Shaping Behaviour and Attitude in Childhood Obesity

Original Editors - Catriona Bartholomew, Brandon Koetsier, Gemma Donohoe, Jessica French and Patrick Holohan as part of the Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice Project

Top Contributors - Catriona Bartholomew, Brandon Koetsier, Jessica French, Gemma Donohoe, Patrick Holohan, Kim Jackson, Admin, 127.0.0.1, WikiSysop, Olajumoke Ogunleye, Tony Lowe and Laura Ritchie  

Introduction

Many of the life-long habits that jeopardize health are formed during childhood. Schools provide an excellent opportunity for preventing and treating obesity through changing these habits. Both physical activity and nutrition-focused interventions are already in place in many primary schools. To effectively implement these programmes teachers need to understand what brings about the actual change in behaviour.

Designing interventions to produce or change certain behaviours; in this case, health behaviours relating to childhood obesity; is best done with an understanding of behaviour change theories and an ability to apply them to practice.

Theories of Behaviour Change and Attitude 

Negative attitudes of obesity reported among schoolteachers and children can promote size discrimination toward large children and body dissatisfaction in children who view their body size as unacceptable. Appropriate education on how to self-monitor daily activity levels can help to empower individuals to maintain healthy long-lasting lifestyle habits.

To alter an individual’s behaviour it is thought that you must first instil a positive attitude towards the behaviour. Weight loss should be looked at from the inside-out, rather than the normal outside-in perspective, meaning, our attitudes and beliefs must be appropriate before methods to change behaviour are implemented. Shifting a child’s attitude is the first step in varying a child’s negative behaviour and beliefs towards weight.  The following are key components that will influence personal attitudes: 

Cognitive [feelings]	involves the student knowledge about the subject that teachers are trying to influence the attitudes on
Behavorial [thoughts/beliefs]	involves having the students engage in the behaviour that you want them to display
Affective [action]	involves the urge to want to perform the desired behaviour.

It is vital to keep in mind that attitudes may not directly cause a behaviour change but are necessary to address to help alter behaviour.

Affirmations

One way to influence the attitudes of pre-adolescents is to try and increase their self-efficacy and to educate them on the effects of affirmations.  Affirmations are statements that declare that something is true. The theory of self-affirmation is a psychological theory with the premise that people are motivated to protect an image of their self-integrity, morality and adequacy. Self-affirmations are said to boost the self-concept and give you the confidence to achieve goals.  Self-affirmation is effective in terms of promoting a greater acceptance and changes in attitudes, intentions and behaviour.

It is important to keep the following in mind when teaching and writing affirmations.
     1. Keep information consistent and congruent so individuals can form a single attitude
     2. Include messages that are high in affect and emotion (have a shock value)
     3. Use messages that connect negative attitudes to past negative behaviours

In understanding how attitudes can be altered with the use of affirmations this strategy can be utilized in daily and weekly activities.

The ‘Create Affirmations’ website has six easy steps to follow when writing self-affirmations:

1. Use the present tense
2. Use your voice, write them how you would speak them
3. Keep affirmations short and precise
4. Make them believable and realistic
5. Be literal
6. Use only positive statements.
   

Ways to Implement Affirmations

• A great site to use to help with writing affirmations is the WIKI How to page, found at&nbsp: http://www.wikihow.com/Write-an-Effective-Affirmation
• Examples of affirmations: (http://www.vitalaffirmations.com/affirmations.htm#example%20affirmations)

Affirmations for Weight Loss:

• I am the perfect weight for me
• I choose to make positive healthy choices for myself
• I will exercise regularly
• I can make healthy choices
• I will be active 3 days a week
  

Attention, Relevance, Confidence and Satisfaction (ARCS) Model of Motivational Design

Motivation consists of the amount of effort a person is willing to exert in pursuit of a goal; hence, motivation has magnitude and direction .

Motivational design is concerned with:

• connecting instruction to the goals of learners
• providing stimulation and appropriate levels of challenge
• influencing how the learners will feel following successful goal accomplishment, or even following failure.
  

Ways to implement model:

The following table outlines the key components of the ARCS model and ways of implementing them.

