Jeannette Larsen & Ann-Dorthe Olsen Zwisler
Health behaviour is often used synonymously with lifestyle, and aspects of lifestyle such as smoking, dietary and exercise habits are strongly related to health, life expectancy and heart disease (1;2).
Lifestyle intervention, comprising systematic education in techniques to change health behaviour, is essential for implementing changes in lifestyle and is an important element in preventing heart disease and cardiac rehabilitation (3–5).
The Cardiac Rehabilitation Unit intervenes in patients’ lifestyles to motivate and support them in changing their lifestyles long term to improve their heart health. This intervention is based on knowledge about the links between heart disease and smoking, dietary and exercise habits.
3.2 Theoretical Basis
There are several theories on how health behaviour is established; different theories have dominated in different eras. Nevertheless, no theory so far has been able to explain fully how lifestyle can be changed in the long term (1), and documentation for the effect of the individual theories on long-term changes in lifestyle is scarce even though these theories are used frequently (6).
The clinical practice in the Cardiac Rehabilitation Unit is based on components from several theories and accounts for the fact that lifestyles change in a complex interaction between behaviour, knowledge and attitudes depending on cognitive, emotional and intellectual abilities and skills, motivation, environment and other factors (7).
The Cardiac Rehabilitation Unit has focused on the stages of change model for lifestyle intervention. This model comprises the basis for many disease prevention services at hospitals in Denmark (8–11). The Unit also uses parts of the health belief model, the self-efficacy theory of Albert Bandura and the principles of action competence. This section outlines the main aspects of these theories, focusing on the elements significant for clinical practice in relation to patients with heart disease and patients with a high risk of heart disease. Due & Holstein (1) and Glanz et al. (12) explore these theories in more detail.
3.2.1 The stages of change model
Psychologists James O. Prochaska and Carlo C. DiClemente developed the stages of change model in the 1980s based on a series of observations of people who had undergone a process that changed their behaviour such as smoking cessation or stopping alcohol consumption.
This model is based on the fact that successful change in behaviour seldom occurs spontaneously. Many people cycle between various stages, and some reach the final stage that signifies long-term change.To support patients in changing their lifestyles, practitioners must be able to identify the current stage of the patient. This allows the practitioners to target the intervention by either using motivational or advisory techniques or by such methods as changing focus from investigating justification for change to making specific plans for change.
The strategy is that practitioners should approach patients differently according to their current stage. The purpose is to motivate the patients to move beyond their current stage; this model is therefore also called the cycle of motivation or the process of change.
A systematic review of studies that used the stages of change model (13) could not document clear effects.
The objective is to achieve dialogue with these patients.
Contemplation: Patients are aware that their behaviour comprises a risk to health. They begin to have conflicted feelings about their lifestyles, since they are aware of several of the risks associated with the behaviour, but they are also satisfied with the benefits the behaviour provides. Thus, they are uncertain as to whether they want to change their behaviour. For many people, this ambivalence becomes a permanent state in which they continually consider changing their behaviour but do not mange to realize the changes.
The objective is to support these patients and to clarify the extent of their motivation.
Preparation: Patients are closer to clarifying their desires and intend to change behaviour in the near future. They have become even more aware of their habits, have often designed strategies and made plans with the aim of breaking their habits and have started to change behaviour in some cases. These patients seek knowledge focusing on the benefits resulting from a change in behaviour.
The objective is to guide the patient in the practical preparation and planning of the programme.
Action: Patients are changing their health behaviour. Altering habits and lifestyle is important in their lives, and they are initially very focused on complying with the planned strategy.The strategy will still need to be adjusted, however: perhaps more time needs to be spent exercising, and patients may have to learn how to tackle situations in which they risk relapse. Many patients are surprised that getting used to their new lifestyle can take many months.
The objective is to guide the patient in how to carry out the plan in practice and prevent relapse.
Maintenance: The new behaviour is beginning to be integrated in the patients’ daily lives, and practitioners must support the patients in focusing on the apparent advantages of the new lifestyle. Practitioners must tell patients that achieving lasting changes in health behaviour is a long-term process during which they must continue to be aware of high-risk situations and the planned strategies still need to be integrated into daily life to avoid relapse.
The objective is to encourage and to help the patients in preventing relapse and to focus on the advantages.
