Behaviour Change Case Study (fictional).

Clare’s perceived barriers to exercise are largely around self-belief psychologically and physically. I noticed that Clare often feels sad and scared, she lacks confidence to engage in daily living activities without encouragement and doesn’t appear to trust her own judgements, capabilities, and skills to navigate the world without support, she does appear to have good self-awareness and understands how behaviours impact close relationships and she possesses the motivation and time implement changes.

Clare appears to lack belief that exercise will work for her and feels ambivalent and is therefore in the contemplating stage of the TTM (Zimmerman et al.,2000). She stated she has social phobias of group settings, and feels she needs high levels of support to achieve change, which highlighted low self-belief (Dobson et al.,2016) in her capabilities psychologically and physically linking to self-efficacy (SE) which is the largest theme throughout the case study and a common predictor of exercise adherence (Bandura et al.,1999: Husebo et al.,2015). Enhancing SE will impact positively on the other barriers; High SE predicts persistence and effort expenditure, therefore improved SE will have a favourable and supportive influence on other barriers (Alharbi et al.,2017).

in 1977; Albert Bandura published his paper “SE: toward a unifying theory of Behaviour Change (BC)”, it has since been used within healthcare of all forms as a construct for many BC models (Maddux, 2002, P201). SE is not a skill but a belief or a perceived capability which is sub-conscious and autonomic in nature, it is built over time from our life experiences (Pettit & Karageorghis.,2020). Bandura, (1981) believed that parental responses and early environments shaped the individual’s SE and children who did not have a secure attachment in early childhood, who experienced a lack of parental guidance, positive role modelling and encouragement developed low SE leading to avoidance of goal attainment due to high uncomfortable arousal states, distraction by their own thoughts, a lack of motivation and negativity toward new tasks (Schunk & Pajares, 2009, P41).

SE is evidenced to be fundamental for exercise adherence, according to Social Cognitive Theory (Bandura,1989: Plotnikoff et al.,2013). Bandura (1977) suggested that people avoid activities they feel exceeds their capabilities or coping mechanisms and seek experiences they feel they can execute well. Improved SE and outcome expectations is thought to boost the likelihood of adherence to an exercise programme (Shaughnessy et al.,2006: Resnick et al.,2000). Many contemporary studies have highlighted exercise referral schemes need to address barriers including SE for successful long-term adherence (Williams et al.,2007; Cleland et al.,2019: Eynon et al.,2019: McAuley & Blissmer,2000: McAuley et al.,2006).

SE is the underlying construct within the Social cognitive model (Bandura,1989; Schunk,1989) which is highlighted on the taxonomy BC mapping interventions; evidenced to support Clare’s barriers to exercise.  The Theory has four main concepts: Mastery of new experiences through practice of incremental small goals giving a sense of achievement at each stage, modelling, and observation, allowing Clare to experience positive physiological states in the form of Serotonin and Oxytocin; producing feelings of safety and eliciting the motivation to continue with further goals (Stone,2018). Some have argued that SE reflects motivation; rather than being a factor that determines motivation (Williams & Rhodes,2016).

Clare appears to feel ambivalent about physical activity according to the taxonomy she would benefit from the health belief model (HBM), created in the 1950’s for public health screening (Strecher & Rosenstock,1997) and since to predict exercise and eating behaviours (Champion & Skinner, 2008). The model would be useful to identify Clare’s beliefs around Perceived severity/seriousness and the impact on relationships if she chooses not to change the behaviour (Guidry et al.,2021). Using the model to identify whether she perceives she has control of her behaviour or believes the benefits (outcomes) outweigh the sacrifice, identifying the cost and physical/psychological barriers such as social phobias and financial constraints, and mobilizing support in the form of cues to action such as reminders, appointment commitments and practised SE (Volkmer et al.,2021). Critiques have highlighted the HBM is a threat-based behaviour prediction, and therefore not a reliable predictor due to humans not being under constant threat (Di Giuseppe et al.,2022).

Theory of planned behaviour (TPB) is an extension of The Theory of Reasoned Action; evidenced to be effective in predicting behaviour through investigation of the individuals conscious and subconscious intentions to change behaviour. Beliefs around whether the behaviour (sedentary) is harmful, assessing subjective norms e.g., whether Clare’s boyfriend and family wish Clare to be sedentary, perceived behavioural control e.g., being sedentary is easy for Clare, behavioural intention e.g., Clare intends to be sedentary (Mesters et al.,2014: Ryan & Carr,2010). Criticisms emphasised the need to include a wider range of intentions within the constructs, to enhance its viability (Sniehotta et al.,2014).