Attention	Incongruity and conflict	use contradictions, play ‘devil’s advocate’ to challenge learner’s past experiences
	Concreteness	use visual representation, anecdotes and biographies
	Variability	change – tone of voice, movements, instructional format, media, layout and design of instructional material and interaction process
	Humour	use puns, humorous analogies and anecdotes and jokes (with moderation)
	Inquiry	use problem solving activities and constructive practices
	Participation	use games, simulations, role-playing etc
Relevance	Experience	• Tell learners how new learning will build on ones existing skills. • Use analogies to relate current learning to prior experience. • Relate to learner interests.
	Present worth	explicitly state the current value of instruction (health benefit, energy levels, fun factor)
	Future usefulness	relate instructions to future goals (SMART, develop with students)
	Need matching	allow students to achieve, exercising responsibility, authority and influence
	Modelling	use enthusiasm, peer-modelling etc
	Choice	student choice
Confidence	Learning requirements	help students understand likelihood of success, advise students of requirements (goals and objectives)
	Difficulty	sequence activities in increasing difficulty with continual but reasonable challenge
	Expectations	forecast outcomes based upon effort; set realistic goals
	Attributions	encourage students to internalize locus of control by attributing success to themselves
	Self-confidence	foster using confidence strategies
Satisfaction	Natural consequences	allow students to use newly acquired skills in realistic, successful settings
	Unexpected rewards	include student expectation of extrinsic reward (for boring tasks) or use a surprise reward
	Positive outcomes	provide feedback – praise, personal attention, motivation – immediately
	Avoidance of negative influences	don’t use threats, surveillance practices and total external evaluation. Do not patronise the leaner by over-rewarding easy tasks
	Scheduling	repeat reinforcement at fluctuating, non-predictable intervals

 

Changing Behaviour

Presented below are popular health models used to describe how people acquire certain behaviours.  There is no 'correct' model, it is best to read through the models and think about which one best suits you and the situation you are trying to apply it to.

Social Cognitive Theory

The Social Cognitive Theory (SCT) explains how people acquire and maintain certain behaviours and has been extensively used in the field of health behaviour for health promotion, prevention and modification.

Human behaviour is explained in terms of a three-way, dynamic, reciprocal model in which personal factors, environmental influences and behaviour constantly interact (Figure 1).

                                                                             Figure 1: Triadic model from SCT.

An individual’s behaviour is uniquely determined by these interactions. Within this framework, there are key constructs that determine behaviour patterns. The core determinants are described in the table , , .

Table 2: Core determinants of Health Behaviour

Components
Knowledge	of health risks and benefits
Reinforcements	to establish the pattern of behaviour
Observational Learning	Acquisition of behaviour through observation and experience
Self-regulation	individual’s ability to manage or control behaviour
Outcome Expectations	The outcomes people expect their actions to bring about. The perceived importance of these expectations may also drive behaviour.
Goal Setting	establishing both individual and group SMART goals
Perceived Self- Efficacy	An individual’s confidence in their own ability to perform behaviour.

Self-efficacy is an important determinant of behaviour and is incorporated into many models of behaviour change. Self-efficacy makes a difference to how people think, feel and act ; . According to the SCT, a personal sense of control makes behavioural change possible . Bandura proposed that the actual performance of a particular behaviour is highly related to an individual’s perceived self-efficacy .

Low Self-Efficacy:

• lower expectations of successfully performing behaviour
• more effected by counterproductive situational temptations

High Self-Efficacy

• Expects to succeed at performing behaviour
• More likely to succeed at performing behaviour

Unlike other models of health behaviour, the Social Cognitive Theory offers both predictors and principles on how to inform, facilitate, guide and motivate people to adopt habits that promote health and reduce those that impair it .

To Increase Levels of Self-Efficacy

• It may be important to provide resources and support to raise individual confidence.
• Behaviour change should possibly be approached as a series of small achievable steps .
• Tasks should be moderately challenging so that students do well and make progress when providing a reasonable effort.
  

Even a strong sense of self-efficacy may not lead to desired behaviour unless there is incentive .

• To facilitate behaviour change it may be important to provide incentives and rewards for the behaviours.
• Incentives may increase extrinsic motivation, especially where intrinsic motivation is lacking.
  

Shaping the environment may encourage behaviour change.

• Provide opportunities for behavioural change
• Assist with changes
• Offer social support
• Recognize constraints that may deter behaviour change.
  