Relapse: Patients have not maintained their new lifestyles, and many are frustrated. Some feel guilty and may not attend the planned meetings to avoid confrontation. All patients need acceptance and understanding. Experience shows that most of the patients who attempt to change their lifestyle cycle through the various stages of the model several times before they achieve long-term change.
3.2.2 The health belief model
Psychologists Godfrey Hochbaum and Irwin Rosenstock developed the health belief model in the 1950s, and since then it has been further developed and modified. The model assumes that the relationship between the experienced threat of illness and the advantages and/or disadvantages associated with changing one’s health behaviour determine whether people choose to change behaviour. The decision results from the desire to become healthy or to avoid illness and the expectation that changing health behaviour can prevent or cure illness.
The extent to which people consider their health threatened depends on how aware they are that their behaviour comprises a risk to health and whether the risk of developing a given disease increases. People’s decision to change health behaviour may also arise from changes in their life situation, such as changing employment, illness or other factors or may be based on other people’s experience in changing behaviour.
This theory has been used to explain why the rate of smoking cessation seems to be very high among patients with heart disease (15;16).
3.2.3 Bandura’s self-efficacy theory
Psychologist Albert Bandura developed the concept of self-efficacy in the 1980s. It is based on individuals believing that they can change their behaviour and having the self-efficacy to change it. Bandura’s self-efficacy theory is the most well-documented theory within heart health. The theory has proved to be suitable to explain why some people manage to change habits that promote heart health in the long term (17–19).
The following figure illustrates the relationship between situationally specific selfconfidence and the effect of changing behaviour.
Situationally specific self-confidence means that people believe that they can carry out a specific change in behaviour. The expectation of effect means that people know which change or changes in behaviour can result in achieving a desired goal. Thus, there is a difference between people knowing that they can lose weight by adopting a low-fat diet and believing that they can lose weight. If people repeatedly attempt to lose weight unsuccessfully through a low-fat diet, this will result in low situationally specific self-confidence and no long-term change in behaviour.
Four factors influence situationally specific self-confidence: prompting by an authority, observing other people in a group context, successful testing and biofeedback.
Biofeedback is a key concept in Bandura’s theory as a means of strengthening people’s situationally specific self-confidence. The evaluation of the achievement of goals by using physiological or biological markers is fed back to strengthen patients’ belief that barriers can be overcome and new behaviour can be established.
3.2.4 Action competence
Tone Gabrielsen (21) has described the concept of action competence. Changing lifestyle aims at developing situationally specific action competence in relation to the fields in which the competence will be used.The aim is to unify knowledge and action. Action competence includes:
The task of the interprofessional clinical team is to motivate patients to adopt attitudes based on their newly acquired knowledge and experience and especially to demonstrate new ways of converting the new knowledge into action. Successfully disseminating health knowledge requires that practitioners ensure that the knowledge disseminated and how it is disseminated are relevant to each patient. One way to ensure this is by presenting patients with knowledge that is individually tailored and related to their daily lives (21).
3.2.5 Relationships between the theories used
The health belief model and Bandura’s self-efficacy theory are psychological theories in which health behaviour is considered to result from psychological processes. The stages of change model is considered a planning model; its purpose is to guide people in the field of lifestyle intervention in choosing appropriate methods but does not seek to explain why people do what they do (1). The theories complement one another and have common characteristics in several areas (22).
The following figure outlines the stages in which the psychological theories and the cross-cutting concept of action competence support the intervention strategy in the stages of change model.
3.3 Cross-Cutting Methods
The Cardiac Rehabilitation Unit uses various clinical methods, and the composition is based on the patients’ motivation, needs and resources.The methods used are described in Chapters 5–10 on the components of patient education, exercise training, support for changing diet, support for smoking cessation, psychosocial support and risk factor management and clinical assessment. This section describes the cross-cutting clinical methods: motivational interviewing or counselling, health communication, prompting by an authority, biofeedback and evaluation, group activities and practical testing.
3.3.1 Motivational interviewing
Psychologists William R. Miller and Stephen Rollnick developed motivational interviewing (or counselling) in the 1990s. This is used in health promotion and disease prevention initiatives in which health personnel attempt to motivate people to change their behaviour based on the stages of change model. Motivational interviewing mainly targets people who are motivated to change behaviour (action and maintenance stages) (23;24).