 Co-creating strategies to increase Clare’s beliefs around capabilities and self-belief would start with listing all barriers, before scoring the behaviours in terms of both importance and the biggest impact on likelihood of BC. Ensuring Clare deals with a few behaviours at one time and incrementally builds upon them (Michie, 2008: Ojo et al.,2019). Clare is likely to prefer 121 works initially, support must include an empathetic and patient approach and goals (Allen,2014: Valente,2015)).

  Michie and colleagues put together a taxonomy of BC models and theories which are evidence based; encouraging BC therapists to follow the step-by-step process for best results (Michie et al.,2013: Abraham & Michie,2008).  Adopting the TDF, Com-b and Taxonomy intervention mapping enhances consistency across the field (Cane et al.,2012), ensuring safety for Clare and enabling clinical based measurement and reflection Michie et al.,2011).

Clare’s fears of exertion negatively impacting her heart condition and depression has been a barrier to exercising, this is common amongst individuals with chronic conditions (Jerant et al.,2005). She doesn’t yet have up-to-date information and experience of the benefits of exercise (McInnis et al.,2003). The Social Cognitive model (Parks et al.,2007: Aaltonen et al.,2014: Resnick et al.,2008), The Self-regulation model (SRM) and Modelling theory (Kelder et al.,2015) are evidenced to support this. The SRM is a framework which can include attention and emotion control, goal setting, planning, monitoring, and metacognitive knowledge, mapping the interplay between coping and self-regulation in times of stress, outside negative influences, and past triggers (Detweiler-Bedell et al.,2008: Pedersen & Saltin,2015).

Depression has many symptoms including poor concentration, fatigue, sleep deprivation which may make Clare feel that the exerted effort is not worth it. Under regulation may be due to Clare's difficulty in managing a range of maladaptive cognitions, hence it is important to agree on the most important aspect to manage in a way which does not conflict with other conditions (Detweiler-Bedell et al.,2008). Commitment to adopt and maintain regular exercise in place of health-damaging behaviours is likely to improve long-term BC, if Clare successfully foresees barriers which may arise when she intends to exercise and executes consistent strong, intrinsic, healthy behaviours which override emotional, impulsive automatic behaviours that are familiar (Schwarzer, 2011: Stadler et al.,2009). Clare may benefit from a phone exercise app, which provides self- monitoring, normative feedback, action planning and identity change. The app may also help Clare feel more supported and able to reduce the high level of support required (Vinnikova et al.,2020).

Clare’s financial barrier sits within the TDF as an environmental lack of opportunity (Cane et al.,2012), a common barrier for people from disadvantaged backgrounds who are more likely to have poorer health, less access to facilities, green spaces and support (Kirkham et al.,2018).), further exacerbated by the COVID pandemic (Fegert et al.,2020: Cauwenberg et al.,2018). Opportunity intervention would be to mobilise social support. Clare would benefit from an exercise prescription specialist or social prescriber who communicates with empathy, trust, and care to reduce financial and physical barriers (Valente,2015: Martín-Borràs et al.,2018)

Clare currently holds the belief that her heart condition and depression are barriers to exercising. Establishing beliefs about capabilities on the TDF, before working with Clare to establish what knowledge gaps she feels are advantageous to learn, and providing environmental information on facilities, myth busting and challenging beliefs around gym perceptions ((Glegg & Levac, 2018: Nikolajsen et al.,2021). Clare would benefit from vicarious observation: Identifying groups as positive role models who have overcome health adversity, who are relatable (Borek & Abraham,2018). A commitment to training in person and homebased exercise guidance between sessions, utilising video call sessions and diary records for self-reflection / self-regulation (Crane et al.,2018). Clare could utilise the knowledge alongside repeated supported exposure to overcome social phobias and master the physical activity goals (Garcia,2017).

Clare has the motivation to set goals, motivation is a key construct of the Com-b model which predicts likelihood of behaviour change, it is evidenced that without motivation BC is unlikely to succeed (Weiner,2009). Whilst SE is an important construct to initiate change, motivation is needed to maintain adherence (Slovinec et al.,2014). Motivational interviewing is a client centered approach to empower individuals to co-create a plan of action to overcome behaviours which are detrimental to their quality of life (QOL) (Westar,2004: Budhwani et al.,2021). Motivation is evidenced to support exercise adherence and links to Transtheoretical model (TTM), Stages of change model, and motivational theories such as Maslow’s hierarchy of needs (Turner & Reed,2022).