Goal Setting

• Goals that students set or endorse themselves have a bigger impact on their behaviour than goals that are assigned.
• Goals must be SMART (specific, measurable, attainable, realistic and timely).
  

Theory of Planned Behaviour

The Theory of Planned Behavior (TPB) is an extension of the theory of reasoned action (TRA). It states that the main determinant of behaviour is the intention to act. The intention, in turn, is influenced by the attitude towards the behaviour, the subjective norm, and the perceived behavioural control.   Figure 2 shows the influences on behaviour and their interactions according to the TPB.

                                                                            Figure 2: Interactions within TPB 

Subjective norm refers to the individual’s perceptions of general social pressure to perform (or not to perform) the behaviour. If an individual perceives that significant others endorse (or disapprove of) the behaviour, they are more (or less) likely to intend to perform it. Attitude towards the behaviour reflects the individual’s global positive or negative evaluations of performing a particular behaviour.

In general, the more favourable the attitude towards the behaviour, the stronger should be the individual’s intention to perform it .

Perceived behavioural control is defined as an individual’s perceptions of their ability or feelings of self-efficacy to perform the behaviour. This relationship is typically dependent on the type of relationship and the nature of the situation.   Perceived behavioural control can also predict behaviour directly to the extent that the measure matches actual control.

Intention = most important variable in predicting behaviour change.  Intentions are assumed to capture the motivational factors that influence a behaviour and to indicate how hard people are willing to try or how much effort they would exert to perform the behaviour.

• Therefore it may be important  to present information to help shape positive attitudes towards the behaviour and stress subjective  norms or opinions that support the behaviour.
  

• For perceived behavioural control to influence behaviour change a person must  perceive that they can perform the behaviour.  Therefore, perceived  control over opportunities, resources, and skills needed is an important part of the change process.
  

Transtheoretical (Stages of Change) Model

In the transtheoretical model, six stages together form a progression for change: Precontemplation: This stage is where the individual is not even considering attempting or thinking about a change in the next six months. Contemplation: The idea of change has been planted in their heads, but they aren’t ready to start right away. They plan to change within the next six months. They have identified the pro’s to change, but also are aware of the cons. Preparation: This stage consists of the individual forming a plan of action to change within the very near future. (within 1 month). Action: The stage where the individual begins to make their change Maintenance: the continuation of their plan, and trying to avoid relapse. The majority of individuals stay in this stage. Termination: the final stage, where individuals have 100 per cent efficacy and will maintain their behaviour. Seldom do individuals reach this stage, because it is so difficult to maintain? These changes are described as "spiralling or cyclical", rather than a straightforward progression. This is since individuals progress through the stages at different rates, and it is very common for individuals to move back and forth along the chain, before eventually reaching the desired goal of maintenance.

Moving forward through the stages is influenced by a set of independent variables known as " processes of change". These processes of change are a major contributing factor that allows us to understand how the shift in behaviour occurs. Numerous studies reveal that to have a successful behavioural change, these different processes should be used at particular stages of change. 

Processes of Change: Experiential = Early Stage Transitions 

Process of Change	Example
1. Consciousness Raising (Increasing awareness)	I remember some information that people gave me on how to not be obese
2. Dramatic Relief (Emotional arousal)	I react emotionally to warnings about obesity and the dangers it can cause to my health
3. Environmental Reevaluation (Social reappraisal)	I consider the view that obesity can be harmful to myself and others
4. Social Liberation (Environmental Opportunities)	I see how society is changing in ways that make it easier to help with obesity
5. Self Reevaluation (self reappraisal)	Seeing how obese I am, makes me feel disappointed in myself.

Processes of Change: Behavioral = Later Stage Transitions 

Process of Change	Example
6. Stimulus Control (Re-engineering)	I remove things from my home and lifestyle that may contribute to my obesity
7. Helping relationship (supporting)	I have someone who listens when I need to talk about my obesity habits
8. Counter Conditioning (substituting)	I find that doing other things instead of eating and sitting around is good for my obesity
9. Reinforcement Management (rewarding)	I will give myself a reward when I lose some weight
10. Self Liberation (committing)	I make commitments not to be obese anymore.

