Shaping Behaviour and Attitude in Childhood Obesity

Original Editors - Catriona Bartholomew, Brandon Koetsier, Gemma Donohoe, Jessica French and Patrick Holohan

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Introduction 

Background

The negative health consequences experienced by overweight and obese children are wide ranging and include an increased risk of hypertension, type 2 diabetes and asthma. Children's mental wellbeing has also been shown to be negatively affected by overweight and obesity. The health risks of an unhealthy weight in childhood continue into adulthood and can result in an increased risk of conditions in life including cardiovascular disease..................

Epidemiology

The Scottish Health Survey 2011 reports that:

• 65.6% of children aged 2-15 had a healthy weight, a small decrease from 70.3% in 1998. 
• 31.6% of children were overweight or obese, a slight increase since 1998 when the prevalence was 28.0%. 
• 15.7% of children were obese or morbidly obese, representing a small rise in prevalence from 13.0% in 1998.
• Boys were significantly less likely than girls to be a healthy weight (65.1% compared with 69.8%) and were more likely to be overweight or obese (32.7% compared with 28.0%). 
• Healthy weight prevalence was significantly associated with age though not in a linear fashion. Prevalence was generally highest in the early years (aged 2-7) and was lowest among boys aged 10-11 (56.6%) and girls aged 12-13 (62.9%). 
• Boys aged 10-11 and girls aged 12-13 had the highest prevalence of overweight or obesity (41.9% and 33.4%, respectively). 
• There is a strong association between parental BMI and child BMI. Children with parents who are either a healthy weight or underweight are less likely to be overweight or obese than children of obese parents (21.0% compared with 40.1%). 
• Boys in the lowest income households were more likely than those in other household income groups to be obese (19.7% compared with 14.2% in the highest income group). 
• Area deprivation was significantly associated with obesity. Girls and boys in the most deprived quintile were less likely to be a healthy weight and more likely to be obese than girls and boys in the least deprived areas. Children living in the 15% most deprived areas in Scotland had a significantly higher prevalence of obesity than those living elsewhere (18.7% compared with 14.5%).
  

 Learning Outcomes

By the end of this Wiki the reader will be able to:

• Recognize demographic and psycho-social aspects underpinning childhood obesity.
• Describe theories that shape and influence behaviour and attitudes.
• To apply behavioural/attitudinal theories to effectively implement strategies to combat childhood obesity in (primary) school. 
• To evaluate the effectiveness of your strategy to change the behaviours of the children.
  

 Theories of Behaviour Change and Attitude 

Changing Attitude:

Negative attitudes of obesity, reported among both schoolteachers and children, can promote size discrimination toward large children and body dissatisfaction in children who view their body size as unacceptable. There are three components of attitude.

Cognitive [feelings]: This component involves the student knowing about the subject that teachers are trying to influence the attitudes on.

Behavorial [thoughts/beliefs]: This component involves having the students engage in the behavior that you want them to display

Affective [action]: This component involves the urge to want to perform the desired behavior.

Theory of Reasoned Action. (Fishbein and Ajzen, 1975*)

This model makes the assumption that human behavior is under the voluntary control of the individual. People think about the consequences and implications of their actions behavior then decide whether or not to do something. Therefore, intention must be highly correlated with behavior. The concept of “attitude” is viewed as a trigger and predictor of  behaviour.

Behaviour: is influenced by intention.
Intention: is influenced by attitude and subjective norm.
Attitude: is influenced by beliefs regarding the behaviour and evaluation of the outcomes.
Subjective norm: is influenced by beliefs of significant others and motivation to comply with significant others.

A limitation to this model is that modifying factors in human behaviour such as demographics are not accounted for. It also does not account for people who have little control or power over their behaviours. As such, the theory of planned behaviour maybe more appropriate when dealing with issues of obesity.

Theory of Planned Behaviour (Ajzen, 1988*)

This is the theory of reasoned action (TRA), with the additional component of Perceived Behavioural Control. It makes the assumption that perceived behavioural control predicts actual behaviour and suggests that the more time between the intent and actually carrying out the behaviour, the less likely the behaviour will happen. The model does not account for intrinsic and unconscious motives.

