AND HEALTH BEHAVIOUR
Stan Maes, Ph.D.
COMMUNICATION OF A MESSAGE
E.g. Patient Package leaflet for ANTIBIOTICS (Mc. Guire et. Al.).
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.
ADHERENCE (adoption of advice)
SELF-MANAGEMENT (responsibility for
* 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)
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
e) Progress evaluation
f) Problem solving
g) Emotion & action modulation
These mechanisms unfold in phases:
(1) goal selection, setting &
(2) active goal pursuit and
(3) goal attainment, maintenance and
I. GOAL SELECTION, SETTING &
1) Cognitive determinants of goal
- Health Belief Model (Rosenstock,
- Protection Motivation Theory
- Theory of Reasoned Action (Fishbein
& Azjen, 1975)
- Theory of Planned Behaviour (Azjen,
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
2) Illness representations as cognitive
determinants of goals
Leventhal & colleagues (1998; 2000):
content and organization of representations.
a. identity or label for the threat (e.g. flu,
b. time line (time to develop the disease
and to recover from it);
c. cause (e.g. exposure to draft, bad food,
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
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
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
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
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
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
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
- feedback mechanisms (monitoring
& evaluation of progress)
- feedforward mechanisms (outcome
anticipations guided by personal
capabilities and context
- activation of control processes
(emotion and attention control)
Carver & Scheier (1998) control theory:
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.
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:
- accomplishments (success raises
mastery, failure lowers)
- observation of others (models)
- verbal persuasion
- emotional arousal as a result of
stressful or taxing situations
I cannot say no to: boys,
cigarettes, food and booze, so I
recorded my answer for an
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
- 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
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
1. Health Promotion: ‘Going for the goal’ :
life skills program for adolescents
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
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
1. Behaviour change is phasic and not an
all or none affair (Prochaska & Di
Clemente, 1986): precontemplation,
contemplation, preparation, action and
2. Many think that predictors initial
behaviour change are the same that
However, initiation: expectations about
Maintenance: satisfaction with outcomes
My doctor advised me to start
exercising following a stage model:
today I drove by a shop were they sell
People who are successful in maintaining
behavioural change report high degree of
satisfaction with how the change affected
Maintenance is also related to realistic
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)
Can be beneficial if goal is unattainable and
leads to reformulation of more realistic
goals (Wrosch, Scheier, Carver & Schulz,
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.
A. The assessment of goal pursuit,
attainment, maintenance and
disengagement deserves greater
research attention. There are still very
few measures, which require also
B. There are also very few real SR
interventions. The following principles
may guide the development of future
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
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
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
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
13) Reassure the individual that relapse is
not failure, but an opportunity for
14) Teach the individual how to cope with
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