- Health Belief Model (Rosenstock,

1974)

- Protection Motivation Theory

(Rogers,1975)

- Theory of Reasoned Action (Fishbein

& Azjen, 1975)

- Theory of Planned Behaviour (Azjen,

1985)

a) risk perception (perceived susceptibility

to and severity of a given disease)

b) outcome expectancies (cost/benefit of

intended action e.g. quit smoking)

c) social influence (important others /

desire to comply)

d) perceived competence to carry out the

intended behaviour


2) Illness representations as cognitive

determinants of goals

Leventhal & colleagues (1998; 2000):

content and organization of representations.

Content:

a. identity or label for the threat (e.g. flu,

astma, diabetes);

b. time line (time to develop the disease

and to recover from it);

c. cause (e.g. exposure to draft, bad food,

alcohol abuse…);

d. consequences, real or imagined (e.g.

hospitalization, absence from work,

sexual dysfunction, sudden death);

e. cure or control (can the disease be

influenced or cured?)


3) Goal setting

LOCKE, 1996 ; LATHAM & LOCKE, 1991

Goals should be specific, important to the

individual, not too easy or difficult to attain

and attainable in a restricted time frame.

-intervention study: Oldridge et al (1999).

Controlled trial Mi Pts.

Pts are asked at entry cardiac rehabilitation

to identify one activity or goal that

represents recovery. Pts who attained their

self-chosen goal had higher levels of wellbeing.


4) Self-determination theory: who sets

the goals?

Deci & Ryan (2000). Autonomous vs.

controlled behaviour regulation.

- autonomous: goal is chosen, emanates

from one’s self, personal importance

- controlled: coerced or pressured to

attain a goal set by external or internal

forces.

Participants in weight loss program with

autonomous motivation lose more weight

and maintain weight loss over time

(Williams et al., 1996).


II. ACTIVE GOAL PURSUIT AND GOAL

PROCESS COGNITION

1) Bridging the gap between motivation

and action: planning

• Gollwitzer (1993), after Heckhausen

(1991) & Leventhal (1967):

Implementation intentions or action plans:

‘I intend to do X, when situation Y is

encountered’: reflect and decide WHEN,

WHERE and HOW to act, thus creating

plans for action.

Formation of implementation intentions

enhances physical exercise, breast selfexamination,

healthy eating & cervical

cancer screening (Maes & Karoly, in

press).


e.g. in a study by Hodgkins & Sheeran

(1997) participants were asked to rate

strength of their intention to perform

breast self-examination in next month

(goal intention).

Participants were asked to record where

& at what time of the day they would do

this (implementation intention). Of those

with strong goal intentions +

implementations intentions 100 %

reported having performed breast selfexamination

at follow-up (vs. 50 % for

those without implementation intentions).


2) Goal process cognition & affect

Ford (1992): Motivational Systems

Theory:

What people THINK (cognitive functions),

FEEL (arousal functions) and DO

(transactional function) helped by feedback

and feedforward mechanisms to

successfully pursue their goals.

a. positive and negative affect

influences goal pursuit.

b. cognitive processes or mechanisms

such as:

- feedback mechanisms (monitoring

& evaluation of progress)

- feedforward mechanisms (outcome

anticipations guided by personal

capabilities and context

expectancies)

- activation of control processes

(emotion and attention control)


a. FEEDBACK:

Carver & Scheier (1998) control theory:

negative feedbackloop.

Feedback interventions:

Sabnis, Pomerantz & Amateau (2003) gave

feedback to vaccine providers on frequency

of missed opportunities for vaccination

(visits of children of 36 months or younger

who were vaccination-eligible) Missed

opportunities decreased from 43 % to 13 %

after the intervention.


. FEEDFORWARD

Bandura (1986, 1997)

a) Outcome expectancies (belief that a

behaviour will lead to certain outcomes)

b) Efficacy expectations (belief that one I is

capable of executing behaviours

required to produce these outcomes).

c) Efficacy expectations depend on:

- performance

- accomplishments (success raises

mastery, failure lowers)

- observation of others (models)

- verbal persuasion

- emotional arousal as a result of

stressful or taxing situations


SELF-CONFIDENCE

I cannot say no to: boys,

cigarettes, food and booze, so I

recorded my answer for an

emergency case.


c. CONTROL MECHANISMS

Kuhl (2000) makes a distinction between:

- attention control: focusing on goal

related rather than on distracting info

- emotion control: disengaging from

negative mood if it interferes with goal

pursuit

- motivation control: enhancing

attractiveness of the goal

- coping with failure: using failure as an

opportunity for learning


Control over competing goals is also

necessary. Gebhardt & Maes (2000)

found that conflicting or competing goals

were associated with not exercising

regularly and not maintaining physical

exercise.

McKeeman & Karoly (1991) found that

smokers and relapsers recall more goal

related interference and higher levels of

goal conflict than quitters.


d. Examples of SR INTERVENTIONS:

Very few real SR interventions

(components)

1. Health Promotion: ‘Going for the goal’ :

life skills program for adolescents

(Danish, 1997).

10 one hour workshops on ‘dare to

dream’, ‘setting goals’, ‘making your goal

reachable‘, ‘making a goal ladder’,

‘roadblocks to reaching goals’,

‘overcoming roadblocks’, ‘seeking help

from others’, ‘rebounds and rewards’,

‘identifying and building your strengths’,

and ‘going for the goal’.