The TTM, Prochaska and DiClemente, 1983 consists of 5 stages of change and may be used to identify the current stage, Clare’s beliefs, and behaviours (consciousness raising), to enable the best strategy to move forward (Velicer et al.,1999: Merz & Steinherr,2021). Where the HBM was designed for health promotion on a population level, the TTM was designed specifically to change individual behaviour; historically is has been used for smoking intervention, however more recently it has been used for exercise BC (Marshall & Biddle,2001) Criticisms of the model include that it neglects impulse / automatic decision-making (West,2006), and that there are no stages of change, only transient, fluctuating cycles of change; it also does not support how to change (West, R. (2005). There are many studies highlighting successful uses for the model (Wagner et al.,2004: Petrocelli,2002: Taylor et al.,2006).

Clare has the incentive to improve her relationship (a goal) and studies have shown goal incentives; if relatable and achievable to be a strong factor for adherence (Davey et al.,2015). linked models for BC commonly used are: Social Cognitive theory, Goal-setting Theory, and self-determination theory (SDT) and the self-determination continuum.

It is accepted within the PA community that adherence to exercise has a 50% drop out within six months due to reported changes in motivation, a lack of improvement, boredom, and a lack of support / accountability (Wilson & Brookfield,2009). BC practitioners could use the (SDT) by Deci and Ryan,1985, with Clare to discover her intrinsic motivations, activities which bring joy and feel effortless, whilst avoiding the associated guilt and resentful feelings associated with extrinsic goals (Deci & Ryan,2008). The goals require relatability, autonomy and must evoke positive feelings to be sustainable and drive increased effort (Ryan & Patrick,2009: Chatzisarantis,2006).  Positive psychology, empowerment and goal setting is preferred by six out of 10 people in psychotherapy. Giving Clare full control over her goals ensures cohesion and agreed focus for support worker and Clare (Cooper& Law,2018. Pg 7-9). There is a large bank of studies showing the effectiveness of the SDT for exercise which could support adherence (Clare Wilson et al.,2008).

Goal Theory intentions highlights the gap between positive intentions to adhere to a goal, behaviour, and failure to perform (Weinstein,1993). By harnessing the SDT Clare can co-create Intrinsic health goals which are relatable and autonomous (Berking et al.,2005: Sheldon & Houser Marko,2001: Ryan & Deci 2000). Where would she like to exercise? what activities bring joy? The Specificity of a goal is associated to simplicity and tangibility, avoiding abstract, vague and complex goals (Locke & Latham,2002: Sheeran & Webb,2012) e.g. I want to be fit and healthy would be vague, as apposed to I would like to hike two times a week. Temporal extension refers to focusing on proximal therapeutic goals as apposed to long-term life goals. Proximal goals supports likelihood of success and allows incremental successes to build supporting SE (Hanley et al.,2015: Macrill,2001). Clare will be focused on Volitional goals, unconsciously it is likely that she will have other complex goals at play, such as her need to build trust with the support worker, which would likely test / evoke the support worker to ensure they care and are trustworthy. It is therefore vital to remain open, accepting and present whilst Clare attains the unconscious goals (Marine et al.,2012: Moskowitz & Grant,2009): Bargh & Ferguson,2000). Applying person centered goal attainment using SDT is evidenced to support this (Flannery et al.,2018: Gould et al.,2017).

Motivational interviewing requires a humanistic approach to Co-create goals which would allow Clare to practice problem-solving and therefore build self-trust and resilience, overtime lessening her reliance on high levels of support (Padesky & Mooney,2012) and attain emotional stability (Rupani et al., 2014). Establishing morals and values, evoking happy feelings by not viewing the goal as problematic and identifying the positives e.g., Clare has the motivation and time to implement goals (Carey et al.,2019), and finally goals need Planning, mastery and feedback (Pappies,2016). Clare would benefit from incrementally building on outdoor exercise, initiation of small groups of likeminded people overtime, supporting Clare through the exposure of sporting facilities to build capability and SE (Resnick et al.,2008 Martin & Murtagh,2015).

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