The technique of motivational interviewing is a form of guidance that places patients in the centre. Instead of directing patients towards a predetermined goal, patientcentred health communication starts with the situation and resources of patients. The practitioner and the patient jointly prepare a strategy that optimally promotes the patient’s action competence. This ensures that patients can process the knowledge they encounter and make decisions on a qualified basis.
The practitioner begins the interview by investigating what patients already know. Patients who need knowledge are offered further information. This information must be based on facts and exclude the practitioner’s assessment. Patients are informed about the effects of various forms of health behaviour. Information presented orally may be supplemented by written material.
The purpose of motivational interviewing is not necessarily to get patients to change their behaviour but more to tailor advice and guidance to each individual. The startingpoint is that the motivation for change arises from personal clarity and liberation from an ambivalent attitude towards change. Health personnel can help patients to achieve clarity and perhaps change by using a motivational interviewing technique in a nonjudgemental atmosphere.
Health-promoting counselling focuses on risks related to heart disease, the links between arteriosclerosis and lifestyle, the seriousness of the disease and the effects of inappropriate lifestyles, the health benefits of changing lifestyle and the opportunities to achieve appropriate health behaviour.
Practitioners attempt to strengthen patients’ situationally specific self-confidence by such means as mentioning positive experience from previous changes in lifestyle. Biofeedback may also be used to emphasize the effects of inappropriate lifestyles. The task of the practitioner is to clarify how patients can be motivated to change their lifestyle and what the current barriers to change are.
3.3.2 Health communication
Health communication is defined here as all communication on disease, illness, disease prevention and health promotion involving a health professional and a patient (25). Health communication is key in intervening in patients’ lifestyle and is an integral part of the theoretical basis of the comprehensive cardiac rehabilitation programme. Lifestyle intervention also integrates the fact that knowledge cannot function in isolation (26;27) but is part of a complex interaction with other factors.
Structured health communication takes place in the structured services for patient education, group activities and individual counselling. The daily clinical practice emphasizes communicating knowledge in a neutral, factual and nonjudgemental tone. The communication is tailored to the motivation, needs and resources of each patient. The Unit attempts to ensure that the various practitioners provide uniform information to avoid confusion and uncertainty about the message among patients. Nonverbal health communication is also consciously promoted in the form of a smokefree environment, bowls of fruit and water instead of sweetened drinks. The effect of practitioners’ health behaviour on patients has been documented in smoking cessation and other areas (28–31).
3.3.3 Prompting by an authority
The Cardiac Rehabilitation Unit consistently ensures that physicians as authorities emphasize to patients how serious heart disease is and inform about the opportunities to prevent and avoid progression of heart disease by changing lifestyle. The importance of the physician prompting changes in lifestyle is based on the health belief model and the self-efficacy theory and is especially well documented in smoking cessation (32–34). In addition, patients surveyed indicated that the physician’s advice has been decisive in their decision to change lifestyle (35).
The Cardiac Rehabilitation Unit evaluates whether goals have been achieved by using physiological and biological markers in all areas. This evaluation is fed back to reinforce the patients’ belief that barriers can be overcome and new behaviour can be established, corresponding to strengthening situationally specific self-confidence in the self-efficacy theory.
Examples of how the Unit uses biofeedback include measuring serum cholesterol levels in dietary intervention,weighing patients as part of a weight-loss programme, measuring carbon monoxide concentrations in expired air and pulmonary functioning as part of smoking cessation and repeatedly testing aerobic functioning and monitoring heart rate in connection with exercise training.
3.3.5 Group activities
The Cardiac Rehabilitation Unit emphasizes social interaction between patients, and many of the rehabilitation components are carried out as group intervention, such as smoking cessation, exercise training and cooking. Group activities as part of lifestyle intervention have especially been documented to influence smoking cessation (36)..
3.3.6 Practical testing
Cardiac rehabilitation at Bispebjerg Hospital emphasizes giving patients the opportunity to test changing their lifestyle in practice. Patients who cook experience that food that promotes heart health can taste good and that very little fat is needed. The exercise training component emphasizes transferring the exercise directly into daily life.
This cross-cutting method is based on several theories. Practical testing contributes to strengthening the situationally specific self-confidence from the self-efficacy theory, positively influencing long-term changes in lifestyle. Practical testing is also a tool for increasing patients’ action competence within a specific area and can give patients experience on which they can draw in planning and implementing change in lifestyle in accordance with the stages of change model.
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