Participants had a better school

attendance, (in boys) a smaller

increase in health compromising

behaviours (such as getting drunk,

smoking, drinking beer or liquor) and a

decrease in violent and other problem

behaviour compared to a control group.

2. Christensen et al. (2002): SR

intervention for patient adherence in

hemodialysis. Weekly group meetings

involving training in goal setting, selfmonitoring,

self-evaluation and selfreinforcement

skills to promote

regulation of fluid intake. At 8 week

follow up fluid intake in the intervention

group was far better than in the control

group.


3. Lorig et al. (1999):

Chronic Disease Self-Management

course (based on success SM course for

arthritis). Course is offered to groups of

chronic patients (heart disease, stroke, l

ung disease, arthritis).

To enhance self-efficacy, weekly group

meetings for action planning sessions

involving problem solving, decision making,

skills training, persuasion and

reinterpretation of symptoms. A randomized

controlled trial showed effects of the

programme on self-efficacy, well-being,

health behaviours and physical health

status in comparison to a control group (see

also Wright et al. for a replication in the UK

with similar results).


III. GOAL ATTAINMENT, MAINTENANCE

AND DISENGAGEMENT

1. Behaviour change is phasic and not an

all or none affair (Prochaska & Di

Clemente, 1986): precontemplation,

contemplation, preparation, action and

maintenance stages.

Mark Twain…

2. Many think that predictors initial

behaviour change are the same that

guide maintenance.

However, initiation: expectations about

future outcomes.

Maintenance: satisfaction with outcomes

(Rothman, 2000).


STAGE MODELS

My doctor advised me to start

exercising following a stage model:

today I drove by a shop were they sell

sports stuff.


People who are successful in maintaining

behavioural change report high degree of

satisfaction with how the change affected

their lives.

Maintenance is also related to realistic

expectations.

Sbrocco et al. (1999) found that women who

set more modest weight loss goals lost less

weight during the program than women who

followed a traditional weight loss program,

but more weight at a 1 year follow up.

Ownership is also an important predictor of

maintenance (Bellg, 2003)


3) Disengagement:

Can be beneficial if goal is unattainable and

leads to reformulation of more realistic

goals (Wrosch, Scheier, Carver & Schulz,

2003)

Moskowitz, Folkman, Colette & Vittinghoff

(1996) assessed coping in couples in which

one partner was dying of AIDS.

At the beginning the healthy partners tried

to overcome the partner’s illness, but when

the illness progressed the goal was

transformed to assisting the partner with

more limited daily activities.


IV.

CONCLUSIONS

A. The assessment of goal pursuit,

attainment, maintenance and

disengagement deserves greater

research attention. There are still very

few measures, which require also

validation.

B. There are also very few real SR

interventions. The following principles

may guide the development of future

interventions:

1) Explore risk perception, the perceived

cost/benefit of intervention targets,

perception of support from important

others, and the individual’s (healthy


person’s or patient’s) perceived

competence to carry out recommended

actions regarding health behaviour

change or self-management targets.

2) Explore the individual’s representation

of the health problem or illness (identity,

time-line, cause, consequences, and

cure or control). If the recommended

action does not fit the individual’s

representation, the likelihood of the

action actually occurring will be low.

Some representations may have to be

changed from this perspective.

3) Encourage the individual to set personal

goals. These goals should be specific,

important to the individual, not too easy

or too difficult to carry out, and

attainable in a restricted time frame.


Try to link intervention targets to these

goals or (if this proves impossible)

discuss an adoption process for

these targets with the individual.

4) Help the individual to observe or

monitor his or her current problem

behaviour, its antecedents, and its

(emotional) consequences.

5) Assist the individual in building an action

plan by asking when, where, how and

how long the patient will act in relation to

a target or goal.

6) Ask the individual to build a ‘goal ladder’

in order to define steps towards goal

attainment. Help the individual in

developing a standard reference for

each step in order to assess progress.

Provide opportunities for feedback.


7) Explore the individual’s perceptions

regarding his or her social environment.

Ask the individual to list sources of

support or coercion and what he or she

would expect in terms of support for goal

attainment. Encourage the individual to

ask for support from health professionals

and relatives or friends and to discuss

support issues with them.

8) Increase the individual’s self-efficacy via

modelling, verbal persuasion, and by

providing techniques to control

disturbing emotions.

9) Ask the individual to monitor carefully

positive and negative emotions related

to goal pursuit and to discuss with others

how these emotions facilitate or inhibit

effective action.


10) Encourage the individual to use selfincentives

when progress is made.

Explore which incentives are most

valued by the individual.

11) Teach the individual the skills to control

distracting information or negative

mood during goal pursuit.

12) Ask the individual to report and

discuss conflicting or competing goals

that arise when striving to attain a

recovery goal and to try to align these

competing goals.

13) Reassure the individual that relapse is

not failure, but an opportunity for

learning.

14) Teach the individual how to cope with

relapse.

15) Inform individuals that they should feel

free to reformulate a goal in a more

manageable way whenever they find

one to be unattainable in its present

form.

More magazines by this user
Similar magazines