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 with respect to 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:SCT three-way, dynamic, reciprocal model

                                                                             Figure 1: Triadic model from SCT.

An individual’s behaviour is uniquely determined by these interactions. Within this framework there are key constructs which determine behaviour patterns. The core determinants, in terms of health behaviour, are described in Table 1 (Bandura 2004, , CommGAP (date)).

Table 1: Core determinants of Health Behaviour

Components
Knowledge	of health risks and benefits
Reinforcements
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
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 (Predicting Health Behaviour Book – Conner and Norman). 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 adapt habits that promote health and reduce those that impair it ().

How can this theory shape your teaching?

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 (Perry 1990).
• Tasks should be moderately challenging so that students do well and make progress when providing reasonable effort

Even a strong sense of self-efficacy may not lead to desired behaviour unless there is incentive (Bandura 1986)

• To facilitate behaviour change it may be important to provide incentives and rewards for the behaviours.

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.

Outcome expectations:

• Students must believe if they complete learning tasks successfully, the outcomes they achieve are worthy of the effort necessary to reach them.

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 proximal determinant of behavior is the intention to act. The intention, in turn, is influenced by the attitude towards the behavior, the subjective norm, and the perceived behavioral control.

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 behavioral control is defined as an individual’s perceptions of their ability or feelings of self-efficacy to perform behavior. This relationship is typically dependent on the type of relationship and the nature of the situation.

Perceived behavioral control can also predict behaviour directly to the extent that the measure matches actual control.

How can this theory shape your teaching?

• Intention has been shown to be the most important variable in predicting behavior change. Intentions are assumed to capture the motivational factors that influence a behaviour and to indicate how hard people are willing to try or how much effort they would exert to perform the behaviour.

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

• For perceived behavioral control to influence behavior change, much like with self-efficacy, a person must perceive that they have the ability to perform the behavior. 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, there are six stages that 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 percent efficacy and will maintain their behavior. Seldom individuals reach this stage, because it is so difficult to maintain. These changes are described as "spiraling or cyclical", rather than a straight forward progression. This is due to the fact that 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 are influenced by a set on independent variables known as "processes of change". These process of change are a major contributing factor that allows us to understand how the shift in behaviour occurs. These processes are internal and external factors  (such as activities and experiencs) that individuals take on when they attempy to change their problem behaviours. There are 10 different processes that contain multiple techniques, methods, and interventions. Numerus studies reveal that in order to have succesful behavioural change, these different processes should be used at particular stages of change. The first five of the stages are classified as "Experiential Processes" and are used for the early stage transitions. The last five stages are known as "behavioural processes" and are used primarily for later stage transitions. 

Processes of Change: Experiential
1. Consciousness Raising (Increasing awareness)
     a. “I remember some information that people gave me on how to not be obese”
2. Dramatic Relief (Emotional arousal)
     a. “I react emotionally to warnings about obesity and the dangers it can cause to my health”
3. Environmental Reevaluation (Social reappraisal)
     a. I consider the view that obesity can be harmful to myself and others
4. Social Liberation (Environmental Opportunities)
     a. I see how society is changing in ways that make it easier to help with obesity
5. Self Reevaluation (self reappraisal)
     a. Seeing how obese I am makes me feel disappointed in myself.
Processes of Change: Behavioral
6. Stimulus Control (Re-engineering)
     a. I remove things from my home that may contribute to my obesity
7. Helping relationship (supporting)
     a. I have someone who listens when I need to talk about my obesity habits
8. Counter Conditioning (substituting)
     a. I find that doing other things instead of eating and sitting around are good for my obesity
9. Reinforcement Management (rewarding)
     a. I will give myself a reward when I lose some weight
10. Self Liberation (committing)
     a. I make commitments not to be obese anymore.

How can this theory shape your teaching?

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

Useful links

Article on role of and applying SCT to the classroom:

http://www.education.com/reference/article/social-cognitive-theory/

Overview of attitude and behaviour change:

http://siteresources.worldbank.org/EXTGOVACC/Resources/BehaviorChangeweb.pdf