It is very important to match behaviour change interventions to people's stages. (e.g. If the student is in the precontemplation stage, it is important to provide to them the information about the pro's and con's of losing weight).   Without a planned intervention, people will remain stuck in the early stages due to a lack of motivation to move through the stages

When children are in the precontemplation/contemplation stage, various factors should be identified to start the process of change:

• Learn the child’s current level
• Identify cues to non-engagement in physical activity
• Identify benefits of engaging in physical activity
• Identify choices that can increase the child’s physical activity
• Identify the child’s BMI
• Identify the impact of obesity on the child’s social function

When children are in the action/completion stage, various activities have been known to work:

• Increase physical activity goals
• Reduce barriers to physical activity
• Recognize benefits of increased physical activity
• Engage in less sedentary activities
• Provide physical activities after school

Intrinsic and extrinsic motivation are both very important to the adoption and maintenance of physical activity. To move through the stages, an individual needs to increase their intrinsic and extrinsic motivation. As the stages progress, the levels of intrinsic and extrinsic motivation should increase.

• In the pre-action stage, “tangible rewards” were more highly endorsed.
• Extrinsic motivators, such as tangible results or receiving monetary compensation may be stronger as people consider and adopt an exercise.
• Intrinsic motivators (effort competence and interest-enjoyment) was highest for participants in the maintenance stage. Showing that continued participation in regular activity relies on internal positive factors.
  

Cognitive approaches are most effective when individuals have not yet changed their behaviour. These may include:

• Consciousness-raising: increasing knowledge of obesity and the health effects of diet, physical activity, and environment
• Social liberation: modifying diet, physical activity, and environmental factors, resulting in social benefits
• Self-evaluation: examining the effects of current diet, physical activity, and environmental factors on obesity and health
• Environmental reevaluation: exploring the relationships between diet, physical activity, and environmental factors, and the physical, social, and emotional environments.
  

Behavioral strategies are more appropriate when individuals have initiated or are attempting to maintain new behaviours, these may include:

• Self-liberation: telling oneself that it is possible to change diet, physical activity, and environmental factors
• Counterconditioning: finding a substitute behaviour for the usual diet, physical activity, and environmental factors
• Stimulus control: removing items or stimuli that remind one of the usual diet, physical activity, and environmental factors

Bringing Theory into Practice

Following on from the information provided above a basic understanding of what shapes attitude and behaviour should have been developed.  This understanding should help to realise aspects that need to be taken into account when applying interventions to combat obesity.  Below are a few more suggestions as to how these theories can be brought implemented.

Questionnaire

A questionnaire can be developed using the Theory of Planned Behavior which  focuses on  health and physical activity (PA) behaviours.  The questionnaire should include assessment of:

• Attitude
• Subjective norm
• Perceived behavioural control (PBC)
• Intention to participate in regular PA .

 Findings from such questionnaires will have implications for tailoring future interventions and physical activity for children. Previous studies suggest that to achieve the greatest PA gains, interventions should implement strategies that reflect the findings on the importance of attitude and especially PBC, for obese students.  They also  suggest that PA interventions aimed at  obese students should endeavour to provide information highlighting the benefits of participating in regular PA , for example, making PA enjoyable (see below).

Education

Children are very easily influenced, especially by the media.  Therefore discussions on the following topics may be beneficial: 

• Specific programs
• Articles in magazines/books
• Pictures from books and magazines 
• Individual/group feelings 
• Pros and cons of these pictures/articles
  

Affirmations

Affirmations are more effective if a child writes their own positive self-statements.

• Write affirmations and encourage them to be read out loud once a day.  Affirmations can change for each day of the week or  every two weeks and repeated daily. 
• Use of journals to write personal affirmations.
• Children can write affirmations and decorate them to put up in their rooms and around the home.

Intrinsic Motivation

Children  need to be intrinsically motivated to implement change.  It is therefore important to have them input ideas of how we can accept healthy attitudes and behaviours. If a child is intrinsically motivated they will be more likely to accept ideas  and in turn more likely to  alter attitudes and  behaviours. 

Useful links

Provided below are some useful links for those requiring more information on any of the content of this page:

• A useful visual guide on implementing ARCS Model
• Article on role of and applying SCT to the classroom
• A more in-depth focus on the Transtheoretical Model 
• Article on role of and applying Transtheoretical Model to the classroom